Breast reconstruction can be done in a number of ways following a mastectomy. It can be carried out in most instances at the time of mastectomy (immediate reconstruction) or later on in a few months or longer (delayed reconstruction). Immediate reconstruction allows the surgeon to preserve the native skin of the breast whilst the breast tissue is removed from beneath the skin. This maintains the contours of the breast and all that is needed to restore the breast shape and size is to find body tissue or an implant or a combination of the two to fill out the skin envelope.
Types of breast reconstruction
There are various ways of reconstructing the breast. This may be achieved by the use of implants alone, transfer of body tissue to the chest with or without an implant. Tissue transfer may involve large areas of muscle from the back (LD flap) or the tummy (TRAM flap). Alternatively one may transfer just skin and fat from another part of the body to the chest along with the blood vessels nourishing the tissue and join the blood vessels to the blood vessels in the chest behind the ribs or in the armpit (microvascular surgery). The sites used are the tummy (Free TRAM flaps, DIEP flaps), buttock (SGAP flap), back (Free LD flap), thighs (TMG,TUG flaps).
Choice of reconstruction
The ideal reconstruction is one that meets the patients expectations with minimum risk. For small breasted women, implants alone may be sufficient. For women with large breasts any technique may be used. The choice is usually dependent on the patients preferences, need for corrective surgery to the opposite breast to achieve symmetry and the possibility of radiotherapy to the reconstructed breast. It is wrong to believe there is one reconstruction option for all patients.
Timing of reconstruction
The ideal time is immediately at the time of mastectomy ( immediate breast reconstruction) so that most of the native skin is preserved and the contours retained. If this is not appropriate or if the patient prefers the reconstruction may be delayed (delayed breast reconstruction).
Reconstruction may be done in two stages with an initial operation using tissue expanders followed by the definitive procedure. The second stage may involve replacing the tissue expanders with a fixed volume implant or the patients own tissues. The benefits of this approach is in the opportunity to revise the pocket in which the implant is to be placed, at the second operation.
Revision surgery of the reconstructed breast
Revision of the implant based breast reconstruction may be necessary where the breast has become hard and painful because of the effects of radiotherapy, infection,bleeding and smoking. The revision procedure may involve removing the scar tissue around the implant (capsulectomy) and replacing the implant with a new one or using a new form of reconstruction (LD, DIEP,TRAM).
Revision surgery may also be required after any form of reconstructive surgery in order to improve the shape. This may be reduction of a DIEP/TRAM flap which is too bulky, recreating the crease on the underside of the breast (inframammary crease), refashioning the scars, adjusting the position of the implant . These operations are short procedures and can be done as day cases.
Are implants safe?
The safety of silicone implants has been well established following several reviews. Implants do not cause cancer, do not mask cancers from being detected and do not cause harm to the rest of the body as was once thought.
Why is radiotherapy bad for the reconstructed breast?
Radiotherapy causes scar tissue which is coarse, thick and unpredictable and tends to shrink with time. As a result, the reconstructed breast will lose shape and become smaller and feel hard. This effect is seen regardless of the type of reconstruction but most noticeable where implants have been used. This would require revision surgery in 60% of the patients where the scar tissue is either removed or released and the implant replaced or a new reconstructive procedure used. In these situations, where radiotherapy is definite, it is useful to stretch the preserved skin envelope with a tissue expander for several months or longer before a definitive reconstructive procedure is carried out (this is called immediate-delayed reconstruction). There seems to be some early indication that lipofilling can be of benefit in making the breast feel softer. This involves removal of fat from some part of the body with liposuction and transferring it to the breast. Its role in the reconstructed irradiated breast is being studied and evaluated. The reconstructed breast that hardens and shrinks after radiotherapy will need revision surgery. The scar tissue will need to be removed in most of the cases and the breast reshaped with the addition of new tissue (LD Flap, DIEP Flap, TRAM Flap , SGAP Flap).
What is skin sparing mastectomy?
It is well recognised that the skin of the breast does not need to be removed unless directly involved by the cancer. Even then most of the remaining skin can be preserved as it helps maintain the original contours of the breast. In most instances the mastectomy is achieved through a small hole created by an incision around the nipple allowing the removal of all the breast tissue underneath and even the lymph glands. The nipple and areola are also removed (circumareolar incision). This can then be camouflaged by a tattoo and a nipple reconstruction so that it is difficult to tell whether the woman has had a mastectomy. Sometimes it is possible to spare the areola and just remove the nipple and the underlying breast (areola sparing mastectomy).
What is skin reducing mastectomy?
Women with large or droopy breasts have an excess of skin. If they chose to have cosmetic surgery, then the excess skin would be removed during the breast reduction or breast uplift. These principles are applied during a mastectomy to tighten the skin and give the patient a more pert breast. Often the opposite breast is also operated upon at the same time to achieve symmetry. This results in aesthetically beautiful breasts after the breast tissue containing the cancer is completely removed.
Complications with breast reconstruction
Infection, bleeding and bruising occur with any type of surgery. Bleeding requiring that the patient return to the operating theatre is rare after breast surgery whether it is lumpectomy, mastectomy, oncoplastic surgery or breast reconstruction. Bruising tends to disappear in two to three weeks and never causes a problem. Patients do find Arnica ( a homeopathic remedy) useful in helping the bruising resolve quickly. Infection is a distressing complication particularly if it involves the implant. In most instances antibiotics help but occasionally the implant needs to be removed until the infection has resolved. A new implant can then be placed under the muscle.
Silicone is safe. If it leaks it may cause lumps in the tissues around the implant. This is very rare now a days with the use of high cohesive gel implants. Silicone does not cause cancer.
Implants may rotate or get displaced and result in change in the contour or shape of the reconstructed breast. They may then require a short procedure to resite them. It is important to avoid strenuous physical activity for 6-8 weeks after breast reconstruction involving an implant. Implants do not readily rupture. Tremendous force is required to cause implants to rupture. Most manufacturers will guarantee their implants for life against this failure.
All implants will be associated with a capsule which usually is very thin and pliable. Sometimes this capsule becomes very hard and causes pain. This is called capsule contracture and tends to occur more commonly when radiotherapy has been given to the breast, when infection has complicated a reconstruction, when there has been significant bleeding and in smokers. Sometimes as a result of this the implant may extrude through the skin.
In cases where ones own tissues have been used to reconstruct the breast , lumpy areas may develop which may cause anxiety. These are usually due to fat necrosis (dead areas of fat) but need an experienced surgeon to assess and investigate them.