Breast reconstruction after mastectomy is a very personal and completely individual choice. Each woman is unique. Her choice will depend on her cancer management plan, lifestyle, body build, personal circumstance, the skills of her surgeon and whether or not she will accept more scars or the use of implants. Her surgeon will be able to discuss all the available options and discuss the benefits and risks of each method relevant to her.
Breast reconstruction is better viewed as a process rather than a single surgical procedure. It takes several steps in order to achieve a complete breast reconstruction. The first step is the reconstruction of a breast mound. Next, adjustments are made to achieve optimal volume and shape in comparison with the other breast. These adjustments may involve surgery to the other breast. Finally, the nipple-areola is reconstructed. Further procedures may be added into the process along the way in order to provide an optimal cosmetic result.
Following mastectomy, a breast may be reconstructed using different techniques.
Procedures used for breast reconstruction include:
- the use of implants or expanders
- the use of skin and tissue from the back (Latissimus Dorsi or LD flap), abdomen (tummy), buttock, thigh or flank
- a combination of the above methods
In addition to the reconstruction of the breast mound, the nipple-areola is reconstructed at a later time, when the ideal shape and size of the breast mound has been achieved.
Symmetry between the reconstructed breast and the opposite breast can sometimes be achieved by surgery to the opposite breast. Procedures may include breast augmentation, breast reduction or mastopexy (breast uplift).
TIMING OF RECONSTRUCTION
Timing is an important consideration once the decision for a reconstruction has been made. Important questions to ask are:
Can it be done at the same time (immediate reconstruction) and would it be wise to have it done at the same time as the mastectomy?
Alternatively, would it be best to recover from the initial mastectomy operation, have all the recommended adjuvant therapy for breast cancer and then have the reconstruction as a delayed procedure?
For some patients, doctors may recommend a delayed reconstruction if chemotherapy and or radiotherapy is necessary as part of the treatment plan. Women can be reassured that an immediate reconstruction will not hide a cancer recurrence (regrowth).
IMMEDIATE BREAST RECONSTRUCTION
What are the advantages of an immediate reconstruction?
The main advantages of an immediate reconstruction are:
- the woman does not have to live with the mastectomy scar.
- the number of operations is reduced without significantly prolonging the hospital stay.
- the overall time spent in hospital and recovering from the operation is less than having it done as a delayed procedure.
What are the disadvantages of an immediate reconstruction?
The major disadvantages are:
- it is a big decision to make, at a time when a woman not only has to contend with the diagnosis of a breast cancer but also the loss of a breast.
- the initial operative procedure would be a more complex one and take longer than a mastectomy alone.
DELAYED BREAST RECONSTRUCTION
Delayed reconstruction can be performed from days to years after the mastectomy.
What are the advantages of a delayed reconstruction?
Sometimes patients wish to have a waiting period in order to address the immediate issues and implications on their life with a diagnosis of breast cancer.
It gives time to recover from radiotherapy or chemotherapy if they are required. It also gives more time to make an informed decision and to get to know the reconstructive surgeon.
What are the disadvantages of a delayed reconstruction?
Once a decision for delayed reconstruction is made, it may take time to obtain an appointment for a consultation with a reconstructive surgeon and there may be a further wait for the operation if there is a waiting list.
HOW IS RECONSTRUCTION CARRIED OUT?
Breast reconstruction is best considered as a process. First, the breast mound is formed either as an immediate or delayed procedure. Any minor adjustments are then made at a later stage and when the shape and size of the reconstructed breast is stable, the nipple-areola can be reconstructed.
The main methods for creating a breast mound are:
- reconstruction with an implant or expander
- reconstruction using autologous (patient’s own natural body) tissue from either the back (LD flap), or abdomen (TRAM flap/ DIEP flap)
- a combination of the above
Other less commonly used methods for creating a breast mound include free flaps from the buttock, lateral hip, thigh, back or abdomen.
After creation of the breast mound, adjustments may be necessary to the scars and the opposite breast in order to give a good match between the breasts.
Reconstruction of the nipple-areola completes the process.
The nipple can be formed using:
- a portion from the opposite nipple -‘nipple share’
- local flaps of skin from the reconstructed breast mound
The areola can be created by tattooing pigments onto the skin surrounding the nipple.
An alternative to surgical reconstruction of the nipple-areola is the use of a nipple-areola prosthesis. Skin adhesives are used to glue the prosthesis into place. The prosthesis can be custom made to match the nipple-areola on the opposite breast or can be purchased ‘off the shelf’.
RECONSTRUCTION WITH AN IMPLANT OR EXPANDER
If the amount and quality of remaining skin after mastectomy is adequate, the use of a fixed volume implant or an inflatable implant is possible. Implants are made of a silicone outer shell and can contain either silicone gel or saline (salt water) or a combination of both. A second operation is required to exchange the expander for a fixed volume implant or autologous tissue for expander reconstructions. Another procedure is usually required for reconstruction of the nipple-areola and, if necessary, to make adjustments to implant size, shape and position, to release scar tissue or to remove the injection port of an expander implant. If an inflatable implant is used tissue expansion will require additional outpatient visits to inflate the implant which starts about two weeks after the initial operation and continues over a 3-6 month period.
If done immediately in addition to the mastectomy, the reconstructive procedure normally takes 1-2 hours to perform. It is done under a general anaesthetic. The implant is inserted through the mastectomy incision if done at the time of mastectomy and placed beneath the skin and upper chest muscles to produce a breast shape. For a delayed reconstruction, the scar from the previous mastectomy may be reused in order to avoid a new scar. If this is not suitable, a new incision is usually made in the crease beneath the breast, ensuring that it will be well hidden beneath the new breast.
If the remaining breast skin is insufficient for reconstruction, it may be necessary to import a flap of skin and muscle from the upper back (Latissimus Dorsi) to cover the implant.
What to expect after the operation
When an inflatable implant (expander) is used, the newly reconstructed breast often looks flattened immediately after reconstruction. This is because the implant is positioned behind tissues that are relatively tight. These tissues stretch and soften over the next few months after the implant is inflated to provide better projection and shape.
Inflation of the implant normally starts in the first 2 weeks after the operation. This involves the injection of saline (salt water) into a port, which is just underneath the skin and attached to the implant. There will be a sensation of pressure during this procedure, which normally settles down after several hours. Inflation is usually carried out in the outpatient clinic at weekly or fortnightly intervals.
In a few weeks the scar will become red but will fade with time (usually over a few months).
The recovery period varies but most patients are out of bed the same or next day, may take a shower the next day and may drive a car after 1-2 weeks. It is best to wait 4-6 weeks before gradually resuming exercise and sporting activities.
If an inflatable implant is used, a second operation may be required to remove the injection port or to move it to a hidden position. In certain cases, this operation may be performed under a local anaesthetic.
RECONSTRUCTION WITH AUTOLOGOUS (natural body) TISSUE
The two most common donor sites for breast reconstruction using autologous tissue are the abdomen or tummy (TRAM or DIEP flaps) and back (LD or Latissimus Dorsi flap). With the TRAM flap, the tissue can be left attached to the blood supply of the muscle beneath it (pedicled), or be transferred as free tissue where the surgeon joins up the tiny blood vessels between the flap and the vessels in the region of the breast using an operating microscope and special instruments.
Tissue from the back (Latissimus Dorsi or LD flap)
When a large breast is reconstructed it is usual to require an implant in addition to the LD flap. For small and medium sized breasts, it is possible to use the fat, skin and muscle of the LD flap alone.
Skin, fat and muscle or sometimes only muscle is transferred from the back by tunnelling beneath the skin on the side of the chest and suturing it into place. This is placed on top of the implant when one is used.
The TRAM and DIEP flaps (abdomen or tummy flaps)
The TRAM (Transverse Rectus Abdominis Musculocutaneous) flap is a flap from the abdomen and includes fat, muscle and skin. It may be transferred as a free flap (using the microscope and special instruments to join up the tiny blood vessels) or a pedicled flap (still attached to the previous blood supply).
The DIEP (Deep Inferior Epigastric artery Perforator) flap is a flap from the abdomen that includes fat and skin but no muscle. It is transferred as a free flap where the muscles of the abdominal wall are left in their original place.
These flaps from the abdomen are considered to be the ‘gold standard’ in breast reconstruction since the cosmetic results can be extremely pleasing. They provide the best form of reconstruction for women who do not wish to have an implant of any sort, as the new breast is made up entirely of their own tissue and skin. The TRAM or DIEP flaps are not suitable for every patient. There is a higher risk of complications if women smoke, are overweight, have hypertension (high blood pressure) or diabetes, or if radiotherapy has been given.
The use of a flap from the abdomen is a major operation and usually takes about 3-6 hours. It is done under a general anaesthetic and usually requires a hospital stay of 4-8 days. Drains are inserted into the operated sites to remove any fluid that accumulates. A urinary catheter (drainage tube in the bladder) is used to drain urine while the patient is confined to bed during the first hours after the operation.
The donor site is closed directly leaving a scar across the lower half of the abdomen often leaving the appearance of having had an abdominoplasty or ‘tummy tuck’.
What to expect after the operation
A primary concern in the postoperative period is that there is a good blood flow to the new breast. The blood supply of the flap is carefully monitored by frequently checking its colour and temperature.
If the blood flow to the flap is compromised (reduced) it will be necessary to have another operation immediately to explore the blood vessels. There is about a 1 in 20 chance that the breast reconstruction operation may fail with this method.
It is normal to spend 1-2 days after the operation in a high dependency unit for intensive monitoring. Women can usually get out of bed 1-2 days after the operation. Most women resume normal activities over the next 4-6 weeks, return to work in 8-12 weeks and may do sports in 3-6 months. Recovery time is shorter if the abdominal wall muscles are not moved with the flap (as with the DIEP flap).
HOW TO CHOOSE THE TYPE OF BREAST RECONSTRUCTION?
The best method for breast reconstruction depends on each individual woman. Her surgeon will take into account the type of breast cancer, treatment plan, her medical fitness and will advise on the best options.
In general, breast reconstruction with implants is simpler, takes less time to perform but does not usually give as satisfying a cosmetic result in the long term as reconstruction with a flap.
Latissimus dorsi (LD) flaps are generally more reliable than other types of breast reconstruction with a flap. The natural body tissue of the flap gives a warm and pliable reconstructed breast. These flaps are sometimes combined with an implant for women with larger breasts.
Abdominal (TRAM or DIEP or other perforator) flaps give warm, soft and pliable reconstructed breasts that resemble natural breast tissue. They are more complex procedures that require specialist surgical skills and instruments and are lengthy. They are not suitable for patients who smoke, have hypertension (high blood pressure) or diabetes. When radiotherapy is planned as treatment after the operation, it is sometimes better to delay breast reconstruction with a flap until after the course of radiotherapy is complete.
PROBLEMS AFTER A BREAST RECONSTRUCTION
Problems are uncommon but they do occasionally occur.
Wound infection is a risk of any operation. A short course of antibiotics is routinely started at the time of the operation. If an infection develops, further antibiotics or a further operation may be necessary.
Haematoma (collection of blood) or Seroma (collection of fluid beneath the skin)
This is normally prevented by the use of drains but if it does happen, drainage with a needle through the skin or another operation is sometimes necessary.
Pain and discomfort
Painkillers are given regularly in the form of tablets, injection or through a drip. Sometimes women can use PCA (patient controlled analgesia) to control the amount of painkillers they receive by themselves.
Although every effort is made to create a new breast to match the opposite healthy one, it is rarely possible to achieve perfect symmetry.
Reduced skin sensation
As the reconstructed breast has reduced sensitivity, a heating pad or hot water bottle should not be used against the skin because of the possibility of accidental burns.
It is a natural reaction of the body to form scar tissue around an implant. In a few women (about 10%) this reaction is excessive and the breast can become hard, painful and deformed. It may become necessary to remove the capsule and then replace the implant.
Weakness of the abdominal wall after a TRAM or DIEP flap may produce a hernia (bulge) that will require additional surgery for correction.
A diagnosis of breast cancer can be a very traumatic experience. Many women may feel depressed even many months after the treatment and breast reconstruction. Members of the breast care team are available to discuss any problems that women may have. There are also breast care organisations that specialise in breast cancer counselling and provide information about living with a diagnosis of breast cancer
ABOUT DR JACQUELINE LEWIS
Based in London, Dr Lewis is a highly respected surgeon, with over 30 years experience in helping women feel good about their bodies.