Nowadays, breast cancer is still the most common tumour of women in our society. For women, this is not only a terrible illness but also often involves a mastectomy or removal of a breast. Women then have to face both the cancer and the loss of a breast or, in other words, the loss of part of their femininity. Breast reconstruction is often an essential step towards regaining normality as it not only reconstructs a lost organ but also helps to regain femininity and helps the woman to forget her terrible fight against her illness.
DIEP is the most up-to-date technique in breast reconstruction. DIEP is the most advanced microsurgical breast reconstruction technique, using only skin and fat from the abdomen and without injuring any muscle or using any material that is foreign to the body (breast implants). The plastic surgeon´s aim is to create a new breast that is as close as possible to a natural one. This procedure does not interfere in the treatment or in the subsequent monitoring of breast cancer, evidenced by the fact that more and more oncologists recommend it.
This is the most popular method in the most prestigious hospital centres the world over. Most patients who have undergone mastectomies can opt for this kind of reconstruction, which is a great step forward in the fight against the repercussions of treating breast cancer. Clínica Planas has the most experienced medical team in this type of surgery in Spain.
We also have a clinic in Madrid. More information can be found under “DIEP Breast Reconstruction Surgery"
Immediate reconstruction or deferred reconstruction?
Breast reconstruction can be performed immediately by restoring its natural shape and volume in the same operative act when the mastectomy is performed.
When the mastectomy has already been performed or in certain situations where complementary treatment with radiotherapy is needed, we will perform a delayed breast reconstruction. Your oncologist will decide with us which surgery is best for you.
If you have already had a mastectomy or a tumorectomy, it is never too late to perform a reconstruction and recover the natural contour before it. If on the other hand you are not happy with the reconstruction performed with other techniques (breast implants or expanders…), we will replace these with your own tissue thus recovering a natural breast.
The choice of the appropriate technique for breast reconstruction will depend on the characteristics of the illness and each patient. When more than one technique can be applied, the patient and surgeon will decide together after studying the drawbacks, advantages and risks involved in each technique.
The DIEP consists of taking advantage of excess skin and fat in the abdominal area, which, given its physical characteristics in terms of colour, thickness and texture is ideal for making a new breast (Fig.2 Diepflap. com). The tissue removed from the abdomen is taken to the chest, where it is joined to an artery and a vein via microsurgery, so that it has its own blood supply. This means a new breast can be remodelled and that it will be very similar to its mate in terms of colour, feel and behaviour. (Fig. 1 Diep Flap. com). In many cases, this technique also provides an aesthetic enhancement to the abdomen, because excess fat is extracted as if it were an aesthetic abdominal lipectomy.
Thanks to a microsurgical dissection approach, a DIEP preserves the nerves and the abdominal rectus muscle in their entirety. Unlike other techniques such as the TRAM, which weakened the abdominal wall or led to functional muscle loss and required a synthetic mesh reinforcement, DIEP has no long-term physical effects. Following the operation, all abdominal movement is preserved and the patient can sit up in bed bed without needing to use her arms and continue practicing sports such as swimming and skiing without difficulty.
Following the operation, the breasts will develop harmoniously, in other words, when the patient loses weight, the breast will become lighter; if she puts on weight, they will increase in volume. When the patient ages and breasts sag, they will do so symmetrically. It is, therefore, a type of long-lasting reconstruction which comprehensively supports body shaping.
Following the operation, you must stay in the clinic for 4-5 days. The first 48 hours are essential for properly monitoring and overseeing the reconstruction. Clínica Planas has nursing personnel specialised in monitoring microsurgery patients, ensuring that there is an adequate response to any unforeseen or possible complications.
A combination of general anaesthesia and epidural is used for the DIEP breast reconstruction technique. Despite being a long surgical intervention, intra-operative pain levels are extremely moderate, since it is an unaggressive intervention, therefore it only requires mild anaesthesia.
Breast reconstruction is often an essential step towards regaining normality as it not only reconstructs a lost organ but also helps to regain femininity and helps the woman to forget her terrible fight against her illness.
After studying your case carefully and assessing your physical and anatomical features and state of health, the specialist will place at your disposal all the necessary information about the DIEP breast reconstruction technique and will advise you on the steps you should be taking from time to time.
During the two or three weeks prior to surgery, it is advisable to follow a healthy and balanced diet rich in proteins, vegetables and fruits, and take vitamin and iron supplements. If you usually take medication, it is very important that you inform the specialist about this. You must stop taking medicines for colds, aspirin, ibuprofen, or their derivatives, as well as any herbal infusions or preparations that may have anti-coagulant effects, at least three weeks prior to the intervention. Drugs containing paracetamol are not contraindicated.
It is important that you rest properly during the preoperative period. If required, your surgeon may prescribe medication that will help you sleep. During the two days prior to the operation, it is recommended that you shower twice a day using antiseptic soap from the chemists (no prescription required). Additionally, you must take a shower just before the operation.
If you are a smoker undergoing breast reconstruction, you should quit six weeks beforehand and not remain in the company of smokers for long periods. Cigarette smoke clogs blood vessels and decreases the blood supply to the tissue used for the reconstruction, which could put the entire operation at risk. Furthermore, tobacco also harms the wound healing process. Nicotine substitutes (gum, patches, etc.) have the same negative effects as tobacco.
Following the hospitalisation period, we recommend a week of rest at home under caution of not engaging in any strenuous physical exercise. Once this period has passed, it is beneficial to take a walk and progressively start resuming everyday activities without performing any domestic tasks until at least three weeks have elapsed. It is very important to follow a nutritious diet in order to speed up healing.
Bathing is not advisable. You may take a shower from the third day following the operation keeping those areas operated on well-hydrated and dry.
At first the reconstructed breast and the abdominal wounds must be protected with dressings. Hot substances must not come into contact with the operated areas, given that since their sensitivity would have been temporarily diminished, this could cause burns.
Due to inflammation, it is possible that the new breast could swell and some abdominal tension may be noticed. Both reactions are normal and will decrease with the passing of time until they disappear. Your mood might also be altered. It is a very frequent side effect in surgical interventions of this nature. This will only be temporary and you will recover completely in a few days.
You must let at least a month pass until you can exercise again. During that time, you must use a seamless bra without wires and open at the rear - a sports bra - together with an abdominal girdle.
Once the scars have healed (three weeks after surgery) it is recommended that silicone sheets be used for 3 - 4 months at least to obtain the best possible outcome. It should be noted that during the first year following the operation in the scarred areas (the crease below the breasts, the armpits and abdomen) you may notice some discomfort or minor pain related to the changes in the weather.
You must not smoke until six weeks following the operation and not drink alcohol until you stop taking the medication prescribed by your surgeon. Avoid direct exposure to the sun in the area operated upon during the first 6-12 months.
Following discharge, and for a specified period of time, you should have weekly appointments with the specialist. Should you notice any changes to the reconstructed breast (changes in colour, temperature, pain, stress...) or the abdomen, you must inform your physician immediately. Following the postoperative period, you should continue having regular appointments with the specialist in charge of your case (gynaecologist/oncologist/surgeon). The new breast can also be examined using mammograms.
WHO CAN HAVE A BREAST RECONSTRUCTION USING DIEP? IN WHICH CASES CAN THIS OPERATION NOT BE CARRIED OUT?
Most women who have had a mastectomy could also have a DIEP. There are only two absolute exceptions. The first, being a heavy smoker. The patient wanting to undergo an operation using this technique must quit smoking for a minimum period of six weeks prior to the intervention. And the second is that they have endured some kind of surgery to the abdomen that has impaired the vascularity of the abdominal wall. This second case is very rare, because most abdominal operations (gallbladder, hysterectomy, appendicitis...) do not damage the abdominal blood vessels.
AT WHAT POINT IN TIME IS IT APPROPRIATE TO PERFORM THE OPERATION?
This type of breast reconstruction can be carried out during the same surgery as the mastectomy (immediate reconstruction) or after it (delayed breast reconstruction). The choice of one time or another will depend on the type of tumour and the advice of the specialist or oncologist.
WHEN CAN THE AREOLA AND THE NIPPLE BE RECONSTRUCTED?
The reconstruction of the areola and the nipple (the nipple areola complex) as well as any other changes or improvements in the size or shape of the reconstructed breast will take place when the transplanted tissue has stabilised in its new location. The procedure is carried out on an outpatient basis.
WHAT ARE THE SPECIFIC RISKS IN TISSUE EXPANSION PLUS IMPLANT TECHNIQUES, RECONSTRUCTION USING THE LATISSIMUS DORSI MUSCLE AND DIEP RECONSTRUCTION?
Risks common to the 3 techniques are: alterations to skin sensitivity, abnormal and unsightly scarring which may require surgical correction, breast asymmetry and skin necrosis. In procedures involving prosthetics obtaining lasting symmetry is more complex since weight changes over the passage of time will cause variations between the un-reconstructed breast and the one with the implant. Regarding the tissue expansion procedure it is possible that the implant (the expander or the subsequent silicone prosthesis) could leak due to the lack of a proper tissue layer or an infection, therefore requiring a further operation to completely remove it. Additionally, there may be intolerance to the material used. Recovering from reconstruction using the Latissimus dorsi may be slow and sacrificing the muscle may cause difficulty when undertaking physical exercise requiring significant active physical mobility of the corresponding arm. Furthermore, there may be total or partial flap necrosis. The most frequent complication is the formation and accumulation of sterile (serous) liquid in the donor area (the back), that can become infected and/or cause damage to the overlying skin, leading to the requirement for draining it using a puncture. Risks specific to DIEP are alterations to skin sensitivity, abnormal scarring, abdominal cutaneous necrosis, pneumothorax and breast asymmetries. Furthermore, all three techniques will require reconstructive surgery of the areola and nipple. The specific risks of this surgical intervention are anomalous scarring alterations, necrosis of the nipple and alterations to the pigmentation of the aereola.
WHAT PERCENTAGE OF WOMEN WITH BREAST CANCER DECIDE TO HAVE A BREAST RECONSTRUCTION FOLLOWING A MASTECTOMY?
Studies carried out a few years ago showed the figure to be around 15%, but there is currently a considerable increase in patients requesting reconstruction and, in most cases, they are encouraged to do so by their oncologists.
WHAT IS THE DIFFERENCE BETWEEN A DIEP AND A TRAM?
A DIEP has all the advantages of a TRAM but without injuring the abdominal wall, thus avoiding future herniation problems as well as pain and disability due to abdominal weakness. Furthermore, postoperative recovery is faster with fewer hospital stay days.
WHAT OTHER MEDICAL TEAMS PERFORM THIS TYPE OF SURGERY IN SPAIN?
The DIEP technique is gradually extending to most centres delivering quality plastic surgery, though implementation will be slow due to the fact that these techniques require a long and complex learning curve. Our Centre pioneered the introduction of this technique in Spain and has the broadest experience applying it in our field.
HOW DO YOU MANAGE TO GET BOTH THE ABDOMINAL TISSUE AND ITS BLOOD VESSELS IF YOU ARE NOT USING THE MUSCLES FROM THAT AREA?
Vascular branches arising from the deep blood vessels span the abdominal muscles from the depths to the surface ultimately reaching the abdomen’s adipose tissue and skin. The DIEP technique consists of following these PENETRATING vessels from the surface to the depths and through the muscle using microsurgical techniques to respect them and their innervation. In this way we can reach the deep blood vessels without injuring the abdominal wall. The deep blood vessels, in this case the lower deep epigastric vessels, will be dissected along with the perforating vessels, the skin and the adipose tissue, and will be connected to vessels of equal diameter in the chest. These deep vessels are completely dispensable since the remaining deep and superficial vascularisation of the body will perfectly make up for their absence.
HOW MUCH ABDOMEN TISSUE IS USED TO RECONSTRUCT THE BREAST WITH A DIEP?
Only skin and abdominal fat are transferred, the outcome being an abdomen level the same as one following a corrective aesthetic abdominoplasty. No kind of muscle structure is transferred.
IS LIPOSUCTION ROUTINELY USED IN BREAST RECONSTRUCTION?
No. It can only be used as a technique for improving the new breast’s shape later on. Although the outcome in the first instance is usually so positive that the need to do so rarely arises.
WHAT ARE THE COUNTER-INDICATIONS FOR A DIEP?
It is not possible to carry out a DIEP on women who, due to prior surgery in the abdominal area, have suffered vascularisation damage in that area. This is uncommon since the most common abdominal surgeries (appendectomy, removal of the gallbladder, hysterectomy and caesarean section) do not usually compromise the vascular system. There is another circumstance that will delay the operation without constituting in itself a counter-indication: the need to quit smoking for at least 4 to 6 weeks prior to the intervention.
CAN A DUAL BREAST RECONSTRUCTION BE CARRIED OUT DURING THE SAME SURGICAL PERIOD?
In the case of a DIEP the answer is usually “yes”, wherever there is sufficient tissue available from the abdomen.
WHY IS DIEP A BETTER PROCEDURE THAN RECONSTRUCTION USING IMPLANTS?
Implants are always subject to the phenomenon of encapsulation or capsular contracture, which, depending on the degree, would require their withdrawal due to the change of shape and/or discomfort. In addition a breast reconstructed using implants does not evolve over the patient’s life, as a breast reconstructed using living tissue such as in the case of DIEP would. A breast reconstructed with autologous tissue, as in a DIEP, increases and decreases in size the same as a normal breast does when there are normal body size fluctuations during the lifetime of any person. A recent study shows that 30% of implants used in BREAST RECONSTRUCTION have had to be removed in the first four years.
IS DIEP USED IN ANY OTHER RECONSTRUCTIVE PROCEDURES NOT INVOLVING THE BREAST?
Yes. It is also used in reconstructive surgery for numerous pathologies. For example, in Poland's syndrome, head and neck surgery, complex reconstruction after tumour resection, following major trauma, etc.
HOW LONG HAVE YOU BEEN CARRYING OUT THIS KIND OF SURGERY?
We started this kind of surgery in Spain in 1999, although in 1997, we were already undergoing training in these techniques.
WHAT EXACTLY ARE THE STEPS INVOLVED IN THIS TYPE OF BREAST RECONSTRUCTION?
It consists of three steps:
- First, transferring the abdominal tissue to the chest creating a new breast.
- Second, reconstructing the nipple using local anaesthesia and sufficient time having passed to stabilise the reconstruction. This is also used to check the flap and the abdominal area and to carry out any improvements if necessary.
- Third, tattooing the areola.
DO YOU RECOMMEND FIBROCYSTIC MASTOPATHY MASTECTOMIES?
In our opinion a mastectomy should be the last therapeutic resort. We therefore consider it should be used in cancer cases or where there is a high risk of the same, not for isolated fibrocystic breast disease.
IS IT USUALLY NECESSARY TO OPERATE ON THE OTHER BREAST?
When we take on a case we will always be looking for the best overall outcome. Due to this philosophy, we often recommend breast reduction or mastopexy (to give the breast a younger look) or even augmenting the other breast. In any case, this procedure will be performed at the same time as the surgical reconstruction.
DO YOU PERFORM THIS SURGERY AT THE SAME TIME AS A LUMPECTOMY OR A MASTECTOMY?
We prefer to carry out the reconstruction at the same time as the mastectomy. In any event, it can also be carried out following the mastectomy with excellent outcomes.
IS THE MASTECTOMY CARRIED OUT BY YOUR TEAM OR IS IT CARRIED OUT BY ANOTHER SURGEON?
Mastectomy may be carried out by a general surgeon (breast surgeon), gynaecologist or a plastic surgeon, but always following appropriate oncology criteria.
IS IT POSSIBLE TO TRANSFER TISSUE FROM ONE PERSON TO ANOTHER TO RECONSTRUCT A NEW BREAST?
No. This would only work if the other person were the patient’s twin and a DNA test had been carried out beforehand. In the U.S.A., Dr R. Allen, who pioneered this kind of reconstruction, has carried out tissue transfer surgeries for breast reconstruction between twins.
ARE THERE ANY OTHER PHYSICIANS CARRYING OUT THIS TYPE OF SURGERY ABROAD?
In most of the world's surgical centres of excellence, this type of operation is the first-choice technique for breast reconstruction. It is carried out in some of the most prestigious hospitals in Europe such as the University Hospital of Ghent (Belgium), Canniesburn of Glasgow (UK) or the U.S. (Robert Allen, Geoffrey Hallock, Charles Dupin).
HOW DO I KNOW IF I AM A CANDIDATE FOR DIEP RECONSTRUCTION?
Virtually any woman is a candidate for this type of reconstruction or a reconstruction using skin/adipose tissue from the gluteal area (SGAP).
CAN THIS PROCEDURE BE CARRIED OUT ON SOMEONE WHO HAS HAD A PREVIOUS RECONSTRUCTION USING A PROSTHESIS?
Yes. Anyone with a previous reconstruction using a silicone implant can benefit from DIEP. The implant is removed, and abdominal tissue transferred using microsurgery techniques in the same way as would be done for a patient without a prior reconstruction. The entire process takes place during the same operation.
IN WHAT WAY DOES YOUR AGE INFLUENCE THE ABILITY TO UNDERGO THIS TYPE OF RECONSTRUCTION?
Any woman at any age is a candidate for this type of surgery, it simply depends on your medical history.
CAN THIS PROCEDURE BE PERFORMED FOLLOWING CHEMOTHERAPY AND/OR RADIOTHERAPY?
Yes. In fact irradiated tissues frequently need to be removed due to microstructural alteration and replaced by abundant healthy tissue such as that supplied by a DIEP.
HOW LONG AFTER HAVING YOUR LAST RADIOTHERAPY TREATMENT DO YOU HAVE TO WAIT FOR A DIEP TO BE CARRIED OUT?
Approximately six months. It is also possible to perform the reconstruction prior to radiotherapy.
IF YOU HAVE A VERTICAL SCAR ON YOUR ABDOMEN FOLLOWING ANY SURGICAL INTERVENTION CAN YOU STILL BE A CANDIDATE FOR A DIEP?
Yes. Depending on the type of abdominal surgery, it may still be possible for you to have a DIEP.
HOW MUCH TIME SHOULD PASS FOLLOWING A MASTECTOMY BEFORE A DIEP CAN BE PERFORMED?
A reconstruction can be carried out from 6 months onwards following the termination of the adjunctive treatment (chemotherapy or radiation therapy).
PHYSICAL ACTIVITY IS VERY IMPORTANT TO MY DAILY LIFE, HOW LONG DO I NEED TO REST FOLLOWING SURGERY?
We have carried out this type of surgery on women who have high levels of physical activity and in some cases, they have been able to take up once again their normal lives three weeks after discharge.
WHAT IF I HAVE ALREADY HAD A TRAM AND I HAD COMPLICATIONS, CAN I STILL HAVE A RECONSTRUCTION USING PERFORATING SURGERY?
Yes, a DIEP will no longer be possible since the abdomen has been altered, but a SGAP of the gluteal region would be our second choice.
HOW LONG WILL I NEED TO RECOVER FOLLOWING SURGERY?
The stay in the clinic is 3-4 days and it would be convenient for you to remain another 4-5 days in Barcelona. The time required to resume a virtually normal life varies, but it is usually between 3-4 weeks.
IS IT A PAINFUL INTERVENTION?
Most patients stop taking pain medication two weeks post-surgery. Any discomfort there is basically arises from the inconvenience of being unable to sleep face down during the first weeks as well as initial abdominal tightness.
WHAT ARE THE EXACT STEPS IMMEDIATELY FOLLOWING SURGERY?
After the surgery patients go directly to the room where a specialised nursing team will thoroughly monitor their recovery.
WHEN WILL I BE ABLE TO DEPILATE THE ARMPIT OF THE OPERATED SIDE?
From the first month onwards.
HOW MUCH TIME IS REQUIRED FOR THE SCARS TO FADE AND THE NEW BREAST TO ACQUIRE A NATURAL APPEARANCE?
Six weeks are required to pass for an overall aesthetic appearance. As the weeks go on, there will be continuous but not necessarily very apparent improvement.
Although the final result depends on each skin, there are silicone dressings which applied to the scars improve the final appearance of the same through what is known as pressotherapy. Similarly there are many cosmetics, oils and creams that can be used. In order for the scars final colour to be lighter, blending with the surrounding skin, laser treatment can be applied.
Compression, cosmetics and lasers, used according to the progress made in each individual case, provide a very good aesthetic outcome in the vast majority of cases.
In one year the scars will be definitely stabilised.
WHAT COMPLICATIONS ARE THERE WITH THIS TYPE OF SURGERY?
The possibility of having to check the flap in the operating theatre 24 - 48 hours following the reconstruction (5%), loss of the flap (1%), infection, necrosis, bleeding and hypertrophic or keloid scarring.
WHAT ARE THE LONG-TERM EFFECTS ON THE ABDOMEN?
Minimal disturbance of the abdominal muscles.
WHAT CHANCE IS THERE OF CANCER RETURNING IN THE RECONSTRUCTED BREAST?
It depends on the type of tumour, its size and the number of nodes affected. The reconstruction does not interfere with the type and duration of the treatment and it has not been shown that it can delay the detection of a recurrence.
CAN MAMMOGRAMS BE CARRIED OUT ON MY RECONSTRUCTED BREAST?
It is not necessary since there is no breast tissue. Should there be any doubt that there is some remaining breast tissue, it is always possible to carry them out.
WHAT ARE THE CHANCES OF AN ABDOMINAL HERNIA FOLLOWING SURGERY?
The incidence of herniation following a DIEP is 1% and following a TRAM, 5-20%.
WHAT EFFECT DOES A DIEP HAVE ON A HYPOTHETICAL PREGNANCY?
None. No aspect of the pregnancy will be affected following this surgery. The physiology of the non-operated breast will remain the same.
The only treatment during the reconstruction process which could alter a pregnancy is the antihormonal medication prescribed by your oncologist. You should consult them on this issue.
WILL I BE ABLE TO PERFORM STRENUOUS PHYSICAL EXERCISE FOLLOWING A DIEP?
There will be no changes to muscle function. It is recommended that you only undertake significant physical activity one month following the operation.
You can also have massages just three weeks following the operation.
WHEN WILL I BE ABLE TO SUNBATHE AND/OR RECEIVED TANNING TREATMENT ON THE OPERATED AREA?
After two months but using extremely high sun protection. If you don’t want to use sun protection, you must wait one year.
WHEN WILL I BE ABLE TO START WEARING A BRA FOLLOWING A DIEP?
On the second day following the operation. You must use a sports bra immediately and for several weeks afterwards. You must sleep wearing the bra during the first 2 or 3 weeks. Following that, you will be able to wear other types of bras, but for a limited period, without underwiring or seams. Eventually, you will be able to wear your favourite lingerie again.
WHEN CAN I SLEEP FACE DOWN?
After one month, when the area has healed. In any event, you will find that your body itself will set the pace of any movement during your night’s sleep.
WILL MY NEW BREAST BE SENSITIVE?
Eventually, sensitive nerve endings will grow at the level of the reconstructed breast. To enhance the sensitivity of the reconstructed breast even further, when it is technically possible, the fourth intercostal nerve (the main nerve involved in nipple sensitivity) will be connected to a sensitive nerve of the abdominal flap.
WILL THE RECONSTRUCTED BREAST CHANGE IF I GAIN OR LOSE WEIGHT?
The perforating flaps will follow the variations in volume of the rest of the body, and, more importantly, will take their lead symmetrically, in terms of size, from the non-reconstructive breast.
WILL THE SCARS ALLOW ME TO WEAR A BIKINI?
HOW MANY DAYS IS IT PRUDENT TO WAIT BEFORE TRAVELLING?
HOW MANY DAYS IS IT PRUDENT TO WAIT BEFORE DRIVING OR LIFTING WEIGHTS?
Between 2-3 weeks.
FOR THE FIRST FEW DAYS CAN I TAKE A BATH, OR DO I HAVE TO USE THE SHOWER?
We recommend a quick shower, without worrying about the wound getting wet.
Lymphedema Screening Program Prevention
One of the great medical advances in the approach to lymphedema is the screening program for an early diagnosis, aimed at patients who have undergone breast cancer, and also for those who have suffered from ovarian cancer or patients who have gone through a prostate cancer or melanoma and they also have a risk of lymphedema.
The screening program is based on a test using the indocyanine green fluorescence scanner. The indocyanine green scanner, also known as PDE, has been shown to be much more sensitive than lymphogamagraphy and other imaging tests.
The treatment consists on a microinjection of indocyanine green in the arm or leg; a simple test that can be done in the consultation. The green coloration allows us to see how is the lymph transportation in the limb affected by the cancer treatment, and compare it with the healthy limb. Thus, before any increase in volume, feeling of heaviness, lymphangitis, etc appears, it can be detected if there is a malfunction as a result of the lymph node surgery done previously.
Dr. Jaume Masià
More and more breasts are being reconstructed with skin and fat of the own patient, since the technique offers a definitive and natural result, and allows the breast to evolve naturally to any physiological change, such as gaining or losing weight. There is also the fat grafting for the partial reconstruction of the breast or for improving the final result whether the reconstruction is by the patient’s own tissue or by prosthesis.
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