Breast Reconstruction

WHAT DOES THE SURGERY INVOLVE?

A variety of techniques are available for reconstruction of the breast mound after breast cancer surgery. Factors which influence the choice of reconstructive technique are: the type of mastectomy which has been performed, the size and shape of the unaffected breast, whether radiotherapy has been used in the affected breast and the body shape and medical history of the patient.

THERE ARE THREE BASIC OPTIONS:

  1. Insertion of tissue expanders/prostheses – this is only usually an option for patients who have not undergone radiotherapy and whose skin remains supple and expandable. They are called expander/prosthesis rather than just expander as they may be left in place permanently and do not necessarily need to be exchanged for a breast implant once they have done their job of expanding the breast skin. Different shapes of expander/prosthesis are available and these are either teardrop shaped or round. The expander/prosthesis is essentially a double lumen bag composed of an adjustable volume inner compartment filled with saline and a fixed volume outer compartment filled with silicone. There is an injection port which is positioned under the skin during surgery to enable the expander/prosthesis to be filled through the skin with a needle, in the outpatient clinic, over the following months. The port may be integral to the expander/prosthesis or connected to it through a remote tube. The expander/prosthesis is usually placed under the pectoral muscle and gradually inflated over a period of weeks until the desired volume is achieved. With this method the surgery is rapid with minimal incisions and relatively low risk of complications. As the expander/prosthesis is foreign to the body, the risk of infection is due to the fact that antibiotics may be ineffective and it may need to be removed and replaced once the infection has settled down. Other than that this represents the most straightforward and acceptable method of breast reconstruction.
  2. The Latissimus Dorsi Flap (with or without a breast implant) is a technique for reconstruction of a partial mastectomy defect, or a small or medium sized breast which has been treated with radiotherapy. A paddle of skin and muscle are taken from the back and tunneled through to the front of the chest. The nerve supply to the muscle is cut to prevent it twitching later on and the incisions in the back and on the chest are closed over plastic suction drains. A silicone breast implant may be necessary to provide fullness behind the paddle of skin and muscle. The surgery takes around two-three hours under general anaesthesia and patients usually stay in hospital for three or four days. The scars are longer than those required for insertion of a tissue expander and the potential risks of surgery essentially relate to the donor site for the muscle in the back where a collection of clear fluid may develop and require drainage (seroma). The chest wall skin, where the paddle of skin is inset, may also be fragile and take a while to heal if it has previously been heavily irradiated. If a breast implant is used then the potential complications of breast augmentation are also possible.
  3. The TRAM or DIEP flap (microsurgical tummy flap) – the TRAM (Transverse Rectus Abdominis Myocutaneous) flap is an excellent way of reconstructing a large breast providing that there is adequate skin in the tummy to make a breast. It was first introduced as a pedicled flap (meaning that it was left attached to its blood supply) for breast reconstruction and the paddle of skin and muscle was simply harvested from the tummy and swung up onto the chest being left connected to its circulatory supply and then sculpted into a breast shape. The tummy wound was closed like a tummy tuck over two suction drains. Problems with weakness and hernial bulging in the abdominal wall following this surgery, which necessitated removal of one of the rectus abdominis (sixpack/abdominal) muscles, prompted the development of the DIEP (Deep Inferior Epigastric Perforator) flap. A lack of predictability about the survival of the skin when it was left attached, and also the relative lack of manoeuvrability of the skin and muscle flap, has led most plastic surgeons to abandon the pedicled TRAM flap and to disconnect the blood supply of the abdominal skin island and reconnect it again in the chest, using a microsurgical technique. The microsurgical DIEP flap is probably the best option for reconstruction of a large breast. The risks of this technique mainly relate to technical aspects of the microsurgery. The small artery and vein which are chosen to reconnect the flap to its blood supply can sometimes become clogged up and need to be redone. This happens approximately 10% of the time. In less than 5% of cases part, or all, of the transferred tissue does not gain an adequate blood supply and part, or all of the flap, may not survive. Potential complications of abdominoplasty or tummy tuck surgery may also occur such as seroma (collection of clear fluid from the raw area created), haematoma (localised bruising) and infection. This is a major operation and requires seven to ten days in hospital. The scars on the abdomen are similar to those of a tummy tuck and the breast scars usually form an ellipse shape around the transferred skin.

WHAT ABOUT THE OTHER BREAST?

If the other breast is very large or very ptotic (droopy) it may not be possible to reconstruct a breast of similar proportions. In this instance an uplift or reduction of the unaffected breast may be necessary in order for symmetry to be possible. This is usually performed at the same time as the breast reconstruction.

WHAT ABOUT NIPPLE RECONSTRUCTION?

This is achievable by a variety of techniques. It is best to wait for six months before reconstructing the nipple in order to allow newly created breast mound to adjust to its permanent level. The simplest way of recreating an areola (the ring of colour around the nipple) is to just tattoo an areola in the appropriate position having mixed tattoo pigments to match the unaffected areola closely. At a second stage the unaffected nipple can be shared between the two sides, or the skin in the center of the new areola can be reconstructed into a nipple using a local flap technique. It is also possible to reconstruct an areola using skin grafting but this leaves a scar elsewhere. The potential complications of nipple reconstruction are lack of survival of the skin grafts or flaps used. These risks are far greater in smokers due to the detrimental effect that smoking has on the blood supply to the skin.