A NOVEL APPROACH TO BREAST RECONSTRUCTION

The HOFF method

Aiming to youthfully improve the shape of the entire bosom permanently in the process of breast reconstruction

Breast reconstruction is intended for breast cancer patients who had to undergo a mastectomy (removal of a entire breast) or a deforming lumpectomy (removal of just the cancerous area). Breast cancer can be devastating. Even after recovering from it, you might never feel the same. At times, concern for your health can overshadow the emotions that come with losing a breast. Living a long, cancer free, life is the most important goal, but wanting to hold on to your femininity may be just as essential to your wellbeing. An estimated 300,000 women are diagnosed with breast cancer in Europe every year. So, you are not alone. Many women experience the breast deformity (that invariably accompanies modern cancer treatment) to be an assault at the very core of their self-esteem. While breast reconstruction after a mastectomy offers only a cosmetic solution, it might be something that truly helps to boost your self-esteem and return to your feminine confidence. This is why breast reconstruction surgery is so widely sought after.

Going for a surgical breast reconstruction is a personal choice that many surgeons may be ready to discuss with you. However, all too often they lack the experience, resources and determination to offer you the best possible cosmetic solution. Whereas acceptance and popularity for breast reconstructive surgery has grown rapidly, the competent provision of good reconstructive surgery could not keep up with this increased demand. This is why dreadful disappointment may be the result of a longwinded treatment, a failure failing to live up to its promise. We see patients regularly, who feel cosmetic insult has been added to their injury, rather than the promise of a “nice new breast”. Principal considerations: Knowing your individual reconstruction options before surgery will help you to prepare for a mastectomy with a more realistic outlook for the future.

Practical decisions about reconstructive surgery depend on many personal factors such as:

1. Over-all health

2. Stage of breast cancer

3. Breast size and shape

4. Amount of tissue available (for example, very thin women may not have enough extra body tissue to make flap grafts)

5. Need for reconstructive surgery on both breasts

6. Insurance coverage for the unaffected breast

7. Your own preference of procedure

8. Size, position and shape desired

9. Your desire to match the look of the other breast

Only after full exploration you will be able to make the best choice for your body and your life after cancer. Research has shown that the more informed you are upfront, the better your plan will be.

WARNING!!!

Choose your surgeon very carefully!

Although breast reconstruction can rebuild your breast, the results are highly variable. Some of the reasons are listed below:

1. Be prepared for multiple additional refinement surgeries.

It would be an illusion to expect a good result from one single surgery. On average 3 to 5 procedures are required to arrive at the best possible result. This includes, more likely than not, enhancement surgery on your healthy side. In all forms of breast reconstruction, nipple reconstruction is performed as a final stage of breast reconstruction, after the breast has reached its final shape and size, and when you are happy with your reconstruction. As there are inevitably changes that occur in the breast following reconstruction, creating a nipple too early would result in a poor match between the two sides.

2. Beware of cosmetic disappointment.

Not all surgery is a total success, and you may not like the way it looks. For instance, your surgeon’s only aim may be the restoration of the preoperative breast form. They attempt to restore a breast to near normal shape, appearance and size following mastectomy. Only in case of gross asymmetry they will do some sort of matching procedure at the unaffected side. Proper aesthetics and symmetry do not appear to be high on their list. Many patients may prefer to take the opportunity to optimize the result cosmetically, by addressing the pre-existing symptoms of drooping and size dissatisfaction at the same time. They often perceive this as a compensation reward for coping gracefully with their disease.

3. Consider symmetry very carefully.

If only one breast is affected, it alone may be reconstructed. Rarely, however this is what one really wants. Often overall cosmetic improvement is indicated, by a breast lift, breast reduction and/or breast implant in order to restore symmetric youthfulness, size and position of both breasts.

4. Expect sensory changes.

Breast reconstruction aims to restore and even enhance the shape, but not the feeling. With time, the skin on the reconstructed breast can become more sensitive, but it will not feel the same as it did before your mastectomy. A reconstructed breast will not have the same sensation and feel as the breast it intends to replace.

5. Be prepared for additional scars.

Any type of mastectomy and reconstruction will result in scarring of the breast. Visible incision lines will always be present on the breast, whether from the reconstruction or the mastectomy or both. Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the back, abdomen or buttocks.

6. General health risk hazard.

Healing may be affected by previous surgery, chemotherapy, some medicines, etc. Also, carefully weigh up the following health risks: Smoking Other dependencies (alcohol, drugs, psycho-pharmacy, etc) Overweight of more than 20 kgs Anorexia / recent severe weight loss Physical and psychological fragility Advanced age Uncontrolled cardiovascular disease (Pre)diabetes and metabolic syndrome The above issues are a very potential hazard for reconstruction failure, as well as, your life in general. In particular when micro-vascular surgery and prolonged anaesthetics are being planned, they become a very good reason not to enter into the adventure.

7. Surgical inadequacy:

Unfortunately, the demand of adequately qualified surgeons is much higher than the supply, and will remain so for the generation to come. Ultimately breast reconstructive surgery is a form of cosmetic surgery. In no other surgical specialism your result is so directly dependent on the holy trinity of the proper surgeon: Talent-Training-Experience. If any of these essentials lack on behalf of your surgeon, absolutely anything can, and most likely will, go wrong. To bump into a good cosmetic reconstructive surgeon in the breast unit dedicated to treating your cancer, would still be a rare exception to the rule, let alone, to find them to be able to operate together as a surgical team.

8. Other important things to think about:

1. You may not want to think about reconstruction while coping with a diagnosis of cancer. If this is the case, you may choose to wait until after your breast cancer surgery to decide about reconstruction.

2. You may, after careful consideration, not want to have any more surgery at all.

3. You may want to reshape the remaining breast to match the reconstructed breast. This could include reducing or enlarging the size of the breast, and lifting the breast. 4. You may dream of a generally more attractive bosom than you had before. After all, a reconstruction is a big effort on your part, and thus, you may as well get the maximum out of it.

The timing of breast reconstruction:

Living in reality.

One of the first choices you will have is whether to undergo immediate or delayed reconstruction. There is no absolute right or wrong choice. However, each patient should carefully contemplate just which option best suits her specific needs. This mainly depends on the availability of honest and comprehensive information before the mastectomy is performed. Regardless of whether an immediate or delayed approach is envisaged, it is important to understand that it may take several procedures to achieve the final aesthetic result. It is important to realize that there are advantages and disadvantages to both immediate and delayed breast reconstruction, depending of the type of cancer, the type of surgery, the patient’s risk factors, the local availability of good reconstructive expertise, the money and the effort one is prepared to expend. Last but not least, the detail of the adjuvant therapies necessary such as chemo- and radiotherapy play an important role. Unfortunately, the full extent of the cancer cannot be determined until the entire tumour is removed, and lymph nodes have been evaluated. Based on your risk factors, your medical work-up including the information from your biopsy, your surgeon will have a general idea of the extent of your tumour. In some patients, prior to any surgery, there may be signs of advanced disease. It may already turn out that radiation will be required as part of the treatment plan. If this is the case, it may be in your best interest to delay the reconstruction until after all treatments have been completed, and the disease has been brought to a halt.

1. Immediate breast reconstruction is done at the same time as the mastectomy. This means only means that the reconstructive process (taking on average 3-5 operations) begins at the time of the mastectomy. After the first surgery, there still may be a number of steps that are needed to complete the immediate reconstruction process. If you are planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take. One technical advantage to this approach is that at the time of principal surgery, the chest tissues are not damaged by radiation therapy or scarring. In very early stages of disease, or in case of preventive mastectomies, this may mean that the final result can look better. Another obvious benefit to immediate post-mastectomy reconstruction is the psychological and aesthetic advantage of waking up after the mastectomy with a lesser deformity and the reconstruction well underway. While delaying reconstruction gives you time to focus on treatments, and research the type of reconstruction that best suits your needs, being entirely without a breast can be emotionally devastating for some. The primary drawback of immediate reconstruction is that it requires a longer surgery and recovery than just having mastectomies alone. Also, if radiation treatments are needed following surgery, the reconstruction may become compromised. Also, whereas scarring is a natural outcome of any surgery, cell death (called necrosis) of the breast skin, the flap, or transplanted fat is not. Immediate reconstruction may be more likely to result in necrosis. If this happens, more surgery is needed to fix the problem and can deform the new breast shape. Another very real disadvantage is that particularly in case of a immediate micro-surgical reconstruction, the general anesthetic required will become extremely long, in the rule exceeding 6 or even 8 hours. This carries still under-reported risks of very serious, even life threatening, long term complications (hyperlink: www.hoeyberghs.com). There is also a real danger that patients do not sufficiently realize that the reconstructed breast will never in all aspects be the same as the one they lost. This is a far too common cause of overly high expectations. This poor informed consent will invariable lead to more disappointment later on. In extreme cases we have known the secondary disappointment with the reconstruction to be a bigger blow even than the initial shock they received when learning they were to loose the breast, or part of it to cancer.

2. Delayed breast reconstruction involves only performing the mastectomy or tumour excision at the first operation. After you have fully recovered and any additional necessary treatment has been completed, a second operation is performed to reconstruct the breast. These are generally a few months apart. Delayed breast reconstruction means that the rebuilding is started later. This, in general, is the better choice if you need radiation to the chest area after the mastectomy. Radiation therapy given after breast reconstruction surgery can cause problems, even to the extent of entirely destroying the initial reconstructive attempt.

Summary: advantages and disadvantages of timing:

IMMEDIATE BREAST RECONSTRUCTION

Advantages: Potentially better cosmetic results in early diagnosis. Smaller breast scars. One major anaesthetic and recovery period. One (very major) hospital stay. Possibly lower psychological impact (no time without a breast shape) provided the informed consent was adequately
Disadvantages: Longer anaesthetic and recovery time. More general complications, in particular from the anaesthetic. Longer waiting time for surgery. Increased risk of infection and other complications. Distortion of reconstructed breast if radiotherapy is required. Increased risk of exaggerated expectations with disappointing result. Impossible to improve the other side at the same time. Often the only aim can be the restoration of the previous breast shape without concomitant cosmetic gain. Difficulty in organizing the combined expertise of aesthetic surgery and cancer surgery at the same time and -in the same place. Prohibitively expensive for most individuals and security systems.

DELAYED BREAST RECONSTRUCTION

Advantages: Staggered surgery (easier and shorter recovery after each procedure). Plenty of time to consider whether reconstruction is right for you without delaying cancer treatment. Fewer issues to deal with at once. Better concentration on each step in the process. Better opportunity to fine-tune the cosmetic expectations in a realistic way. Better bilateral cosmetic control possible. Possible under light sedation only (can be safely performed on patients with general health risks). General anaesthesia can always be avoided, even at the major reconstructive stage. Day surgery at all stages is very comfortably possible. No hospital stays necessary (reduced infection risk). Treatment abroad is a real option (choice of surgeon).   Disadvantages: Additional general anaesthetic (only if modern cosmetic infiltration and sedation technology are unavailable). Experienced cosmetic surgeon (to balance both breasts to a ideal shape, rather than the pre-existing shape). Possibly longer breast scars. Usually dependant on good implant technology

TECHNIQUES

Finding your way to the HOFFmethod

The different technical approaches to breast reconstruction:

Breast reconstruction can be achieved through various plastic surgery techniques. The approach to your reconstruction should be tailored to your individual needs. 1. Pure implant reconstruction:

Pure “implant only” reconstructions involve making a space between your ribcage and pectoral muscles and inserting an implant into this space (sub-pectoral implant reconstruction). The overlying skin is then sutured together to close the wound. The implants are usually expandable implants, which are slowly enlarged over 3 to 6 months to give the desired shape and size and then may be changed to a permanent silicone implant. Alternatively, the skin is conditioned over weeks to months with a saline solution, and a silicone or saline implant is then inserted. The aesthetic result of a pure implant reconstruction is always compromised, as the shortage of tissue between muscle and skin means that they will be very palpable and visible and very prone to hardening. This often ends in ultimate implant extrusion. It may cause substantial discomfort and even pain.

2. Pure autologeous “flap” reconstruction:

Autologeous reconstructions involve moving tissue from your back, buttocks or tummy to the site of your breast and reshaping the tissue to form the new breast mound. As the tissue is alive and natural, it provides the most natural shape and feel to the reconstructed breast at the expense of undergoing surgery and creating scars in healthy parts of your body. In contrast to prosthetic reconstructions, there is an adequate skin and tissue mount available immediately after the operation. However, this tissue is likely to change shape and size slightly over the first few months following reconstruction. Finally, ptosis (drooping) may have to be accepted.

Free Flap Transfer with microsurgery. The TRAM flap, SIEA flap and DIEP flap involve the transfer of your own skin and fat from your tummy to recreate the breast. Similarly, skin and fatty tissue can also be taken from your buttocks, without removal of muscle as a free SGAP flap. Due to advanced microsurgical techniques, this can be accomplished without removing the main abdominal muscle and without using breast implants. The technique will allow the breast to evolve with changes in body weight, and generally droop like normal breast tissue. Although for adequate volume restoration, there may be an immediate need for the use of implants. In due course, overt ptosis will likely need to be corrected. In order to enhance the upper pole in the cleavage implants will be necessary.

WARNING!! It is important to reinforce that this type of microsurgery is a very major surgery, more extensive than your mastectomy. They require good general health and strong emotional motivation. Even so, patients may end up on an intensive care unit for recovery from the long anaesthetic. If you are very overweight, smoke, have had previous surgery in the area the flap would be taken, or have any circulatory problems, a micro-vascular tissue flap procedure is not a good idea, as the chance of failure is far too great. If you are very thin, you may not have enough tissue in your abdomen or back to create a breast using this method. Also, please consider the added anaesthetic risks.

HOFFmethod

Polyurethane covered implants in adequately sklled hands.

3. Mixed “implant assisted” flap reconstruction:
This type of surgery involves the use of a muscle flap in combination with a breast implant. This technique is referred to as "pedicled flap”. It pulls skin, fat, and muscle from other parts of the body without the need for microscopic repair of the blood vessels. This method produces a very sturdy pocket, which will be safe for implant use. It is technically possible to immediately insert the implant but for the best cosmetic outcome we recommend a delayed implantation. This allows the tissues to first settle in their new position. We routinely take advantage of this first stage to fashion the healthy breast to match the reconstruction, and thus allow good symmetry. This is the ideal preparation to finish the reconstruction permanently in the second stage.

Pedicled flap reconstruction.
The most common type of “implant assisted” flap reconstruction is the latissimus dorsi (LD) flap. The LD muscle is a thin sheet of muscle on the back. It is mobilized together with fat and skin. This compound tissue flap is then moved to the front to create a pocket for an implant to be placed. Its principal blood supply is left intact throughout. So, there is no need for tedious dissection an a long and complicated revascularisation by microscope.
This method allows for the creation of a safe and speedy construction of the implant pocket. This will serve as the basis for a long lasting, comfortable and aesthetically pleasing reconstruction using advanced implant technology in the next stage.

Recent advances in implant technology:

MPS (Polyurethane Microsurfaced Silicone) implants for long term Satisfaction.
Traditional silicone implants have 30 percent chance of the long term cosmetic complications of hardening and drooping. In breast reconstruction the complication rate is a lot higher than for standard mammary augmentation. The reasons are the bigger volume that is required and the altered conditions of the tissues that need to surround the implant. The polyurethane covered implants (polyurethane micro-surfaced implants or MPS) have a completely different relation with the living body. The tissues literally grow inside the implant shell, rather than stimulating a distinct fibrous capsule. This is a very important advance, particularly in breast reconstruction surgery. In recent years, MPS implants have been constantly providing encouraging results for primary breast reconstruction. This is both in terms of lower complication rates as well as a lesser likelihood of hardening or drooping. Furthermore, in particular when used in combination with the latissimus dorsi flap, they appear to withstand radiotherapy very well. MPS implants have a much longer life span than the traditional silicone implants or the expander-implants. They can be used both for immediate as well as for delayed reconstruction. Therefore, MPS implants can be considered to be a longterm solution, as they need not systematically to be replaced after any given time. This stands in stark contrast to traditional implants, that are generally considered to be up for replacement every 10-15 years. Therefore, MPS implants currently serve as our first choice, by a long stretch.

Matching the other side in a youthful way.

Who doesn't want a perky pair?

4. matching the other side for size and shape:

This is the real key to patient satisfaction. Breast cancer usually develops in aging breasts. It displays preponderance for the bigger women, with a rather sizable bosom. This is reflected in a variable amount of breast drooping depending on bra size and age. Even the women of smaller than average size tend to regret the disappearing of fullness in the upper pole and cleavage that comes with age.

There really is only one effective treatment to reverse this breast-aging trend forever: all the tissue below the breast crease (inframammary fold) needs to be removed together with the relocation of the nipple at a higher level. This, admittedly rather aggressive, breast reduction, can only be safely performed by a very skilled cosmetic surgeon. It tends to reduce the breast size to a B-cup. In a later stage (from 3 months) the implantation of a carefully chosen implant for size and shape will allow for a size and shape enhancement up to size DD. When using MPS implants, that fix themselves to the body by a certain in-growth, future drooping is halted entirely, in the big majority of instances, provided the remaining own tissue is limited to a thickness of about one inch maximally.

Although it may be possible to perform both the reconstruction, the breast reduction on the other side and the implantation in the same operation, the risks are still prohibitively high, even in our hands. Furthermore, accurate symmetry is next to impossible to achieve in one stage. This is why we use 2 separate stages with a standard 3 month interval.

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