Reconstructive surgery and cancer

Reconstruction, in which cases?

Breast cancer affects more than 55,000 people each year. One-third of patients will be treated by mastectomy (complete ablation of the breast). Reconstruction techniques form an integral part of the treatment for these cancers. Ablation and reconstruction may sometimes be carried out during the same operation (immediate mammary reconstruction) or deferred (secondary mammary reconstruction), depending on the other treatments that may be necessary.

The reconstruction may call for a prosthetic implant identical to those used in plastic surgery. More and more often, however, it is carried out using the patient’s own tissue. This is known as autologous reconstruction. The results are often more natural and satisfactory and require fewer subsequent re-interventions.

The surgeons use “flaps.” This may be a so-called pedicle flap like the grand dorsal muscle (back muscle), which is partially detached while preserving the blood vessels (artery and vein) that nourish it, then reversed onto the anterior surface of the thorax to reconstruct the breast’s volume and shape. A free flap, completely removed and then grafted, may also be used. The most frequently performed technique is called the DIEP, for Deep Inferior Epigastric Perforator flap. It consists of removing a quantity of fat and skin from the abdomen as well as the artery and vein that vascularise them, and reattaching the artery and vein to the blood vessels on the thorax, via micro-surgery. The tissues are then remodelled to obtain the shape and volume of a breast. The breast can also be reconstructed by removing and reinjecting fat taken from the patient (lipomodelling).

These reconstructive surgical techniques may also be used in the case of conservative treatment (when only the tumour is removed and the breast preserved) to prevent and treat aesthetic after-effects (deformation, loss of volume, mammary asymmetry and pain) as well as treatment of after-effects (radiotherapy, chemotherapy).

Cancers of the vulva, vagina and cervix may also require the use of reconstructive surgery techniques in order to fill in the operated-upon region or to reconstruct a vagina with flaps.

In the case of testicular cancer, the ablation of a testicle may lead to its replacement with an implant.

Tumours of the eyeball or eyelids also benefit from reconstructive surgery techniques, either for the reconstruction of a lower or upper lid or to fill in an eye socket when the eye has been removed. It is necessary to apply techniques that make it possible to remove the tumour, conserve the protective eye functions and preserve facial aesthetics. Lipomodelling may be useful in improving the aesthetic appearance of patients who wear an ocular prosthesis. Free or pedicle flaps may also be used

Head and neck cancers pose a complex problem due to the vital nature of the organs treated (oesophagus, trachea), their essential functions (speech, swallowing, chewing) and the major aesthetic after-effects of such surgery. Reconstruction techniques are absolutely essential here in order to provide satisfactory cancer surgery while ensuring that functions are preserved. For example, a free fibula flap (bone taken from the leg) enables a jaw to be reconstructed, a free cutaneous flap taken from the inside of the upper arm enables a palate or a trachea to be reconstructed, a free flap of dorsal muscle fills in the base of a skull, and a free flap of intestine (jejunum) helps to reconstruct an oesophagus.

Skin cancers, in particular melanomas, may also require the application of reconstructive surgery to fill the operated region. Local cutaneous flaps, pedicle flaps or skin grafts may be necessary here for this surgery to be performed successfully.

Care management at Institut Curie

The historic vocation of Institut Curie is to offer unique surgical treatment to patients with cancer. With the aim of positioning the patient and their cancer as the focus of the treatment, all of the surgical teams of Institut Curie, whatever their specialties, are trained and have mastered reconstructive surgery techniques in order to meet the patient’s needs as best possible. The most complex techniques, namely those calling for microsurgery, are performed regularly by our teams.

Institut Curie contributes to the dissemination of this expertise and knowledge within the surgical community through university diplomas, practical training, scientific publications and participation in expert committees. Several degree programmes have been set up:

• University degree in ocular oncology
• University degree in cancer and reconstructive surgery, Université Versailles-Saint-Quentin
• University degree in mammary disease

Institut Curie trains many interns (30 per year) and assistants (six per year) in reconstructive surgery techniques.

Our research

Several studies are underway at Institut Curie:

• A study on mammary reconstruction by implant.
• A study on patients who develop breast cancer on an aesthetic mammary implant.
• A study on complications of reconstruction by DIEP.
• A study on complications linked to lipomodelling in breast surgery.
• Medical device vigilance regarding implantable medical devices.

Expert committee

Our surgeons participate regularly in expert committees organised by the Institut national du cancer (INCA) and the Agence nationale de sécurité du médicament (ANSM), such as the PIP Implants Commission and the Commission Lymphome anaplasique à grandes cellules et implants mammaires.