Breast cancer

04 March 2008

Types of breast reconstruction

The various types of breast reconstruction include the following:

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1. Prosthetic:
This is a commonly-used type of reconstruction. The prosthesis is inserted under the muscle or under the breast skin. The size of the breast that can be constructed is dependent on the amount of skin available.

Silicone prostheses are the most commonly used. They have been shown to be safe and are longer lasting than saline.

The shape of the prosthesis is generally round but contoured prostheses may be used. The shape used should be discussed with your surgeon.

Pros
The procedure does not add many hours to a simple mastectomy.

If radiotherapy is required (unexpectedly) and does give complications, the prosthesis may be removed and replaced.

Should there be poor wound healing and the reconstruction fails, the removal of a prostheseis is a relatively small procedure.

Cons
In the long run, asymmetry of the breasts will increase. The natural breast will tend to drop. The prosthesis will not.

Should any infection occur, the prosthesis will have to be removed. If there are problems with wound healing, the prosthesis may need to be removed.

Some women develop capsule formation. This results in the breast becoming very round and hard. It may occur soon after the reconstruction or many decades later.

Rupture of the prosthesis is a rare event and will only happen after major force has been applied to the prosthesis. Silicone may cause lumps in the breast and it would have to be removed should that happen.

Autologous reconstruction
This involves a reconstruction using a woman’s own tissues. Either muscle or fat is used.

In order for any tissue to stay alive, it must receive a blood supply. This means that either the native blood supply must stay intact or the vessels within the tissue must be joined to local blood vessels. These flaps are known as free flaps.

There are several advantages over prosthetic reconstruction. With time, the reconstructed breast will tend to drop at a similar rate to the natural breast so the symmetry will tend to remain. It also means that a foriegn body is not being placed in the body. With that is a lower risk of infection.

Skin overlying the muscle or fat may be part of the flap. This means that the skin over the flap may be used to increase the size of the breast being reconstructed. It is not limited by the natural skin overlying the chest wall.

There are different methods of autologous reconstruction:

A. Latissimus dorsi (LD) flap:
A section of muscle and skin is removed from the back (the latissimus dorsi muscle), with the attached pedicle which provides the blood supply to the flap. The flap is tunnelled under the skin, pulled out through the original mastectomy wound and the site of the original breast. This procedure leaves a scar on the back. The muscle is used to recreate a breast mound. The procedure is a reasonably long operation and is fairly painful.

Pros
The LD is a robust flap. If radiotherapy has to be given, it will withstand radiotherapy well and rarely causes many problems. The flap may be used in tissue that has already received radiotherapy.

As the breast is made from the patient’s own tissue, it will tend to age in a symmetrical fashion.

Cons
The site of the original muscle (the back wound) tends to cause more problems than the reconstructed breast itself. Fluid may build up there (seroma formation) and may need draining.

There may not be enough muscle bulk to recreate the whole breast, so this procedure may be combined with a prosthesis.

B. TRAM (Transverse Rectus Abdominous Muscle) flap:
A section of skin, underlying fat and a portion of abdominal muscle is excised from the abdominal wall. The tissue (skin and fat) requires its own blood supply. This is taken from the underlying muscle (the rectus abdominus) so leaving a flap of tissue with the natural blood supply. The flap is tunnelled under the abdominal wall to the chest and to cover the mastectomy wound. The edges of the breast incision are sutured to the flap.

Pros:
The TRAM flap creates a natural texture and can be shaped to match the other breast.

The fat ages at a similar rate to the native breast and thus symmetry is maintained with time.

A ‘tummy tuck’ i.e. abdominoplasty is performed at the same time allowing a woman to loose her abdominal bulge.

Extra skin may be taken to the site and thus the size of the breast is not limited by the remaining skin from the mastectomy.

Cons
It is a long operation. Generally, in surgery, the longer the operation, the more the complications!

Some women experience abdominal weakness, and there is increased risk of developing abdominal hernia (bulging of internal tissues through an area of abdominal wall weakness).

The patient’s natural breast skin may be used or the skin may be transplanted from the tummy. The advantage is that a ‘tummy tuck” is done at the same time..

DIEP (Free flap):
This is being performed in specialist centres. An "island" of fat and skin is cut free from the abdomen and stitched in place over the mastectomy wound. Microsurgical techniques are used to attach the blood vessels supplying the flap to those in the chest wall. Since it is not necessary to remove as the abdominal muscle, some side effects of the TRAM procedure are avoided.

Nipple Reconstruction
Nipple reconstruction can be done in conjunction with reconstructive breast procedures but is usually done after the reconstruction has healed. Tissue from the upper inner thigh may be used. The areola can be tattooed with flesh-colored pigment.

 

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