University of Gothenburg
Bröstimplantat som användes vid rekonstruktiv bröstkirurgi. I bakgrunden ses plastikkirurgen Emma Hansson
Photo: Paul Björkman Sahlgrenska Universitetssjukhuset
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Reconstructive breast surgery

Research group
Active research
Project owner
Emma Hansson
Research partners
Professor Ulf Smith, Lundberg Laboratory for Diabetes Research Associate Professor Carolina Lunde, Department of Psychology Professor Monika Fagevik Olsen, Department of Health and Rehabilitation National Centre for Priority Setting in Health Care, Linköping University
Area
Health and medicine
Topic
Plastic surgery Surgery Cancer and Oncology

Short description

Plastic surgery may be needed for several different conditions, such as after breast cancer and when the breasts are very large. The purpose of breast reconstruction is to enhance patients’ quality of life. In this research project, we hope to be able to create more individualized breast reconstructions.

The goals are:
• The highest possible quality of information and facts to guide the patient’s decision before the operation.
• Surgical techniques with as low a risk of complications, and as good a cosmetic end result, as possible.
• Cost-effective treatment: conceivably, it may not be certain that the operation costing least to perform is the cheapest one in the long run, since it may necessitate more corrections and new operations.
• Scientifically based guidelines for breast reconstruction.
• Improved care of the patient in the event

Background

Research in the group specializing in reconstructive breast surgery is conducted in two main areas: reconstruction, when patients have breast cancer and/or are at high risk for it, and reduction for large breasts (breast hypertrophy).

An understanding of both areas is now obtained from prospective randomized controlled studies (RCTs) and cohort studies on methodological development, indications, complications, quality of life, esthetic and functional results, and cost-effectiveness.

Breast reconstruction — cancer

Breast reconstruction for patients who have breast cancer and/or are at high risk for it

Breast reconstruction has a self-evident place in modern breast-cancer care. Roughly 1/3 of all women who undergo mastectomy (breast removal) experience long-term psychosocial problems, such as impaired self-esteem, insomnia, anxiety, depression and sexual problems.

The purpose of breast reconstruction is to enhance women’s quality of life and improve their body perceptions. However, reconstruction is no panacea for achieving these aims, and several studies show that some women regret their choice to undergo the procedure. Accordingly, there is scope for improvement in our selection and care of patients, and in our methods.

There are various techniques for breast reconstruction, but extremely little high-quality evidence for which methods give the best results and genuinely enhance the patient's quality of life. Ahead of breast reconstruction, patients and surgeons face two main choices. The first is whether it should be performed at the same time as the breast is removed (“immediate reconstruction”) or later, in a separate operation (“delayed reconstruction”). The second is which technique should be used: for example, how an implant is to be covered.

Most outcome studies have serious methodological shortcomings, and the majority are retrospective. One precondition for the patient’s ability to make a well-informed choice about breast reconstruction is for the care services to offer high-quality factual information on complication risks, long-term repercussions and anticipated esthetic and functional outcomes.

At Sahlgrenska University Hospital, since the 1970s, we have specialized in breast reconstruction and played a part in developing modern techniques, such as the deep inferior epigastric artery perforator (DIEP) and lateral intercostal artery perforator (LICAP).

Immediate reconstruction:
– in which the breast is recreated in the course of the same operation as the mastectomy.

Some current projects:

Some questions we are working on:

Delayed reconstruction:
– in which the breast is recreated in a separate operation after the cancer treatment is completed.

Some current projects:

Some questions we are working on:

  • What are the long-term effects of breast reconstruction using a flap from the latissimus dorsi? (a broad, flat muscle covering the middle and lower back)
  • What is the quality of life is enjoyed by patients who undergo delayed reconstruction with various methods?
  • How cost-effective are the various reconstruction methods in the long run?
  • Comparison of using a latissimus dorsi flap and a thoracodorsal artery perforator (TDAP) flap for reconstruction, with respect to donor site morbidity (on the donor site on the patient’s back) and/or complications and long-term results.

Psychological aspects of breast reconstruction:
– effects of expectations, body perceptions and complications on outcome

Some questions we are working on:

  • How do the patient's expectations and body perception affect the course of care and satisfaction with breast reconstruction?
  • What effect does implant loss have on long-term quality of life and patient satisfaction?

Read more about psychological aspects on Region Västra Götaland’s research website.

Breast reduction for hypertrophy

Breast hypertrophy is a common condition and some 1,500 breast reductions are performed in Sweden.

However, it is unclear how large, to be defined as hypertrophic, the breasts need to be.

Previous studies have concluded that a medium-sized breast is approximately 300–400 ml in volume. According to Sweden’s national medical guidelines, breast reduction is indicated at a volume exceeding 800 ml — that is, twice as large as a medium-sized breast. However, there is little evidence regarding the volume at which women may experience breast-related symptoms; whether this varies according to their physique; and at what volume they may benefit from breast reduction.

Moreover, breast reduction is an operation commonly performed for cosmetic purposes within privately funded plastic surgery. Cosmetic procedures are normally rationed in publicly funded care, but at present the demarcation is extremely unclear with regard to conditions like breast hypertrophy.

Historically, the Department's research on breast hypertrophy has mainly involved development of techniques and use of antibiotics associated with surgery. In recent years, however, there has been a progressive shift to quality of life and the question of which patients benefit most from breast reduction.

Some current projects:

Some questions we are working on:

  • What is the evidence to support current indications for publicly funded breast reduction?
  • Do current indications result in cost-effective treatment?
  • Are there differences in physical symptoms associated with a particular breast volume, depending on whether the breasts are natural or augmented (enlarged)?
  • What are the connections between the body's other dimensions, such as height, shoulder width and thoracic width, and the symptoms caused by a particular breast volume?
  • What are the molecular biological characteristics of the adipose tissue around the mammary glands in women with differing physique?

The research group’s HTA projects

Read more about the Health Technology Assessment (HTA) Center at Sahlgrenska University Hospital.

  • Indications for breast reduction, 2021
  • Effects of radiation on complications and outcomes of direct breast reconstruction in mastectomy, 2019
  • Acellular dermal matrix for breast reconstruction after mastectomy, 2017
  • Reconstruction with fat transplantation after breast cancer: oncological outcome, 2015.

Ongoing doctoral projects

Theses

Project participants

Whether to recreate a breast: a complex issue for a new research team

Sahlgrenskaliv (“Sahlgrenska Life”, a magazine from Sahlgrenska University Hospital) has published an article about Emma Hansson and her research group. Read the full article in Swedish here.

Can a breast be recreated? Technically, yes, it can be done with good results. But the issue is more complex than that. Which patients benefit most from breast reconstruction and, in that case, how and when it should take place are questions that have yet to be thoroughly explored. And Professor Emma Hansson, chief physician at Sahlgrenska University Hospital, and her research team in Plastic Surgery want to change that.
Read more at the research groups Swedish website

Four illustrations on breast reconstructions

Bröstrekonstruktion (pdf)
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