Introduction and the chance of postoperative radiotherapy.22 Primary or direct breast reconstruction must especially be recommended to patients with a low risk of postoperative radiotherapy. Technically, primary reconstruction aesthetic outcome is facilitated by the natural quality of the native skin and the preservation of the inframammary fold and the three‐dimensional breast skin envelope.23,24 Studies with selected patients show that patients themselves prefer a direct reconstruction above a secondary reconstruction.25 They experience less discomfort and feel better mentally.26 As they are spared a life without a breast, they are more satisfied with the final result compared with patients who have had a secondary reconstruction.27 Contralateral breast surgery is often performed to achieve more symmetrical results and may be performed in a primary or secondary setting. The type of breast reconstruction chosen by patients not only is a personal choice but also is influenced by several factors, including patients’ general health and comorbidity, breast irradiation, availability of sufficient tissue in case of autologous breast reconstruction, and possibilities in treatment center. Patient satisfaction is greater over time with the autologous method compared to the prosthesis method, although the first method is often associated with more scars and initially, greater morbidity.28 Breast reconstruction with implants The choice of breast reconstruction with a prosthesis is dependent on the quality and vascularization of the overlying skin remaining after the breast mastectomy, the shape and size of the breast, and the preference and expectation of the patient. Silicon breast prostheses have been the subject of discussion concerning both possible systemic and locoregional complications. Although silicon has been blamed for systemic complaints a causal relationship has not been demonstrated.29 The quality of implants and the increased possibilities in shape, size, texture, and cohesiveness have increased the possibilities for the reconstructive surgeon and improved aesthetic results of this reconstructive technique. Complications after silicon implantation (such as wound infection), late complications (such as capsular contracture), and the need for breast irradiation are important factors to consider when choosing the method of breast reconstruction. When mastectomy skin flaps are not viable, autologous breast reconstruction or latissimus dorsi flap with or without implant can usually performed. Implant‐based breast reconstruction can be performed as a single‐stage procedure. This is usually reserved for skin‐sparing mastectomy in patients who have relatively small, non‐ptotic breast and who do not want a change in breast size. The use of anatomic cohesive silicone implants has had a postive effect on the aesthetic outcome. A‐cellular dermal matrix, seems to further improve the aesthetic outcome in selected patients, although there is a slightly higher complication rate related to implant exposure.30,31 A two‐stage procedure using tissue expander (TE)/implant is still the most commonly used method of implant‐based breast reconstruction. 13
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