[Secondary mammary reconstruction after radical treatment of cancer of the breast. Indications and results].

The author reports his experience of more than 500 secondary total breast reconstructions over a period of 8 years. Every patient should at least be referred for an opinion concerning the type of reconstruction which can be proposed and the delays are defined. The role of breast reconstruction and follow-up in oncological surveillance is explained. The complications most frequently encountered after mastectomy and lymph node dissection and after radiotherapy are described together with their consequences for reconstruction. This reconstruction is always proposed in two operative sessions consisting of recreation of a breast volume and restoration of symmetry, while the areola is only reconstituted on stable volumes, possibly as an outpatient procedure. A prosthesis is used to create volume in 75% of cases, even after irradiation, without a previous expansion phase by means of a thoraco-abdominal ascension flap. A myocutaneous flap is required in 25% of cases; the TRAM was used in 15% of cases, particularly in obese patients, in the absence of any abdominal contraindication; and a latissimus dorsi flap was used in 10% of cases. The advantages, indications, limitations, contraindications, complications and disadvantages of each technique are described. The history and the risk of cancer in the contralateral breast and the attitude adopted in such a case are discussed. Morphologically, a symmetrisation prosthesis was necessary in 5% of cases, but never in the case of TRAM; in hypertrophic and/or ptosed breasts, a symmetrisation plasty was necessary in 50% of cases of prosthesis, 40% of cases of latissimus dorsi flap and 30% of cases of TRAM and, in this latter case, always at a second operation. Reconstruction of the areolo-nipple complex was performed in only 70% of cases. The nipple is best reconstructed by longitudinal splitting of the opposite nipple or more rarely by a local, tattooed flap. In the case of a local flap, the nipple is always grafted from a thigh flap, despite its disadvantages; more than 90% of nipples can be tattooed.