There are many possibilities when considering breast reconstruction to replace the whole, or part of the breast, removed for cancer-related reasons. Our purity bridge team of Consultant Plastic Surgeons have put together this blog that we hope might be useful in understanding the options.
Breast reconstruction can be done at the same time as the mastectomy (immediate breast reconstruction) or may be done at a later date some time after the mastectomy (delayed breast reconstruction). Broadly speaking, the reconstruction can either be based on using only the patient’s own tissue (skin, fat and occasionally muscle) or can also be performed by techniques that involve the use of a breast implant.
No matter what technique of breast reconstruction is chosen, it is common for 2 or 3 operations to be needed to complete the breast reconstruction: typically, the first is to make the breast “mound”, the second to make any adjustments (perhaps to the other breast to improve symmetry) and the third is to reconstruct a nipple.
Plastic Surgeons, whenever possible, tend to prefer to use techniques that involve only the use of the patient’s own tissue. These techniques are complex and time-demanding (for patient and surgeon) and are not always suitable for everyone. However, arguably they give the best long-term aesthetic outcomes and in addition, unlike implant-based techniques, once the breast reconstruction journey is complete, no further surgery is necessary in the patient’s lifetime.
The gold standard method of breast reconstruction is the DIEP flap. This involves taking skin and fat from the abdomen (the same tissue that is removed during a tummy-tuck) and sculpting this into a new breast. However, taking the tissue off of the abdomen means that it is no longer alive, as there is no blood running through it. Therefore, blood circulation needs to be restored to bring it back to life. This is done through microsurgery, in which an artery and vein that have been carefully removed with the tummy tissue are stitched to an artery and vein in the chest under the operating theatre microscope. Once the blood flow is restored, the tissue is “brought back to life” and can then be sculpted into a new breast. The whole operation takes 6-8 hours and needs about 4-days in hospital. It can take some people several months to get all their energy levels back to normal, so is quite an initial commitment. However, the benefit is that the reconstruction does not need to be re-operated on later in life. Other parts of the body can also be “borrowed” from to reconstruct a breast without an implant if there is not enough tummy fat. These areas include the upper inner thigh, the buttocks or the back. More recently combining using the skin and muscle from the back with fat grafting at the same time (also known as lipofilling) is becoming popular.
If the complexity of the above procedure deters someone from this route, or the patient is not suitable for these operations for other reasons, implant-based reconstructions are alternatives. The most straight forward is to use a “fixed-volume” implant straight away – i.e. using an implant of the appropriate size to recreate the breast mound. However, many women will have an inflatable implant (an expander) placed as the first of a 2-stage procedure: the empty, deflated expander is inserted under the muscle of the chest wall as the first operation. Subsequently, in the outpatient clinic saline is injected into it to inflate it gradually until the desired size is reached. Once this has been achieved (usually after several months), a second operation may be performed to replace the expander with a softer, more realistic fixed-volume prosthesis. More recently, the introduction of animal derived or synthetic supportive material to support the weight of the implant in the lower pole of the breast has grown in popularity. These offer a simple reconstruction from a technical point of view, but are not permanent reconstructions, as they involve an implant. Whatever breast implant technique is used, it must be accepted that the breast implant will most likely need replacing within 5-10 years.
Many women receive radiotherapy as part of their breast cancer treatment, and this causes long-term scarring in the tissues of the chest wall. If so, it is not advisable to put an implant in as described above, as problems with tight scarring around the implant will occur within a year or two in most cases. Therefore, in this situation, a protective layer of soft tissue needs to be brought in from a part of the body that has not been affected by radiotherapy if an implant is to be used to provide the lost volume. The area used is the back, in which case a muscle and piece of skin attached to the muscle (the latissimus dorsi) is used. The skin and muscle are brought through to the front via a tunnel created under the armpit, and are used in combination with an implant for the reconstruction.
The above is a short overview of the common options available. What is important is that any woman considering breast reconstruction is given the choice of all the techniques that are suitable for her. This may often need the input of a plastic surgeon, as well as the breast cancer surgeon. Not all methods will be suitable and one size does not fit all: the best choice is the one decided on between patient and surgeon after a thorough discussion of all the options. We hope this brief overview has been helpful – please get in touch for more information.