Breast Reconstruction Surgery
What is Breast Reconstruction?
Breast reconstruction is a procedure (or operation) that recreates a breast shape on the chest wall following a mastectomy. Breast reconstruction is an option for most women who have a mastectomy. There are a number of different techniques that can be used to reconstruct the breast. For some women, one type of reconstruction will be more suitable than another. For others, it will be a matter of personal preference. Factors like body shape, medical conditions and the type of treatments you require can influence what type of reconstruction is recommended. A/Prof Mak and Dr Graham work closely with plastic surgeons to ensure that the we recommend the most appropriate reconstruction option for you.
When can breast reconstruction be performed?
Breast reconstruction can be performed at the same time as mastectomy (immediate) or at a later time (delayed). There may be things about your cancer or treatment that means delayed reconstruction is recommended. Immediate breast reconstruction is a much bigger operation than mastectomy alone, and carries more complications. For most women, the decision between immediate or delayed reconstruction depends on your choice and availability of surgical facilities.
Breast reconstruction is not for everyone. Many women choose to wear an artificial breast form (external prosthesis) in their bra rather than have surgical reconstruction.
How is a breast reconstructed?
There are several different surgical techniques that can be used to recreate a breast shape. These include:
Breast implant reconstruction – using a silicone gel implant that best matches your breast
Single stage/“Direct to Implant” - insertion of a silicone gel breast implant
Two stage - insertion of a tissue expander (saline filled) that is later replaced with a permanent gel silicone breast implant)
Tissue flap reconstruction
Latissimus dorsi flap reconstruction (back flap)
TRAM or DIEP flap reconstruction (tummy flap)
Symmetrising surgery of the other breast is sometimes required to match the reconstructed side better
A/Prof Mak and Dr Graham only do implant-based reconstruction. They work with a number of plastic surgeons who perform the other types of reconstruction. To fully understand your options, they recommend you speak to a plastic surgeon as well.
Implant Reconstruction
Implant reconstruction involves using a silicone gel implant or saline filled tissue expander (later replaced with a permanent silicone gel implant).
Breast reconstruction using an implant can be performed either as a:
Single stage operation/“Direct to Implant” - the permanent silicone gel breast implant is inserted immediately after the mastectomy
Two stage operation - a saline filled tissue expander is inserted after mastectomy. At a later operation, it is later replaced with a permanent gel silicone breast implant.
The most suitable option depends on number of factors including your current breast size, desired breast size, body shape and cancer-related factors as well as taking into account any other medical problems you may have.
Single Stage “Direct to Implant” Reconstruction
Depending on the size and location of the cancer and your breast size and shape, the breast skin and nipple can be preserved at the time of mastectomy. This means that it may be possible for the permanent implant do be inserted at the same time as the mastectomy.
The implant is placed beneath or in from of the chest muscle (pectoralis). Dr Graham will discuss this with you. Part or all of the implant is often covered in a “mesh” or support sling (IMAGE) which helps keep the impact in the correct position.
“Direct to Implant” operation are complex surgical procedures and therefore have higher carry a higher risk of complications. Dr Graham will have a detailed discussion with you to ensure this is the right option for you and to discuss the possible risks.
Two Stage “Tissue Expander” Reconstruction
A tissue expander is inserted after mastectomy when skin and/or muscle need to be stretched to make enough room for an implant, or to avoid tension on the skin flaps after the mastectomy.
A tissue expander is a silicone shell or “balloon” that can be filled with saline (salt water) via an injection port. It is a temporary implant that is filled over the period of weeks to months until it is the correct size. When it has reached the right size, the expander is removed and it is replaced with a permanent silicone gel implant. Occasionally, the tissue expander can be used before an autologous or tissue based reconstruction.
Advantages
Relatively short procedure
Relatively short hospital stay
Quicker recovery than with tissue flap (autologous) reconstruction
Only scar is on the breast/chest area (no additional scar elsewhere on the body)
Disadvantages
The reconstructed breast may not look as natural as tissue flap reconstruction
It is difficult to reconstruct a very large breast with this technique
The reconstructed breast does not change over time. It will not “droop” like normal breast will and will not change in size with weight loss or weight gain. Over time, the difference between the reconstructed and normal breast may become more obvious.
It may be possible to feel the edges of the implant or see the edges of the implant “rippling”
Infection may occur. If this happens, antibiotics and/or treatment with specialised dressings may be required. If this occurs, it is possible that the implant may need to be removed.
In some cases implants need to be removed over time as the implant becomes hard or misshapen due to “capsular contracture”. The risk of this happening is significantly higher if you need radiotherapy.
If you need radiotherapy, the results may not be as good and the risk of complications is greater. Dr Graham may suggest alternative reconstruction options if radiotherapy is required to treat your cancer.
Breast implants have been associated with a rare type of cancer, breast implant associated cancer (BIA-ALCL). Dr Graham will discuss the type of implant being used, in addition to the risks and benefits of using breast implants in your case.
Tissue Flap Reconstruction
Tissue flap reconstruction uses tissue from your body (fat, skin and/or muscle) to recreate a breast shape. Tissue can be taken from the abdomen or back and moved to the chest. Flap reconstruction is a more complicated and involved procedure than implant reconstruction, however the final result is more natural in feel and appearance. Occasionally a combination of a flap and implant may be recommended.
Flap reconstruction is not suitable for everyone. A/Prof Mak and Dr Graham do not perform tissue flap reconstruction; they work closely with plastic surgeons who will perform this procedure if it is required. A/Prof Mak or Dr Graham will discuss whether this procedure is an option for you and will refer you to a plastic surgeon, if required, to discuss this further.
Types of Flap Reconstruction
Transverse rectus abdominus muscle (TRAM) flap or deep inferior epigastric perforator (DIEP) flap – tissue is taken from the lower abdomen and moved to the chest. The blood supply is disconnected and reconnected to blood vessels in the chest with microsurgery (free flap).
Latissimus dorsi (LD) flap – tissue is taken from the back and tunnelled under the skin to the chest. The blood vessels remain connected (pedicled flap). Sometimes extra volume is required to match the other breast and an implant or tissue expander is placed under the flap.
Other - less commonly thigh or buttock tissue can be used for tissue flap reconstruction
Advantages
Flap reconstruction can result in a very natural looking reconstructed breast
The reconstructed breast will change with your body (for instance if you lose or gain weight)
It is a good option for delayed reconstruction following radiotherapy
Disadvantages
Flap reconstruction is a long procedure. The operation takes at least four hours to perform
The recovery period is much longer than it is following implant based reconstruction
There is an additional wound (from where the tissue is taken from e.g. back or abdomen)
What Will My Reconstructed Breast Look Like?
It is important to have realistic expectations about breast reconstruction. The aim of breast reconstruction is to provide the contour or shape of a breast so that when wearing most types of clothing, including swimwear, you look normal. A reconstructed breast will never look or feel exactly the same as your breast.
How Does Breast Reconstruction Affect My Breast Cancer Treatment?
Reconstruction does not normally interfere with other breast cancer treatments (like radiotherapy, chemotherapy or anti-hormone treatment). The different parts of your treatment will be coordinated so that reconstruction does not delay important cancer treatment. There may be situations when your cancer specialists recommend delayed rather than immediate reconstruction to make sure that cancer treatment is not delayed.
If you require radiotherapy, there are some special considerations with breast reconstruction. When radiotherapy is given after a reconstruction, there may be hardening (capsular contracture) around the implant or shrinkage of the tissue flap.
A/Prof Mak and Dr Graham will discuss with the options with you and the timing of treatments to ensure that we recommend the most appropriate reconstruction option for you.
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A/Prof Mak and Dr Graha advocate the National Law and Australian Health Practitioner Regulation Agency (AHPRA) guidelines that any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.