Breast Reconstruction

Breast Reconstruction after Mastectomy

After the news that a mastectomy is required, it can be difficult to remember all of the information that has been discussed.

The information here can help remind you and your family of some of the things we have talked about.

If you are waiting to see me about a reconstruction, then reading through this can help you form some ideas about the type of reconstruction that you might wish to undergo.

When should I have a breast reconstruction?

The answer to this is whenever you are happy to have one. It can be at the same time as your mastectomy (immediate reconstruction) or at a later date, after you have completed all your treatment (delayed reconstruction).

The only time I can not carry out reconstruction is during the period of chemo- or radio-therapy that may follow a mastectomy.

What are the benefits of immediate reconstruction?

  • It is performed at the same time as your mastectomy, leaving no time when you are without some kind of breast shape
  • Preservation of the breast skin which leads to less scars and a smaller skin patch
  • You will only need a single hospital admission and in-patient stay and there will be no need for further surgery after you have finished your chemo or radio-therapy

What are the risks of immediate reconstruction?

There is a tiny risk that complications after your reconstruction could delay any other treatment required. (There is this risk after mastectomy alone too).

What are the benefits of a delayed reconstruction?

You can choose the time for your reconstruction. Many people feel that they would rather get the mastectomy done and worry about reconstruction later after the trauma of mastectomy and other treatments have passed.

Are there any other alternatives?

On some occasions I can offer another alternative, this is called delayed – immediate.

This is where I place a silicone implant under the skin at the time of the mastectomy with a view to removing it at your formal reconstruction. This has the benefit of lessening the immediate surgical time and waiting for a final decision about the need for radiotherapy to be taken. Radiotherapy can sometimes have a detrimental effect on the appearance of your reconstruction.

What is involved with a breast reconstruction?

There are many different methods and techniques for breast reconstruction. The information here will give you a guide as to what is available. However, we will discuss this in detail when I see you, as not all methods are suitable for everyone.

Reconstructions can be divided into those using silicone implants (implant reconstructions) and those using only tissue from your own body (autologous reconstructions).

Remember that it is very unlikely to involve a single operation to achieve completion of your reconstruction.

The best reconstruction plan for you could involve surgery to the opposite breast to lift or reduce it, this can be either at your request or on my advice. This can also affect the type of reconstruction that you ultimately select.

Implant only reconstruction

This is a simple procedure in the short term where a silicone implant is placed under the muscle of the chest wall to replace the missing breast volume.

This type of reconstruction does have a few drawbacks and a fairly high complication rate.

Up to 15% of people have the implant removed in the weeks following surgery, usually because of infection around the implant.

There is a 35% chance that further surgery will be required in the first three years due to ‘hardening’ of the implant, or a change of shape among other lesser possibilities.

Implant reconstruction cannot achieve the same drooping shape of a natural breast.

If you are considering having a delayed reconstruction using an implant, or for some people undergoing immediate reconstruction with an implant, then it may be necessary to use an expander-implant. This is a silicone implant with a separate chamber, which can be inflated with saline during the weeks after surgery to achieve the required size and shape. This involves several (weekly or fortnightly) visits to the out-patient clinic after surgery to adjust the size of the implant.

Implant plus flap reconstruction

This is where we make a flap to cover the implant, by using a piece of skin from your back, along with a large muscle called the latissimus dorsi, which is usually known as lat dorsi or LD.

Using the flap to cover the implant reduces the complications associated with implant only reconstructions, however there is still a significant rate of implant loss.

In addition to the mastectomy scar, there will also be a linear scar on your back.

Reconstructions performed without using implants

Extended Lat Dorsi Flap (from the back)

This reconstruction takes some skin, fat and muscle from your back and moves it around to the front of your chest, to replace the skin that has been taken during the mastectomy. This is then shaped to give the final appearance.

The muscle which is used for this operation is not usually ‘missed’ after it has been moved. It is only really important in small groups of people such as wheelchair users, speed climbers and Dragon boat racers, the remainder of people can adjust perfectly well to the loss of this muscle.

This reconstruction is a little more complex than a simple implant reconstruction; however has a very low complication rate.

About 3% of people have an area of delayed healing (either on the front or back wound), this can occasionally require a prolonged course of dressing treatment.

There is a limit to the size of breast that can be made with this technique, depending on the individual – if this is something you would like to consider then please let me know.

The biggest drawback after this operation is the very significant chance that a seroma (a collection of fluid at the back where the flap was taken from) will form.

This can be managed by visiting the hospital to have the fluid removed, whenever necessary.

DIEP flap (from the abdomen)

This is the most versatile reconstruction and offers the best chance of symmetrical reconstruction.

It involves taking the skin and fat from your lower abdomen and transplanting it to make the new breast (therefore having a “tummy tuck” as part of the operation).

The operation relies upon small blood vessels from the skin and fat which pass through the muscle of the abdominal wall and onto a larger artery and vein being joined onto the blood vessels inside the chest.

During the first few days after surgery a very close watch is kept on the flap to ensure that blood flow is maintained – if not then another visit to the operating theatre may be required to restore circulation (3-5%).

Overall this surgery, although complex, has a low complication rate, however there is still about a 1-2% chance of the flap failing completely. Other minor wound complications can occur, with about the same frequency as seen after an extended lat dorsi (-3%).

Again this reconstruction may not be suitable for everyone and the option should be discussed when me meet. The scars following this surgery are across the lower part of your abdomen usually within the ‘knicker line’ and at the patch of new skin on your breast.

Complications

Any surgical procedure has the risk of not going entirely as planned, this is called a complication.?Complications may be specifically related to the procedure or more generally associated with a surgical patient.?The specific complications of the procedures have already been mentioned and I will discuss these again with you during your consultation and prior to surgery.?General complications include infection of either the wound or chest and DVT (Deep Vein Thrombosis). This is a blood clot in the leg, very occasionally there is a grave result of DVT called PE (Pulmonary Embolism) which is when the DVT gets too big and part detaches into the general circulation.?Radiotherapy and chemotherapy undoubtedly have an affect on the chance of certain complications occurring, as does smoking – all of these things we will discuss at your consultation.

If you have any questions then please call my secretary, Ann Breakwell on 02392 366661, she will be happy to help you.

Summary of reconstruction techniques

  IMPLANT ONLY IMPLANT + FLAP (LD) AUTOLOGOUS LAT DORSI DIEP FLAP
Hospital Stay 2-4 Days post op 5 – 7 Days post op 5 – 7 Days post op 5-7 Days post op (first 2 days post op on High Dependency Ward to monitor flap)
Recovery Uncomfortable 2 weeks, off work 6 weeks Uncomfortable 2 weeks, off work 6 weeks Uncomfortable 2 weeks, off work 6 weeks Uncomfortable 2 weeks, off work 6-10 weeks
Driving Not for 2 weeks Not for 2-3 weeks Not for 2-3 weeks Not for 2-3 weeks
Complications Relatively high, but good when trouble free Better than implant only, not as good as autologous operations Low Low
Special Considerations Poor choice if radiotherapy needed Can be effected by radiotherapy if needed Amount of tissue available Amount of tissue available, previous surgery may make this impossible

Nipple Reconstruction

This should be considered in two parts. The nipple is defined as the part which ‘sticks out’ from the breast, and the areola is defined as the coloured area surrounding the nipple.

Nipple reconstruction can be performed in three ways:

Silicone Rubber Nipple

This is a popular method, where a silicone rubber nipple can be made (usually as a model of the opposite nipple), which can then be fixed in place with silicone adhesive.

An advantage to this method is that it avoids the need for surgery altogether, although is not a true reconstruction and the nipple and areola area are dealt with all at once.

Some people do react to the adhesive, making continued use impossible.

Surgical nipple reconstruction

This method is performed some time after the reconstruction of a new breast mound and allows gravity to act on the new breast. This ensures that the new nipple is sited correctly.

The reconstruction is broken down into two parts, reconstruction of the nipple and the areola.

The nipple area is reconstructed by taking half of the opposite nipple and placing it on the new breast as a graft. This can be done under local anaesthesia as a day patient.

Alternatively, some of the skin from the new breast can be rearranged in such a way as to create a new nipple (also under local anaesthetic).

Once the nipple has been created, then the areola is completed by using a tattoo. Tattooing is performed in the same way as other decorative tattoos. The procedure is painless, as the skin of the new breast, where the tattoo is placed, is usually anaesthetised at this stage and we will also use a local anaesthetic cream to ensure the process is pain-free. A tattoo may need touching up from time to time should the colour fade, but provides a good quality match (especially in colour) to the opposite side.

If you have any questions, concerns or worries then please call my secretary, Ann Breakwell on 02392 366661 who will be able to get you any advice you need.