Breast reconstruction

• Delayed breast reconstruction
• Immediate reconstruction
• Types of reconstruction
• Prosthetic reconstruction
• Advantages and disadvantages of prosthetic reconstructions
• Reconstructions using the patient’s own tissue
• TRAM flap
• Advantages and disadvantages of TRAM flap
• Latissimus dorsi flap
• What about the nipple in reconstruction
• Breast reconstruction in summary

Breast reconstruction may be delayed or immediate. The aim is to create a breast that is similar to the breast as it was before the operation or similar to the breast on the other side.

The procedure may be done as part of the original cancer operation or may be done at a later stage.

There are different procedures that may be used and there is no one that "fits all". The healthy breast on the other side may also be operated on at the same time. For example, a breast reduction may be done on the other breast to help the matching process.

Delayed breast reconstruction

Traditionally, it was done six months after the cancer operation. There are advantages to this and this may still be the best for some people.

Advantages of delayed reconstruction:

• Mastectomy is not a very painful operation and the postoperative discomfort is often psychological as much as physical. Having the reconstruction makes the operation bigger and more painful.
• Some women find that having a flat chest is acceptable and choose not to have a reconstruction after some time.
• If postoperative radiotherapy is needed, it may cause distortion of the breast after reconstruction.

Disadvantages of delayed reconstruction:

• When a regular reconstruction has been done, the chest wall will be flat. In order to allow for a reconstruction, the skin either has to be "stretched" or skin has to be used from another part of the body e.g. the tummy or the back.

Immediate reconstruction

Advantages of immediate reconstruction:

• Only one procedure is necessary.
• The mastectomy can sometimes be done through the nipple so the normal breast skin can be used for the reconstruction.
• The results are better cosmetically.
• The patient’s nipple may sometimes be used if the cancer is at the edge of the breast tissue.
• The psychological trauma after the operation is less as the patient can wake up from the operation with a “breast”.

What types of reconstructions are there?

• Prosthetic reconstructions: silicon or saline.
• Reconstructions using the patient’s own tissue: this may be muscle from the back or fat from the tummy.

Prosthetic reconstructions

There are two types that are commonly used: saline or silicon. Whatever type is used, the implant is composed of a capsule containing the fluid. There may be problems associated with the capsule or the type of fluid within it.

Silicon has had a lot of bad publicity when used for breast augmentation in America although it is still widely used for reconstructions elsewhere. Most of the links with other diseases such as connective tissue diseases have not been proven. The advantages of silicon are that the breast feels more like breast tissue.

Saline has been used instead of silicon. Although it has not been associated with other disease processes, the saline more commonly leaks out into the surrounding breast.

The capsule may become hard with time. It is more likely that this will happen if the patient has radiotherapy to the breast.

The prosthesis may be inserted as the size it will be or may be injected with fluid to stretch the overlying tissue over time.

For reconstruction after mastectomy, the prosthesis is inserted under the muscle. A pocket of muscle may be formed from the muscles over the back or from the muscle underlying the breast.

Advantages of prosthetic reconstructions

• The operation is smaller than using the patient’s own tissue.
• The size may be altered according to the size of the opposite breast.

Disadvantages of prosthetic reconstructions

• Involves the insertion of a "foreign body". Although there is no good evidence to suggest that it causes any problems for the body, many women don’t like the thought of it.
• The capsule may harden with time.
• The capsular contents (silicon or saline) may leak out.

Reconstructions using the patient’s own tissue:

The bulk of the breast may be made from muscle or fat. The muscle used is usually from the back (the latissimus dorsi muscle) and the fat from the patient’s tummy (TRAM flap).

TRAM Flap

The best tissue to use as a replacement for breast tissue is fat. If the skin covering the breast can be kept then the sensation to the breast remains largely unaltered and this combination is the most acceptable for many patients. If the skin overlying the breast needs to be removed or the procedure is done as a "delayed reconstruction" then the skin from the tummy (abdomen) can be used.

Any tissue requires a blood supply. The tummy fat usually gets its blood from the underlying muscle (the rectus abdominus). If the fat from the tummy is to be used, the fat needs to take its blood supply with it. To achieve this the muscle has to be removed to provide the blood supply.

The procedure is only suitable for patients who are relatively young (< 60 yrs), are non-smokers and do not have diabetes. There are far more complications if any of these diseases are present.

Advantages and disadvantages of a TRAM flap

Advantages:

• This reconstruction will give the best cosmetic result out of all the options and the most natural "feeling" to the reconstructed breast.
• The tummy is "tucked" at the same time.

Disadvantages:

• The operation is a big procedure. There may be a need for blood transfusions.
• There may be patchy areas of skin loss around the nipple.
• There may be problems with the abdomen - infection, pain or swelling.
• The cosmetic results take six months to achieve their final appearance. The woman may be disappointed with the results in the meantime.

Latissimus Dorsi Flap

This involves using the muscle from the back with the overlying skin. It was the standard form of reconstruction but is only done in a few patients now.

Disadvantages:

• It is difficult to get enough muscle to recreate the shape of the breast.
• The consistency is different from normal breast tissue.

Advantages:

• It is not such a large procedure as a TRAM flap.
• It can be used in combination with a prosthesis.

What about the nipple in reconstruction?

Some women do not wish to have a nipple recreated immediately. The options available are increasing. Occasionally, the cancer is away from the nipple and very small in size. This may mean that the nipple itself may be used as a reconstruction. The other options are that skin from elsewhere in the body may be used. The skin can be tattooed or shaped to be similar to the other breast. This may be done at the time of the reconstruction or at a later date.

Many women do not feel that they want a nipple at all. They prefer to have an acceptable "mound" to put in their bra and not have to wear a prosthesis.

Summary

There are many possibilities when the question of reconstruction is considered. There is no correct answer.

The options depend on:

• The stage of the cancer and the type
• How healthy and young you are
• What your figure is like
• What the other breast looks like
• What cosmetic result you will find acceptable and how much you are prepared to go through to achieve it

Read more
Breast surgery: the how and why