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    Breast Reconstruction

Breast cancer is the most prevalent of all malignancies amongst women, both in Israel and in the western world at large. The frequency of breast cancer reaches 1 woman in 7. Many of these women are obliged to undergo a partial or total mastectomy in order to prevent the malignancy from spreading. Women who have been through this experience describe it as traumatic, and as a blow to their self-appreciation and femininity. Reconstruction of the breast is of ultimate importance in order to restore to the patient her figure, the wholeness of her body and her self-esteem. The reconstruction procedure will be undertaken by a plastic surgeon in full cooperation with the breast surgeon performing the mastectomy. The reconstruction can be performed immediately subsequent to the mastectomy, at the same surgical opportunity, or be delayed to a later juncture. Today, most reconstructions are carried out immediately after the mastectomy, which contributes to the patient's return to health and her feeling that her body is still whole. Reconstruction procedures can be divided into two: those described as autologous, that is, they make use of the patient's own tissues, including fat; and implant-based reconstructions, in which a silicone implant is inserted, as is done in cosmetic procedures for augmenting the breasts. The most widespread type of reconstruction procedure is implant-based. The principal grounds for this is that use of an implant does not require the usage of tissues taken from other parts of the body, and so the possible complications at the donor sites are avoided. Furthermore, many women do not yet know at the time of the mastectomy whether or not they will be required to undergo complementary therapies such as radiation, which is likely to cause tissue damage, including those that may have been reconstructed.

Dr. Yoav Gronovich maintains that the aim should be to reach the optimal results as early as possible, already at the mastectomy stage, in order to grant the woman a feeling that her body has remained whole despite the mastectomy. If the mastectomy does not include the areola and the nipple, the reconstruction process will be completed at this stage. If the breast tissue is extensive and requires reduction, this will be carried out at the mastectomy stage. Dr. Gronovich considers attention to the second breast as a central focus. If it is at all possible, any changes that are required in order to match the two breasts (lifting, augmenting or reduction) should be made at the same surgical opportunity.

In order to actualize this approach, Dr. Gronovich prefers to perform a direct-to-implant reconstruction by the insertion of a permanent implant at a pre-pectoral plane (superficially to the pectoralis muscle). The final decision regarding this method can be made only at the conclusion of the mastectomy and assessment of the current condition of the tissues. Nevertheless, in the absence of any conflicting factors, this will be the preferred method, in that it shortens the operating time, shortens and eases the period of convalescence and gives excellent aesthetic results even in cases where the patient is obliged to undergo radiotherapy.

A different category of reconstruction, which is generally delayed, in cases where for various reasons immediate post-mastectomy reconstruction is impossible or undesirable, is the method whereby autologous fat (taken from the patient's body) is introduced together with use of the BRAVA device. Presently, Dr. Gronovich is one of the few plastic surgeons in Israel who offers such a possibility.

In this method fat is harvested from various body sites (thighs and belly, for example) and injected into the chest area to create new "breast" tissue. In order to allow for injection of a quantity of fat that will be large enough to rebuild and reshape the breast, the site has to be prepared so that it will contain the filler. The BRAVA device creates a space which can be provided with new blood vessels, even after the patient has undergone radiotherapy. Such a favorable bed will allow reconstruction of the entire breast by the use of fat alone. The final aesthetic outcome will be a breast that shows almost no scars other than that which has resulted from the mastectomy, with appearance and texture very similar to those of the natural organ. There will be a period of preparation prior to the operation during which the patient will wear the BRAVA, which is a vacuum based device that is worn for about three weeks before the surgical procedure on the mastectomy site at which the fat will be injected. This mode of reconstruction presents many advantages. The surgery itself is brief and simple, with almost no side-effects, and the outcome is excellent. The procedure is suitable under all situations, even after radiotherapy and where the tissues have suffered extensive damage. An additional advantage of this approach is the possibility of reshaping the areas from which the fat is harvested (thighs, belly, etc). The central drawback is the necessity for applying the BRAVA device for several hours each day for three weeks prior to the operation, which will be accompanied by a certain degree of discomfort. An additional disadvantage is that several procedures are necessary in order to achieve the optimal results. The outstanding advantage is, that the device is suitable for all kinds of patients, even those who have had radiation therapy and would have been obliged to undergo complicated operations in order to achieve reconstruction, such as local or free flap transferred from the back or the abdomen to the chest. This is a convenient procedure that saves the patient from prolonged periods of hospitalization and convalescence. Although the patient will probably experience considerable discomfort during the hours when she is obliged to wear the BRAVA device, she will profit from a surgical procedure that will leave her with almost no scars, excellent results without any implant and a final appearance that is aesthetically superior to that which any available alternative can offer.

Dr. Gronovich is aware that each woman has her own sentiments about her breasts and that these feelings should be taken into account when planning the operation. Dr. Gronovich endeavors to plan the surgical procedure according to the patient's personal desires and feelings and follows each women through every stage of the process until full satisfaction is achieved.

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