Breast Reconstruction - A Guide for Women

Breast reconstruction

Breast reconstruction is usually an option for women who had a mastectomy due to breast cancer. A reconstruction often involves a sequence of operations rather that a single procedure.

 

Why you may choose to have breast reconstruction

  • Re-establish your body symmetry
  • Your breasts look balanced when you wear clothes
  • The convenience of not requiring an external breast prosthesis
  • You may feel more attractive and feminine, with improved self-esteem
  • Resolution of breast cancer treatment

 

Decisions to be made around your breast reconstruction

There are a number of choices when we plan your breast reconstruction. These choices depend on several aspects of your personal medical history. They include the timing of reconstruction which can be immediate or delayed, as well as the type of reconstruction. Reconstruction types include implant reconstruction, TRAM flap (‘tummy tuck’ flap) and Latissimus Dorsi Flap (‘back flap’) reconstruction.

 

Is an immediate or a delayed reconstruction right for me?

An immediate reconstruction is performed at the same time as your mastectomy. During an immediate reconstruction, I may be able to preserve some of your breast skin to give your breast a more natural appearance. It also means one less operation. However, immediate reconstruction will increase the operating time, time in hospital and recovery time, compared to mastectomy alone.

Delayed reconstruction occurs after you have completed all treatment for breast cancer. This may be advised if you are likely to have radiotherapy or chemotherapy following your reconstruction. There are a number of reasons for this. Firstly, I do not want you to have any delay in beginning adjuvant treatment (chemotherapy and radiotherapy) due to late-healing wounds and one of the possible complications of breast reconstruction is that your wounds can take longer to heal than expected. Secondly, radiotherapy after a reconstruction may make the reconstruction less successful due to scarring from the radiotherapy.

Having to cope with breast cancer AND making decisions about breast reconstruction is a lot to deal with. Sometimes “getting the cancer treatment over with” and then, when you are recovered, thinking about reconstruction, can be the best option. In any case, I will talk you through your options at any stage in the process, and answer any questions you may have.

 

Types of breast reconstruction

Implant reconstruction

Implant reconstruction is often considered the ‘simplest’ method of breast reconstruction, but it is technically very demanding. It is generally not recommended if you require, or have undergone radiotherapy treatment. Radiotherapy will eventually create much scarring around the reconstruction and make the reconstruction un-natural, tight and uncomfortable.

For an immediate reconstruction, an implant reconstruction can usually be performed in one stage (one operation).

For a delayed reconstruction, two operations are required as the skin and soft tissue needs to be gently stretched (using an expander) to accommodate the implant.

Implants are made of silicone and placed underneath the pectoralis muscle of your chest wall, recreating the breast mound.

 

Immediate reconstruction – One stage techniques

  • For small to moderate breasts: A pocket is created to hold the implant; the upper half of the silicone implant is placed under the pectoralis muscle and the lower half under the Acellular Dermal Matrix (ADM). Your original breast volume should be retained if your nipple and areolar are preserved, or may be slightly smaller if the nipple and areolar need to be removed.
  • For moderate to larger breasts: Reconstructing a very large breast is difficult. A somewhat smaller and more youthful breast is created by using your own skin to help in forming the lower half of the pocket for the implant.

 

What is Acellular Dermal Matrix (ADM)?

Acellular dermal matrix (ADM) is a tissue substitute that is sometimes used to help create the pocket for the implant. The original tissue comes from specially prepared animal skin (pig or calf) that is chemically stripped of all cells so the body accepts it; the result is a soft, supportive tissue that helps support the implant and hold it in the correct place. The ADM is incorporated into the body over time.

 

Delayed reconstruction – Two Stage technique

Skin expansion is required to replace the skin lost after a mastectomy and an expander (silicone balloon) is placed beneath the pectoralis muscle during the first operation. Once the wound is healed, there is a ‘port’ within the expander that can be accessed via a small needle through the skin. Saline is then injected into the expander port over a number of clinic visits. This is not especially painful as the skin of the site of a mastectomy is usually numb. The skin is gently stretched until the desired volume is achieved. Then it may be stretched a little more to provide a degree of natural droop / softness. At a second operation, 3-6 months later, the expander is exchanged for a silicone implant (second stage).

The first operation takes about 2-3 hours, and you will need to stay in hospital for 2-4 nights.

Please plan ahead for your return home, as you will need help with childcare, shopping and housework for about 3 weeks. You also won’t be able to drive for 3-4 weeks. Depending on your occupation, you will be off work for 3-6 weeks. You can expect to return to full function around 6 weeks after the operation.

 

Advantages of implant based reconstruction

  • Simple and flexible technique
  • Short operation time and hospital stay
  • Shorter recovery time
  • Easy to detect local cancer recurrence
  • Can be used for bilateral reconstruction

Disadvantages of implant based reconstruction

  • Expansion process of two-staged reconstruction can be inconvenient
  • Difficult to achieve a ‘natural’ look - the gentle natural softness that occurs with aging
  • Difficult to achieve symmetry
  • The reconstructed breast will always have a very pert and youthful appearance and will not age like a natural breast.
  • Much less suitable if radiotherapy has been performed or is expected. This is due to a higher risk of complications and poor result.

 

Latissimus Dorsi (LD) Flap + Implant Reconstruction

The flap consists of muscle (latissimus dorsi), skin and blood vessels from your back. The flap is tunnelled under the skin and around to the front of the chest. The flap and an implant are used to create a breast mound. In an immediate reconstruction, the flap and implant are placed behind your breast skin. In a delayed reconstruction, some of the skin of your back forms the skin of the new breast. If a larger volume reconstruction is required, an expander may need to be used to gain additional volume (please read about expander based reconstruction in the above section).

The LD Flap operation takes about 4-6 hours. You will need to stay in hospital for 4-6 days.

Please plan ahead for your return home, as you will need help with childcare, shopping and housework for about 3 weeks. You also won’t be able to drive for 4 weeks. Depending on your occupation, you will be off work for 6-8 weeks. You can expect to return to full function around 8-12 weeks after the operation.

 

Advantages of LD flap reconstruction

  • Reliable, low rates of failure (<1%)
  • Can produce a natural feeling breast
  • Large volume reconstruction possible, (may require an expander)
  • Can be used for a bilateral reconstruction

Disadvantages of LD flap reconstruction

  • Scar on the back
  • Back skin may have a colour mis-match with the natural chest wall skin
  • Difficult to achieve symmetry
  • Weakness of the shoulder muscles. This usually responds well to physiotherapy and strengthening exercises and by 2-3 months most women are back to their usual activities. However for athletes or women whose occupations or hobbies depend on shoulder girdle strength e.g. rowing, swimming or mountain climbing, then other reconstructive options may be considered.
  • Not suitable if you have had some forms of previous surgery, for example a thoracotomy, on that side.

 

TRAM Flap

Many women have some excess abdominal tissue that is perfect for making a breast. This creates a very natural breast without the need for an implant or expander. I harvest the tissue from the abdomen, in a similar way to a ‘tummy tuck’, which leaves a long scar over the lower portion of the abdomen. The tummy button is preserved and repositioned at the end of the operation. The flap includes one of the rectus abdominus muscles (one of the ‘six pack’ muscles) that provides blood supply to the flap and keeps it alive. The entire flap (rectus muscle, fat and skin) is rotated up through a subcutaneous tunnel to create the new breast.

Losing one of your rectus muscles can create weakness of your anterior abdominal wall; however post-operative physiotherapy and exercise programmes will usually ensure good recovery. Patients are often concerned that their core strength will be reduced. If you ski, horse ride or cycle, it is very likely you will be able to get back to these activities. I replace the rectus muscle with mesh to reduce the chance of hernia formations or a bulge in the abdominal wall following surgery.

To improve blood supply to the flap, I perform a short operation in the month leading up to the main procedure to divide one of the blood vessels that supply the flap. This is called a ‘delay procedure’ which takes about an hour. I can perform it as a day case, or you may need to stay in hospital for one night. The procedure helps enhance the blood supply within the tissue that will be transferred.

The TRAM operation takes about 6-8 hours, and you will need to stay in hospital for 4-6 days.

Once you return home, please have assistance in place for childcare, shopping and housework for about 4 weeks. You may drive again 4 weeks after the operation, and you can return to work about 6-8 weeks. Expect to return to full function 2-3 months after the procedure.

 

Advantages of TRAM reconstruction

  • Large volume, natural feeling breast
  • No implant required
  • Ages in a similar fashion to the remaining breast

Disadvantages of TRAM reconstruction

  • Not suitable if both breasts require reconstruction
  • Fat necrosis (fat dies due to poor blood supply) may cause lumpiness or discharge of fatty fluid from the new breast. Usually settles over time.
  • Abdominal wound and tummy button wounds may take a long time to heal
  • Tummy button may be lost
  • Hernia or abdominal wall weakness (extremely rare)

 

What is a DIEP flap?

In a DIEP (deep inferior epigastric artery perforator) flap, the rectus muscle is spared and the blood vessels are divided and re-anastomosed, using a microscope, to vessels in the chest beside the sternum. The benefit of this operation is that more of your abdominal tissue can be taken for reconstruction (it may be possible to reconstruct both breasts) and your abdominal muscles are spared (reducing the risk of hernia). However the operation is much longer, the need to return to theatre is greater and if the operation fails then the entire flap is lost. It also requires very specialized post-operative care. I do not provide this procedure in Dunedin, but I can refer you to Christchurch if it is something you would like to consider.

 

How do I know which reconstructive options are available to me?

When we talk about which types of reconstruction may be options for you, we will need to consider the following factors:

  • your overall health and fitness for long anaesthesia
  • your weight
  • whether you smoke
  • risk factors for complications: diabetes, steroid use
  • the size and shape of your natural breasts
  • the size and stage of your breast cancer
  • whether you will need additional chemotherapy or radiotherapy
  • whether you require bilateral reconstructive surgery.


Will I need any further operations?

Breast reconstruction can be a long process and may require three operations. The first operation creates a new breast. This is generally the biggest operation, with the longest recovery time. Sometimes a second operation is required to reduce or increase the size remaining breast to match, or exchange the expander for an implant or simply to optimise symmetry between both breasts. Finally, when we are both happy with the size and shape of your new breast, a nipple reconstruction can be performed.

 

Procedures on the remaining breast

An operation may be required on your remaining breast to optimize symmetry between both breasts. This may involve a breast reduction or an augmentation.

 

Nipple reconstruction

This will hopefully be your final operation! A nipple is created out of your breast skin: small flaps are elevated and folded to create the nipple. When it is healed then the nipple and areola are tattooed to match your natural breast.

 

Your Operation and what you can do to Optimise your Recovery

Smoking cessation

Like most reconstructive surgeons, I will not proceed with reconstructive surgery while you are smoking or on nicotine replacement therapy. Smoking cessation will greatly improve the healing and recovery from your operation and ensure that you have the best outcome possible.

 

Weight loss

Having a normal body mass index (BMI) greatly improves your body’s ability to come through the operation and anaesthetic without incident. It lowers the rate of wound healing problems and infection.

 

Pre-assessment clinic

This assesses your general health and fitness before surgery. You will meet an anaesthetist and discuss your anaesthetic. Please bring a list of all your regular medication. Blood tests, an ECG and occasionally a chest x-ray are required.
This is where we talk again, discuss your operation in detail and ask you to sign the consent form. Please allow a few hours for the pre-assessment clinic to be completed.

 

On the day of your operation

You must consume no food by mouth for 6 hours before the operation. This includes sweets and chewing gum. Any food in your stomach could cause choking and damage to your lungs under anaesthetic.

It is okay for you to drink clear fluids such as water, black tea or black coffee up to two hours before your operation. Please take your normal medications the morning of surgery. Should you become unwell near the time of surgery, please let me or my team know, as it may be safer to postpone your operation.

 

Your post-operative recovery

After your operation, you will wake up in the recovery area and then transferred back to the ward. The nursing staff are very experienced and will ensure your post-operative course is as straight-forward and comfortable as possible. They will monitor your new breast to check all is well. Drains will be placed around the breast and donor site to allow any excess fluid to drain away. The drainage is measured.

I like you to keep your new breast(s) warm and covered with a fleecy blanket (passive heating rather than active heating) at all times. If you become too hot, feel free to stick your feet out from under the blanket, but keep your breasts toasty and warm at all times!

Your new breast and tummy (if you have had a TRAM reconstruction) will be numb and this is permanent. Please do not put hot water bottles, hot wheat bags, etc… on these areas as burns may occur without your notice.

You may have a catheter (a tube that runs into the bladder to drain urine) for a few days.

You will have pain relief to make sure you are as comfortable as possible. There will be some discomfort but it should be manageable. If your pain is not well controlled, please let us know as occasionally some women have nerve mediated pain (LINK to complex regional pain syndrome – see complications) that requires special medicine for control. This type of pain is often described by patients as burning, throbbing or like an ‘electric shock’. It is very unpleasant, but responds well to special medication.

After the operation, you will have an injection into your tummy or thigh to thin your blood and prevent clots developing. The nurses will teach you to give this injection to yourself, as it is beneficial to have the injection for 28 days in total, as so it will continue when you go home.

You will also wear compression stockings and may have compression pumps on your calves, also to help prevent clots developing.
Physiotherapists will visit you and provide you with exercises to optimise your recovery.

You will be able to shower 48-72 hours following your operation.

 

After you go home

You will need to rest and take it easy. Make plans to have people around who can look after you, take over childcare, prepare meals and look after your house. There will be a period of some weeks before you can drive again.

Sometimes, I may recommend you wear a non-wired supportive bra for 23/24 hours for six weeks.

If you have had a TRAM reconstruction you will need supportive or ‘shaper’ knickers to wear for six weeks. These should be firm and come up to under your bust. They help your tummy heal. After a TRAM type reconstruction, it is likely you will need to self-administer blood thinning injections for 28 days. The nurses on the ward will teach you how to administer these injections at home. Alternatively district nurses may visit at home to do this for you.

I will ask you to tape your wounds for six weeks following surgery. Both Micropore and Hypafix tapes are suitable, and you can buy them from your local pharmacy. After six weeks, and when your scar is healed, you can massage it for 5 minutes twice a day with a plain, unscented, hypoallergenic moisturizing cream. It is very important that you avoid exposure to UV light for two years following the operation. You can either use a high factor sun block or avoid sun exposure altogether.

Your breasts will feel tender and you may not feel up to physical contact initially - resume sexual activities as you feel comfortable. Your partner may be afraid of hurting you, and women may interpret reticence as a lack of desire. As a couple, you need to talk over your fears and feelings.

 

So how do I decide between the types of breast reconstruction available to me?

You will have many questions to ask me before having a breast reconstruction. Bringing a support person and writing the questions down before you come to see me may help you to make decisions. More than one consultation may be required to reach a decision.

This list may include the following questions:

  • What kind of reconstruction is best for me? Why?
  • Will the reconstructed breast match my remaining breast? Will I need an operation on my remaining breast to improve symmetry?
  • What are common risks and complications?
  • How long is the recovery time?
  • How will the breast change over time?

 

Important factors to consider

Your body image and self-esteem may improve after reconstruction, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery.

The difference between a reconstructed breast and the remaining breast can be seen when you are nude; the reconstructed breast will not feel the same sensations as a normal breast.

Surgeons may suggest you wait for various reasons – this is usually to improve the outcome of the reconstruction. Waiting until after radiotherapy and chemotherapy will mean there is no chance of delay in your cancer treatment. Weight loss will reduce the risk of anaesthetic and wound healing complications.

Smoking cigarettes (nicotine) precludes breast reconstruction. Breast reconstruction is not undertaken until 2 months following cessation of all forms nicotine consumption.

Your final reconstruction may require three to four operations: the initial reconstruction, surgery to improve symmetry between the breasts and then the nipple reconstruction. The initial operation tends to have the longest recovery time; the others have a progressively faster recovery time.

 

Possible Risks & Complications

All surgery and anaesthesia carries some uncertainty and risk. I do my best to minimise untoward events, and serious complications are fortunately rare.

 

General complications:

Haematoma (bleeding)

Bleeding may require a second operation to control the point of bleeding and remove the collection of blood. If this happens a blood transfusion may be required. If you have strong philosophical objections to receiving a blood transfusion please let me know.

Infection

Wound infection can occur after any surgical procedure. An infection will often require antibiotics. This may be associated with wound breakdown (see below). Smoking increases the risk of infection.

Wound breakdown (wound healing problems)

Wounds may not heal in a straightforward fashion. The area may ‘breakdown’, meaning it takes longer to heal; the area may require regular dressings or even a return to theatre to remove dead or infected tissue. Areas of wound breakdown often result in thicker, more obvious scars. Smoking and obesity increase the risk of wound breakdown.

Scars

Any operation leaves permanent scars. Most scars will eventually settle to become pale, fine lines – this may take up to 12 months. Some people develop hypertrophic or keloid scars, which are raised, thickened, itchy or red – these may need steroid injections and silicone therapy to improve. If you have a tendency to poor scarring, please let me know. Sometimes scars need a further small operation to improve their appearance.

Seroma

Sometimes a collection of fluid occurs following the operation, either around the reconstructed breast or in the area that was harvested to create the new breast. The drains will remove the fluid in the immediate post-operative period. If the fluid accumulates after the drains have been removed then the fluid will be aspirated (removed) using a small needle and syringe. Usually the area that the needle passes through has reduced (or no) sensation due to the operation.

Deep Vein thrombosis (DVT)

A blood clot in the legs is a serious complication following surgery and bed rest. A clot in the leg can break off and pass to the lungs (a pulmonary embolism or PE) which maybe life threatening. Some people have a familial tendency towards having DVT and it is more common in people taking hormone therapy or the oral contraceptive pill. We will ask you to stop all forms of hormone replacement therapy, including Tamoxifen, for about 4 weeks around the time of your operation. You will wear compressive stockings and receive blood-thinning injections to reduce the risk of DVT and PE.

Chest infection

A general anaesthetic carries a small risk of post-operative chest infection. Smoking increases the risk of chest infection.

Symmetry

Your surgeon will make every effort to optimize the symmetry of your breast reconstruction to your remaining breast, however there may be differences in the size, shape and appearance of your breast. Your reconstructed breast and remaining breast may age differently, due their different compositions. Implant based reconstructions tend to be gravity and age resistant.

Complex regional pain syndrome

Is a condition that we do not understand fully. It seems to be a nerve mediated pain; the pain is more than we expect and poorly controlled by usual analgesia. The pain may be described as burning, throbbing or electric-shock like and patients find it distressing. Please let us know if your pain is poorly controlled as there is a medication called Gabapentin that works well for this condition.

Further surgery

Sometimes further surgery is required to improve the symmetry of your breasts. This may occur some years after your initial operation.

Psychological aspects

Women usually find breast reconstruction a positive event. Sometimes women will be disappointed with their reconstruction and feel their reconstructed breast is not as they had imagined. This is certainly more common in women who have suffered a complication. Your surgeon and breast care nurse will be there to provide support.

 

Implant specific complications:

Infection around the implant

This is very serious and requires the implants are removed for a minimum period of 3 months

Capsular contracture

The body will form a scar around the implant and this is a normal process. In some women the scar may become very thick and then contract; overtime this process can distort the implant, causing a high and tight look to the reconstructed breast. This may require further surgery.

Asymmetry between your new breast and your native breast

Your reconstructed breast and remaining breast will feel and look different due their different compositions. Implant based reconstructions tend to be gravity and age resistant.

Exposure of the implant

If the wounds should break down and the implant is visible at the base of the wound then the implant must be removed temporarily.

Anaplastic Large Cell Lymphoma (ALCL)

ALCL is a lymphoma and not a breast cancer. Researchers are currently exploring a possible link between breast implants and a rare type of immune system cancer. It is extremely rare – 3 cases in 100 million people per year within the US.

 

Flap specific complications:

Flap failure

Sometimes there is a problem with the blood supply to the flap and part or all of the flap may die. This becomes apparent between 24-48 hours following the operation. If this happens you will need another operation to remove the dead parts of the flap. If the entire flap dies then you may require another reconstruction. Complete loss of the flap is devastating and extremely uncommon.

Fat necrosis

This occurs when a pocket of fat cells die (although the majority of the flap is fine and has a good blood supply) leaving a hard area within the reconstruction. Sometimes the fatty area swells and releases a greasy fluid. Fat necrosis tends to settle overtime and occasionally needs antibiotic and dressings. Surgery is only rarely required.