Plastic surgeons are frequently involved in the primary reconstruction of the breast following a mastectomy – that is, following the whole or partial removal of the breast to help treat or prevent breast cancer.
Reconstructive breast surgery is a multi-disciplinary treatment, coordinated with cancer surgeons and cancer specialists (known as oncologists). Reconstructive surgery aims to rebuild the breast, either wholly or partially, to normalise the look of the breast and leave the patient with a symmetrical bust. It also aims to improve the patient’s body image and self-esteem, helping the process of recovery on a physical, emotional and psychological level.
Current evidence suggests that breast reconstruction, either at the time of (immediate) or after (delayed) cancer treatment, has no adverse effect on the outcome of a patient’s cancer. According to guidance from the National Institute of Clinical Excellence (NICE link), all patients should be offered immediate breast reconstruction following a mastectomy.
Breast reconstruction can be a complex procedure, often involving microsurgery techniques; it is therefore best carried out in specialist centres equipped with state-of-the-art facilities. As patient awareness of breast reconstruction grows, there is likely to be increasing demand for this procedure – as a result, plastic surgeons are becoming common and integral parts of the multi-disciplinary teams treating breast cancer in the UK.
What are the benefits?
The benefits of immediate breast reconstruction are:
Better cosmetic results
The skin of the breast can be preserved
Smaller breast scars
Only one anaesthetic and recovery period
Only one stay in hospital
No period of time without a breast
The benefits of delayed reconstruction are:
Staggered surgery, resulting in an easier and shorter recovery following each procedure
Time to consider whether reconstruction is right for you without delaying the cancer treatment
Less to deal with at once
Breast reconstruction involves recreating the breast to match the remaining natural breast as closely as possible. The main aim is to recreate the breast shape and volume, either at the same time as the mastectomy, or at a later date.
One of the first choices confronting patients is whether to undergo immediate or delayed reconstruction. Immediate reconstruction is performed during the same operation as the mastectomy. Delayed reconstruction occurs once a patient has fully recovered from a mastectomy (usually after several months).
The favoured technique amongst many plastic surgeons is to use a patient’s own tissue to reconstruct the breast and in recent years this type of reconstruction has become more and more popular amongst patients. This tissue is usually taken from the abdomen or back, but sometimes from the buttocks or thighs:
1. The latissimus dorsi muscle from the back along with an overlying patch of skin. This muscle’s blood supply makes it extremely useful for breast reconstruction, as it gets its main blood supply from vessels emerging from the armpit. In this procedure, the muscle is transferred to the breast area by swinging it around the ribcage so that it lies at the front of the body. Using this procedure skin removed at the time of mastectomy is replaced along with some volume. Some patients will also need an implant to further augment the volume, but it is sometimes possible to remove enough fat from the back attached to the flap to replace the missing breast volume without an implant.
2. The skin and fat of the lower abdomen is often the ideal tissue for breast reconstruction. A large amount of skin and volume can be replaced in order to achieve a very natural look and feel. Removal of excess skin and fat can often be a welcome bonus for the patient, resulting in a “tummy tuck”. When first described the operation involved tunnelling the lower abdominal flap with the underlying rectus abdominis muscles beneath the upper abdomen to the chest – a pedicled TRAM flap. Whilst this technique is still sometimes used most surgeons find that transferring this tissue as a free flap is more reliable. Free flap reconstruction involves the transfer of living tissue from one part of the body to another, along with the blood vessel that keeps it alive. Free flaps are entirely disconnected from their original blood supply and are reconnected using microsurgery in the recipient site. This procedure involves hooking up all the tiny blood vessels of the flap with those in the new site, and is carried out with use of a microscope, hence the name ‘microsurgery’.
3. In free flap breast reconstruction, skin, fat and sometimes muscle from one part of the body is transferred to the breast area. During this process, the skin and fat is completely removed from the original area and reconnected in the recipient site. Blood vessels from the armpit, or near the breastbone, are used to create a new blood supply for the transferred tissue. There are several variants of lower abdominal free flap transfer depending on which blood vessels are used and whether any muscle is transferred, these are:
For some patients, however, an implant-based reconstruction is more appropriate.
When a breast is reconstructed using an implant alone a silicone implant is inserted under the skin and muscle of the chest to replace the breast volume that has been removed at the time of mastectomy. This is quite a simple operation that does not involve incisions elsewhere on the body. Sometimes an adjustable implant called an expander-prosthesis can be used and this is adjusted by injections of saline which can be done in the outpatient clinic in the weeks after the operation.
How long does the operation take?
Surgery can take between 2 – 5 hours to perform dependent on the extent of the surgery
How long do I stay in hospital?
Between a 1 – 2 night stay in hospital is required and your surgery is performed under a general anaesthetic.
What can I expect afterwards?
On discharge home from hospital you will feel very tired initially, and would we would advise that you have someone around to help you. After the first week you should be starting to look after yourself and begin to resume normal activities. The recovery period varies depending on which of the operations you have had done. A few weeks after the operation you will be seen again in clinic to check how you are doing and make sure all your wounds are healing well. You will then be seen a few months later to assess the outcome.
What are the risks?
With any surgical procedure there are always associated risks. However, if your surgery is undertaken by a qualified plastic surgeon the risks are reduced, nonetheless, specific complications may occur. The most frequent complication is delayed wound healing. This risk is greatest in some of the larger flap operations where the incisions are longer. If there is a wound problem it is usually minor, but more major wound healing problems can occur such as infection, skin loss, wound separation and possible reoperation. Very occasionally, soon after the surgery, bleeding may occur this may necessitate a return to theatre to stop the bleeding. Sometimes patients can collect fluid beneath the operation site, this may need to be drained off Such as the risk of infection which is reduced by taking preventative measures such as administering antibiotics both at the time of and following your surgery. However despite these measures mild infection is relatively common and can occur around the incision site, but usually subsides over a period of about 2 weeks.
It is important for you to examine the reasons for undergoing a cosmetic surgery procedure as it is unlikely to resolve any life issues you may have. Having surgery for someone else is not the basis from which to make a decision. Cosmetic surgery will certainly boost your self esteem but you do need to be realistic about your expectations. Cosmetic surgery will lead to marked improvements but you need to be aware that the end result of your surgery can and does take time and you need to allow your body to recover.
Our aim is to fully understand your concerns and desires before agreeing on a treatment plan which is in your best interest. At consultation your consultant surgeon will explain your treatment fully including any potential risks and complications. Your consultation surgeon will advise you of the best strategy to address all of your needs and will also explain all aspects of your post-operative care.
If you would like to speak to one of our consultant surgeons, Mr Alan Park or Mr Sudip Ghosh, please do not hesitate to telephone or fill out our online form.