Developments in breast reconstructive surgery

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Published: 31 Jan 2023
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Dr Maria João Cardoso - Champalimaud Cancer Centre, Lisbon, Portugal

Dr Maria João Cardoso speaks to ecancer at BGICC 2023 about the advancements in breast reconstructive surgery.

She outlines that previously breast implants were positioned behind the pectoral muscle, but in more recent years there has been a shift to position the implant in front of the pectoral muscle directly behind the skin.

Dr João Cardoso highlights the need for future trials to gather more long term effect data on this surgical technique.

Breast reconstruction has changed a lot in the last years and it’s changed because now we can propose in almost all cases when we need to have a mastectomy and, fortunately, mastectomies have been reduced in number. So now in most developed countries we have around 10-20% of mastectomies maximum; of course, this is not the reality all over the world. But we can offer immediate reconstruction to all patients, to almost all patients. But if not, we need to discuss this anyway. 

Regarding the type of reconstruction either we use the tissues of the patient or we use implants. For a long time, implants were put behind the pectoral muscle. The pectoral muscle is the muscle that is used for several efforts in our shoulder, for instance, a very athletic patient that wants to go to the gym and do resistance training etc. will be not the ideal candidate to have an implant behind the muscle. It gives some pain to the patients and it pushes the implant up in the majority of cases so we need to symmetrise the other breast. So 5-10 years ago, but more five, the implant being placed in front of the muscle gained popularity because at that time what we call the coverages of the implants were admitted and approved by the FDA and by EMA and these sheets of natural cells of synthetic meshes allows us to put a cover around the implant and directly behind the skin and not behind the pectoral muscle, protecting the implant and not changing the pectoral muscle. So a more natural approach. Many people thought that this was going to be very complicated because the implant is going to be rejected, more infections, more complications, but, in fact, it doesn’t seem so.

The problem is, like it happens frequently in surgery, things go ahead of trials. So once the implants are on the market, once the coverages are on the market, surgeons start doing things without the publication of trials, not knowing exactly what is the long-term effect of doing so. So we know that this changed the spectrum of reconstruction; the majority of surgeons now prefer to put the implant in front of the pectoral muscle. It’s not for all patients – smoking patients, very obese patients, patients that have any type of complications and sometimes patients that are considered to have post-mastectomy radiotherapy need to be aware that the rate of complications is higher in these cases but it’s possible to do it. What is the problem? Meshes and coverages are costly products so we need to add to the surgery this cost and in many countries this is not covered by insurance companies, they are not available in the public hospitals so patients need to pay out of pocket money to have this type of procedure.

So we are waiting for the results of some trials. A big trial that is called I-PREP in the UK and one of the new trials of the U-Breast Trialists group that is called I-Prepare is going to start to allow us to understand how this is going on in the real world.