Breast reconstruction overview

About a third of mastectomy patients choose to have the breast rebuilt using prosthetic implants and/or tissue from other parts of the body (autologous tissue reconstruction).

Breast reconstruction may be done at the same time as the mastectomy (immediate reconstruction), or after all cancer treatment is finished (delayed reconstruction). Immediate reconstruction may lessen the emotional impact of mastectomy, but the operation is longer and increases the chance of problems as the wound heals.

Lumpectomy patients may benefit from reconstruction if a large amount of tissue has been excised. However, a lumpectomy is usually followed by radiation therapy, and irradiated tissue tends to heal poorly. Changes may continue in the shape of the breast for months after treatment. For the majority, the aim of BCT (breast conservation therapy) is to avoid reconstruction.

Why?
After any form of breast cancer surgery, many women find the resultant breast asymmetry the most constant reminder of their cancer. The aim of breast reconstruction is to minimise the asymmetry.

Breast reconstruction may be necessary after a total or partial mastectomy. In principle, symmetry may be acheived by modifying the non-cancerous breast (reduction or enhancement) or by rebuilding the breast that had the breast cancer.

A reasonable reconstruction should allow a woman to feel symmetrical especially when dressed. It generally allows the woman to wear a swimsuit and proceed with general daily activities without having to worry abaout an external prosthesis.

When should reconstruction be performed?
It is very important that any woman who has just been diagnosed with breast cancer should have time to come to terms with the diagnsosis and make a decision about the type of surgery that is appropiate for them. This means that first, the decision about the surgery for the breast cancer. Is breast conservation possible or should a mastectomy be considered? (see breast cancer section).

The timeing of the reconstruction depends on:

When making the decision, it should always be remembered that the long term appearance is the most important and this should not be compromised for short term gain.

1. Immediate reconstruction
Ideally, reconstruction is performed at the time of the original breast cancer surgery. This is not always appropiate or the option that will give the best longterm result. Immediate reconstruction means that as much breast skin as possible is left at the time of surgery. A mastectomy performed in this way is known as a skin sparing mastectomy.

Generally the skin over the breast cancer and areola/nipple will have to be removed as part of the cancer surgery. All the rest of the skin of the breast can be left. The breast is then reformed using either a prosthesis or a woman’s own tissue (see below).

To get a good result, there has to be excellent healing at the time of surgery. Patients who may have poor wound healing would include those who have had prior raditherapy, smokers, those with impaired immune systems (e.g. diabetes) or patients with hypertension. Each of these factors would have to be weighed up against the woman’s general health.

2. Delayed reconstruction
This may be done in 2 ways. If a woman knows she will want a reconstruction but has not got enough skin to allow for an immediate reconstruction, a tissue expander may be placed at the time of surgery. A tissue expander is a silicone envelope that is flat on initial insertion. This means a woman intially has a flat chest but the space either under the muscle/skin is gradually stretched with saline to allow the placement of either muscle/fat or prosthesis as a second precedure.

This may be done at the same time as chemotherapy/radiotherapy is being given. The expansion takes place every week or two for a few months. Saline is injected through a valve until the expander is inflated to a size slightly larger than the implant. This stretches the skin until the surgeon can replace the expander with a permanent implant. (Some implants combine the expander and the permanent implant. After the skin expansion is complete, the filling valve is sealed and the expander remains as a permanent implant. )

Some women will need radiotherapy after the mastectomy. Radiotherapy impairs wound healing and will cause some tissue to die (eg fat used for a reconstruction). At the time of initial presentation of the cancer, it may be clear that for complete cancer treatment, radiotherapy and a mastectomy will be necessary Generally, an immediate reconstruction is best avoided in these circumstances. Either a delayed reconstruction could be considered or insertion of an expander.

There are many decisions to be made at the time of diagnosis and some women prefer to wait until the inital stages of management of the breast cancer are over. If this is the case, a delayed reconstruction should be considered. If a woman is undecided, they should not embark on an immediate reconstruction: they can always decide to have a delayed reconstruction later. It is not sensible to go backwards after the insertion of an expander or immediate reconstruction.

Types of reconstruction
1. Prosthetic:
This is a commonly used type of reconstruction. The prosthesis is insrted 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.

Advantages
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.

Disadvantages
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 foreign body is not being placed in the body. With that comes 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.

Advantages
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 patients own tissue, it will tend to age in a symmetrical fashion

Disadvantages
The site of the original muscle (the back wound) tends to cause more problems than the reconstrcted 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) and so leaves 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.

Advantages:
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’ ie abdominoplasty is performed at the same time allowing a woman to lose 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.

Disadvantages
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 some 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 are usually after done after the reconstruction has healed. Tissue from the upper inner thigh may used. The areola can be tattooed with flesh-coloured pigment.

Important points about the principles of breast reconstruction
When reconstruction was started as a technique, there were misgivings about whether or not the patient who had had the reconstruction would do as well from a cancer point of view as a patient who had not had a reconstruction. It is now clear that that is not the case. Importantly, the following points are all well proven:

• The way the breast cancer behaves is not affected by whether or not a reconstruction is performed. I.e., a breast cancer is NOT more likely to spread or come back after a reconstruction has been perfomed.
• Having a breast reconstruction does not mean that the treatment of the cancer is in any way compromised.
• Immediate reconstruction does not alter the outcome of the breast cancer.li>
• Reconstructions do not interfere with treatment of systemic disease. I.e, should the cancer spread around the body at a later date, the standard treatment for the disease could be given.
• Immediate reconstruction does not interfere with detection of local recurrence i.e., if the cancer should come back on the chest wall, it could still be detected easily.
• The need for postoperative chemotherapy is not a contraindication to immediate reconstruction.

Summary
The management of the breast cancer is the most important part of the surgery and should never be compromised in order to get a good cosmetic result. If the reconstructive process needs to be put on hold to allow chemotherapy/radiotherapy to be given, then reconstruction would continue later.

Reconstruction is a possibility for many women and should always be discussed.

The long-term results are important and shouldn’t be comprised for short-term gain.

(Written by Dr Jenny Edge, breast surgeon)