In some cases, mastectomy is inevitable – in case of an advanced breast disease, when the size ratio of the tumor to breast does not allow to preserve it, when there are mutations in the BRCA 1/2 and some other genes, and finally, if the patient desires so. When removing the breast, the surgeon must do everything possible to restore it, i.e., reconstruction. Reconstruction is possible immediately following mastectomy, in this case it is called simultaneous breast reconstruction and it is the best option because the aesthetic results of these operations are better, and the patient does not suffer from the lack of the organ. If for any reason simultaneous reconstruction is not performed, it can be done later once the main stage of cancer treatment is over. This is called delayed breast reconstruction. In this case, however, the surgeon must perform the first oncological stage of the operation in a way that does not complicate the future breast reconstruction but on the contrary – in a way that prepares it. The surgeon must preserve the submammary fold, skin of the breast along with the areola and the nipple, perform the incisions in places that are not easily visible if possible. Breast reconstruction can be one-stage when a permanent implant or a part of the patient’s own soft tissues is immediately inserted in place of a removed breast; or two-stage when an expander is inserted first – a temporary implant with the possibility of changing its volume and which is later replaced with a permanent implant or patient’s own tissues. Two-stage reconstructions have less critical complications even though the aesthetic results are somewhat worse. During the reconstruction an implant or expander may be inserted underneath the pectoralis major muscle (retropectoral) or on it (prepectoral). Every option has its features. Prepectoral reconstruction is a quicker and less traumatic operation, the patient recovers faster, there are less restrictions on physical activity in the postoperative period, but there is a greater likelihood of ‘visibility’ and ‘waviness’ of the implant under the skin and that it will be felt on palpation. Retropectoral reconstruction makes the upper part of the restored breast look more natural, but it is a more traumatic operation which often requires using special meshes to fix the pectoralis major muscle that must be partially incised to insert the implant underneath it. This may cause the animation effect – twitching of the skin in the reconstructed breast. Following reconstructive surgery additional fat transplantation is recommended in the area of reconstruction which is called lipografting. This is especially relevant for prepectoral reconstructions.
The choice of an optimal surgical option depends on the anatomical features of the patient, comorbidities and risk factors, the need for radiation therapy and the final result desired by the patient and surgeon.