Breast reconstruction

Breast reconstruction following mastectomy essentially consists of three surgical options - tissue expansion (implants) , the latissimus dorsi flap and the TRAM flap. The suitability, advantages and disadvantages of each will be discussed at length.

General points.

It is vital to understand that removal of breast tissue after mastectomy is permanent, and it is NOT possible to replace the missing breast with another breast. What is possible however is to use available skin and fat with or without a muscle carrier, to be reshaped into a breast-like mound. This can be very similar in size and shape to the opposite breast and is often virtually identical in cup size. The reconstruction is often more youthful in appearance and the patient may wish to have the normal breast reduced or uplifted to make both appear more symmetrical.

In addition it is possible to create a nipple using a combination of tattooing and skin graft or flap techniques. As the reconstruction does not contain breast tissue there is no chance of the original tumour recurring within the reconstruction. There may however be a very small risk of recurrence at the mastectomy scar line where the origninal tissue was removed, and hence you will still require to be monitored for a period of time by your breast surgeon.

Immediate versus delayed reconstruction?

Increasingly there is a demand for having reconstruction done immediately after mastectomy. This is a choice made by both patient, surgeon and available resources. Interestingly there is often a higher level of patient satisfaction with the delayed reconstruction, as they have had a period of loss of their missing breast. Clearly there would also be a longer anaesthetic in an immediate reconstruction, with the accompanying potential disadvantages.

What factors determine the choice of procedure?

Previous or future need for chemotherapy and radiotherapy: The use of implants is undesirable if other treatment is considered, as there is a far higher risk of implant related problems such as capsular scar contracture and extrusion. Any patient on Herceptin should complete their treatment prior to undergoing surgery.

Opposite breast size:

The larger the opposite breast (normal breast) the more difficult it will be to achieve a symmetrical result, especially with one's own tissues alone. In this case it may be preferable either to consider tissue expansion (if suitable) or consider opposite breast surgery such as a reduction.

Age:

Patients over a certain age (60+) or those with a significant medical condition such as diabetes, may be more suitable for a shorter surgical procedure such as the tissue expander or lat dorsi flap. The TRAM flap may well take up to 6 hours to complete, and this could have an adverse effect on one's recovery.

Smoking:

It is alway advisable to reduce or if possible stop smoking for at least one week prior to surgery. There is evidence to suggest that smoking is related to poor wound healing, and may affect complications after recovery from anaesthetic eg. chest infection. All three surgical options would be possible if smoking was ceased.

Previous surgery.

The presence of surgical scars from previous surgery may render use of some of the flap options not possible. For example abdominal surgery as in repair of a hernia, gall-bladder operation will leave scars on the front of the abdomen which may have interfered with the blood supply of the TRAM flap. These will be discussed with your surgeon.

1. Tissue expansion/implant.

A pocket is created under the chest wall muscle (pectoralis muscle) to accommodate a silicone expander with a magnetically located injection dome. This expander is gradually inflated with saline at a clinic visit until the required size is achieved (anything up to 6-8 visits). After a period of time to allow the newly expanded skin to settle, the expander is removed and an anatomical breast shaped permanent silicone implant is replaced at a second operation.

No of Operations required: 2

Surgical time: 1 hour for each procedure (excluding mastectomy if part of the procedure)

Advantages:

• To match normal breast size of most sizes up to D cup size
• Skin of the chest retains it's sensation
• Ideal for bilateral breast reconstruction
• Short surgical time
• Single scar technique (the implant is usually inserted through the original mastectomy scar)

Disadavantages:

Should not be used if radiotherapy or chemotherapy is planned or has been used in the past
Risk of infection or extrusion of the implant

400cc Tissue expander on right side