Breast Reconstruction Hamburg, Germany

A reconstruction of the breasts may be necessary after accidents, burns, infections and benign breast diseases. However, the need for a breast reconstruction usually arises in the context of breast cancer. Statistically, one in nine women will have breast cancer at same stage in her life. The treatment of the breast cancer has priority before the diseased breast is reconstructed. Breast cancer therapy should always be an interdisciplinary effort. Gynecologists, oncologists, pathologists and radiologists are involved in the process of diagnosis and treatment before the reconstruction of the breast is performed by a Plastic Surgeon. Reconstruction of the breast is not always necessary, but it should always be done by a Plastic Surgeon if it is done. Only a Plastic Surgeon can offer you the entire repertoire of reconstructive techniques, including microsurgical options.

  

Dr. Thorsten Sattler is one of very view Plastic Surgeons in Germany holding an additional qualification in “Breast Surgery”. He is a member of the “German Society for Senology” and knows all common breast reconstruction techniques, including microsurgery. He has perfected his highly advanced surgical skills at major university breast centers in Germany, North America and Japan, and he received an award for his outstanding microsurgical skills in the UK.

Breast Reconstruction Overview

  1. Before Your Operation
  2. Operating Techniques
    a) Breast reconstruction with breast implants
    b) Breast reconstruction with tissue expanders, followed by breast implants
    c) Breast reconstruction with autologous fat transfer
    d) Breast reconstruction with “pedicled flaps”
    e) Breast reconstruction with “free flaps”
    f) Operations of the contralateral breast
    g) Reconstruction of the nipple and areola
  3. Breast Reconstruction Results with Dr. Sattler
  4. After Your Operation
  5. Frequently Asked Questions About Breast Reconstruction:
    a) Does it make sense to combine a breast reconstruction with other procedures?
    b) Can a breast reconstruction be performed several times?
    c) Is it possible to achieve perfect symmetry of my breasts?
    d) Is my treatment completed after my breasts are reconstructed?

 

1) Before Your Operation

Not every breast needs to be reconstructed and not every woman wants her breasts to be reconstructed. Sometimes breast reconstruction does not make sense, for example, if the disease has advanced too far and if the patient is terminally ill. However, in most cases breast reconstruction is possible and makes sense. The breasts are part of most women’s identity and are important for their self-esteem and sexuality. After mastectomies many women find it difficult to undress in front of other people, e.g. in changing rooms and showers in the gym. Every woman should have the opportunity to be treated by a qualified Plastic Surgeon if surgery is desired. Usually, in Germany the health insurance covers the cost for a breast reconstruction. However, you should have this in writing from your health insurance before you undergo surgery. This especially applies to women that need a breast reconstruction for other reasons than cancer.

Before the operation, you will have to undergo “staging” of the disease in order to determine the local spread of the cancer. It is also important to recognize any existing metastases or the involvement of lymph nodes as early as possible. All relevant findings should be discussed in a tumor board in order to find the best therapy for you. If chemotherapy or radiation therapy is necessary, it is important to coordinate the breast reconstruction with the other doctors in order to achieve the best aesthetic result possible.

You will have a consultation with Dr. Thorsten Sattler least twice before any breast reconstruction is planned. Each visit will last about 1 to 2 hours. He will examine you personally. Due to the fact that each person is unique, he will create a personal treatment plan for you based on the latest methods and knowledge in Plastic Surgery. He will take photos and will explain the operation to you with the help of drawings and photos. Limitations, possible risks and alternative treatment options will also be discussed.

The main goal of a breast reconstruction is to create somewhat symmetrical breasts. Thus, fashionable clothes can be worn again without the need of external prostheses and the quality of your life will increase.

In order to obtain the best aesthetic result possible, breast reconstruction may be combined with other procedures, for example a breast reduction or a breast lift of the contralateral breast. The nipple of the operated breast can also be reconstructed if the “original” nipple cannot be preserved due to the breast cancer.

A well-balanced healthy diet including enough protein is very important for your wound healing. Plastic surgeon Dr. Sattler is not only a board-certified Plastic Surgeon, but also holds a degree in Nutritional Medicine. He will happily give you advice with regard to supplements and healthy diets. If there are problems in your partnership, Dr. Sattler may be able to help you in this regard as well since he also holds a degree in Sexual Therapy.

2) Operating Techniques

Only safe and modern surgical methods are used by Dr. Sattler. A breast reconstruction is performed under general anesthesia, a hospital stay for several days is usually required.
Many different techniques to perform a breast reconstruction are known. Dr. Sattler will choose the best and safest method for you, depending on your anatomy, the extent of the disease, your overall health and your aims and desires. Every surgical procedure has its advantages and disadvantages. After a detailed consultation Dr. Sattler will decide together with you which technique is the best for you.

The surgical methods used are very complex and cannot be described in full detail in this short overview. Breast biopsies, tumor removal, a possible removal of lymph nodes or metastases are also not part of this short overview. Same accounts for the oncological, radiological, pathological and radiotherapeutic aspects of breast cancer. The aim is to give you a short overview of the different techniques for breast reconstruction without any claim for completeness. But every woman suffering from breast cancer should know that there are surgical options for virtually every woman who would like to have her breast(s) reconstructed.

a) Breast reconstruction with breast implants

This method seems to be the easiest, but it is used very rarely by Plastic Surgeons. First of all, the skin envelope has to be loose enough to carry the implant. In addition, skin and connective tissues must be of good quality, which is usually not the case after radiation therapy or previous operations on the breast. Usually good symmetry of both breasts is impossible to achieve if an implant is used on only one side. If a (smaller) implant is also used on the contralateral side, symmetry might turn out better. An additional autologous fat transfer can also optimize asymmetries and can improve the skin quality in addition. After a breast reconstruction with implants wound healing problems, infections and capsular fibrosis occur much more often than after a breast augmentation for aesthetic reasons. The benefit of a breast reconstruction with implants is that the procedure does not take much time and is usually associated with little blood loss, short scars, short hospital stay, not so much pain and a rapid recovery.

b) Breast reconstruction with tissue expanders, followed by breast implants

With the help of a tissue expander tight tissue can be stretched before the breast implant is inserted. A tissue expander is like a balloon. It is filled in intervals with saline through a valve under the skin until the skin coat is sufficiently stretched. The expander will be removed in a second operation and the definitive breast implant will be inserted. Additionally, the implant can be placed in a special matrix if the soft tissues are very thin. But this method in itself can cause problems, since an additional foreign object is introduced into tissue, that already lacks healthy blood supply. The risks and limitations of this procedure are similar to those described in a).

c) Breast reconstruction with autologous fat transfer

If the skin coat of the diseased breast is healthy and wide enough an autologous fat transfer can be performed. The maximum breast volume that can be achieved with autologous fat transfer is about one cup size, but it can be less. Therefore, this technique especially makes sense if the other breast is rather small. An autologous fat transfer can be repeated several times until the size of the contralateral breast is matched. In addition, the larger “healthy” breast can be reduced or lifted to optimize the overall symmetry. The advantage of an autologous fat transfer is that no foreign material is used and damaged skin (for example after radiation therapy) can recover better with the help of stem cells that are a component of the transferred fat. The disadvantage of an autologous fat transfer is that several operations may be necessary to create a rather large breast. Of course, enough fat must be present in order to harvest and transfer it. Unfortunately, this is not always the case after a chemotherapy. If enough fat is available, not only the breasts will get more symmetrical, but also the body silhouette improves, because excess fat on the abdomen, waist and tights will get eliminated. Another advantage of the autologous fat transfer is that the remaining scars are very small and usually only a short stay in hospital is necessary.

d) Breast reconstruction with “pedicled flaps”

Tissue can be shifted on a pedicle from other parts of the body to the breasts. In the past, parts of the abdominal muscles were sacrificed in the process of reconstructing a breast. Nowadays this method is considered obsolete among well-trained Plastic Surgeons. Therefore Dr. Sattler does not offer this old-fashioned technique. Unfortunately, this technique is still propagated in the media, although there are significant disadvantages for the patients. Frequently these flaps get necrotic because the pedicle gets twisted by 180 degrees. Also, the twisted part causes contour problems at the upper border of the abdomen. Additionally, this technique will weaken the stability of the trunk significantly. A much better alternative is to bring the large muscle from the back to the front. The muscle with some overlying soft tissues and skin is pulled through the arm pit to the front in order to create a new breast. The nipple can be reconstructed in a second operation. If the muscle is too small to achieve good symmetry, a breast implant can be inserted under the muscle in addition to match the size of the contralateral breast. This operation is very safe and good results can be achieved. The disadvantage is that a relatively large scar remains on the back.

e) Breast reconstruction with “free flaps”

Nowadays in the western world the reconstruction of the breast with “free” flaps is considered the gold standard. However, these microsurgical techniques require a specially equipped hospital with intensive care unit. They also require a longer stay in hospital of the patients, and a very well-trained team of anesthetists, nurses and micro surgeons is needed. In addition, the duration of the surgery is quite long. The treatment is expensive and therefore not available in poorer parts of the world. A special surgical microscope and specific microsurgical instruments are required. Therefore, in England this procedure is currently no longer offered to every patient. The Microsurgeon, who is almost always a Plastic Surgeon, has to be very well trained in microsurgery. He has to master a lot of microsurgical procedures in order to be able to successfully deal with problems such as small vessels or vessels that are too short. If a “free flap” is performed, a piece of tissue is removed from the body and transplanted to the chest. All blood vessels of this piece of tissue are disconnected in the course of this transfer. Later, these vessels are microsurgically connected to the recipient vessels near the sternum or the axilla. The free flap can be harvested from the lower abdomen without sacrificing the abdominal muscles. Thus, the stability of the trunk remains and a tummy tuck is a nice side effect after closing the wound. However, there will be a scar on the lower abdomen. If this is not acceptable for the patient a free flap can also be harvested from the buttocks or thighs. Dr. Sattler likes to use a specific free flap from the lateral thigh. This option is very useful for the reconstruction of a small breast. Many different free flaps are described in the literature. They all have in common that the degree of difficulty and the failure rate increases, the smaller and shorter the blood vessels of the harvested tissues are. The quality of the recipient vessels is also crucial. Damaged vessels, for example after radiation therapy and chemotherapy, can become a nightmare for the surgeon. Previous surgeries might also be a problem, because scarred tissue shows poor circulation and important blood vessels may have already been cut. If the disease has already advanced to the end stage and the patient is in poor health, microsurgical procedures are usually not the right choice. Same applies for smokers, since nicotine damages the vessels and the result of a free flap transfer becomes unpredictable. The advantage of microsurgical techniques is that only the body’s own tissue is used and the muscles are usually not sacrificed.

f) Operations of the contralateral breast

The human body is never perfectly symmetrical. Same is true for the female breast. Usually the asymmetry of the breasts becomes worse after breast cancer. Various reconstruction techniques are known. Unfortunately, all of them have in common that very large breasts cannot be reconstructed and that the shape of the reconstructed breast often deviates from the other breast. Therefore, it is often useful to adjust the “healthy” breast to the size and shape of the reconstructed breast, by a breast lift or a breast reduction. The breasts should look somewhat symmetrical at least while wearing underwear and tight clothes. If inspected nude there will always be at least a small difference in breast shape and volume because the maturation of scar tissue is never predictable. Differences in the breast volume can nicely be adjusted by an autologous fat transfer.

g) Reconstruction of the nipple and areola

After the breast is reconstructed, the nipple and areola can be reconstructed in a second procedure. In some cases, this may also be possible during the initial breast reconstruction. Reconstructing the nipple and areola is beneficial for the symmetry and overall appearance of the breasts. The nipple and areola can be reconstructed using local flaps. Sometimes it also makes sense to use the opposite nipple and areola as a donor, especially if the areola and nipple of the contralateral breast are large. Skin grafts are also a good alternative. Pigmented skin can easily be harvested from the groin or the labia. Especially the labia are good donor sites, because the scars are hardly visible after some time.
Because there is a large number of different surgical techniques, Dr. Thorsten Sattler will discuss with you in detail, which technique should be used to achieve your aims and desires. Usually two consultations of one to two hours are required for each patient. Dr. Sattler can perform all of the techniques described above at the highest level, including perforator flaps (DIEP, ALT etc.), the most difficult form of breast reconstruction techniques.

3) Breast Reconstruction Results with Dr. Sattler

The topic breast reconstruction cannot fully be covered by a short overview like this. The cases are too complex and too different from another. Therefore, patient images are intentionally not shown on the internet. In addition, by German law, we are not allowed to show you before/after pictures online. However, during your personal consultation with Dr. Thorsten Sattler this will be possible.

4) After Your Operation

Usually, a hospital stay for several nights is required after a breast reconstruction. After a free flap procedure, you will have to stay in ICU for at least 24 hours. Depending on the reconstructive technique chosen, the treatment after the operation may vary significantly and cannot be described as part of this short overview. However, Dr. Sattler will instruct you in detail as part of your personal consultation(s). In order to support the wound healing and to obtain the best result possible, you should follow a healthy and balanced diet and you should stay away from alcohol and nicotine.

If you suffer from breast cancer it is of utmost importance to never skip any of your follow-up appointments. If you notice any changes it is very important to report these abnormalities to your doctors immediately in order to diagnose a progression or recurrence of the disease as soon as possible!

5) Frequently Asked Questions About Breast Reconstruction:

a) Does it make sense to combine a breast reconstruction with other procedures?

If an autologous fat transfer is used to reconstruct a breast, the fat is harvested from regions of the body that have excess fat, such as the abdomen, waist and thighs. Therefore, as a side effect of the breast reconstruction, the overall body contour will improve and rather small breasts look bigger if the body is slim. If the contralateral “healthy” breast is large or droopy, lifting or reducing this breast can significantly improve symmetry. Usually, health insurances in Germany will cover the cost for a breast reconstruction. However, you should get this in writing from your health insurance before you undergo surgery.

b) Can a breast reconstruction be performed several times?

If a breast reconstruction did not deliver the result you wished for, there are usually alternative methods that can be used. If the breast reconstruction was successful, but the breast still appears too small, the breast can be enlarged by autologous fat transfer. In implant-based reconstructions it may be possible to exchange the existing implant for a larger one. However, this increases the risk for wound healing problems, infections, or capsular contracture. Therefore, it is usually not advisable to use large implants for breast reconstruction. Most often, a breast lift or a breast reduction of the contralateral breast is the better alternative.

c) Is it possible to achieve perfect symmetry of my breasts?

The human body is never symmetrical, neither are the breasts of a women. If a breast has been operated on in the context of breast cancer, this asymmetry may increase. Reconstructed breasts are usually smaller than the original breast and most often have a different shape. Especially after radiation therapy, the skin and connective tissues often show structural changes that cannot be reversed. Therefore, it may be useful to match the contralateral breast, for example with a breast lift or a breast reduction. This way the symmetry can be improved, but will never be perfect. If a bra is worn the breasts can look quite symmetrical even if tight clothes are worn. And other people will not notice that you had breast cancer in the past.

d) Is my treatment completed after my breasts are reconstructed?

No, it is very important that you do not skip your breast cancer follow-ups with your gynecologist, oncologist and radiologist, even if the breast reconstruction is completed by the Plastic Surgeon. You should report any changes to your doctors immediately, even if your next follow-up appointment is not due yet. It can be life-saving to diagnose any recurrence or progression of the disease as soon as possible.