What is Breast reconstruction?
Breast reconstruction is often performed after tumour treatment has finished (delayed reconstruction), although it may occasionally be possible at the time of tumour removal (immediate reconstruction). Each person will need their own circumstances to be weighed up by a specialist to decide which category they fall into.
Once a breast lump has been removed, there may be a noticeable change in breast size or shape. In the case of a mastectomy the entire breast may have been removed. Whilst some women may be happy to use a prosthesis to replace the breast, many prefer the concept of actual tissue being used to provide a permanent replacement.
Various breast reconstruction options are available, including implant, expander, latissimus dorsi flap, TRAM flap or free flap reconstruction. The final choice may be limited by your tumour type and circumstances, but is also very much dictated by your own wishes.
Breast reconstruction is often major surgery and has its own risks. Many patients, though, find reconstruction to be an important final step in their journey and are extremely happy to have made this decision. Always be sure to discuss any concerns with your Specialist, and only make a decision once you are completely satisfied with their explanations.
What is 'implant' breast reconstruction?
As the name suggests, this technique uses an implant to reconstruct the breast. The size of implant may be limited, so reduction of the remaining larger breast may be necessary to achieve symmetry. Implants may be advised against if the specialist feels you may need radiotherapy after surgery, or you may need to have an expander first (see below). Despite this, implant reconstruction is one of the simplest forms of breast reconstruction with the quickest recovery time. More information on implants can be found in our breast augmentation article.
What is 'expander' breast reconstruction?
The expander is a salt-water filled bag that has a tube connected to a small 'filling port'. Expanders are often placed under the chest muscle. The filling port is then placed just under the skin near the rib area. Some expanders have ports that are in the expander themselves.
After surgery, you will usually return to clinic every 2-3 weeks. The expander is filled with a little more salt-water, by injecting through the port. By slowly filling the expander over a number of weeks, the overlying skin is slowly stretched. The expander can then be exchanged for an implant in a relatively simple procedure; the stretched skin allows the implant to sit more naturally, giving the breast more fullness near the bottom half. Some newer expanders do not need to be exchanged, and so further operations are not needed.
What is 'latissimus dorsi flap' breast reconstruction?
The latissimus dorsi muscle is a large muscle on the back, and has a main blood supply from an artery in the armpit region. The muscle and overlying skin can be raised off the back, keeping the artery attached (it is now termed a 'flap'). The flap is then swung around to the front of the chest. This bulky muscle and skin adds volume to the chest area, and can be used to form a new breast mound. More volume is usually needed to match a larger opposite breast, and an implant can be used under the flap to give this increase in size. The back area is then stitched closed.
This form of breast reconstruction is more involved than the above two techniques, and may involve a few days in-hospital stay. The back area can sometimes form collections of fluid, which can be easily drained with a fine needle. Using the muscle from the back generally causes little problems, unless you are quite athletic; in particular this operation will lead to weakness when pulling yourself upwards, such as in climbing.
What is 'TRAM flap' breast reconstruction?
The tummy has two thick straps of muscle (the rectus muscles) that run from the breast-bone to the pubic bone. These muscles give off blood vessels to the overlying tummy skin.
The TRAM (Transverse Rectus Abdominis Musculocutaneous) flap uses tummy skin from the pubic/hip line up to the belly button. The skin and fat are kept attached to one of the underlying muscle straps, which is detached from its pubic attachment but kept attached at the breast bone. The flap can then be swung around to deliver muscle, fat and skin to the mastectomy area. This gives a very good volume, and can provide a natural looking breast mound. The tummy area is then closed in the same way as for an abdominoplasty - giving a tummy tuck at the same time!
Disadvantages include weakening of the tummy muscles, and possible hernia development which may require further procedures. Rarely the flap does not respond well to being moved and the skin can die away, needing further procedures. For this reason, some specialists may 'delay' the flap, whereby the operation is performed in two stages 2-3 weeks apart. This gives the flap more time to get its blood supply ready for the move.
What is 'free flap' breast reconstruction?
This usually involves more hospital stay than the above procedures, and takes a number of hours to perform. Despite this, free flaps can give excellent results and are considered by some as the 'gold standard' in breast reconstruction.
The technique uses muscle, fat and skin from an area of the body, such as the tummy (free TRAM or DIEP flaps) or buttock area (SGAP or IGAP flaps). The tissue is lifted with its blood supply (now called a 'flap'), and then completely detached from the body. The blood vessels are then attached to vessels in the armpit or chest area, providing new blood supply to the flap. The area the flap came from is now stitched closed.
The advantages of these methods of reconstruction are that they provide very good volume and a natural result, and often have minimal problems from where the tissue is taken.
Disadvantages include long operating time and hospital stay. Whilst free flaps are often very reliable, they can occasionally respond poorly to surgery and the blood supply may block off, causing flap loss and need for further alternative reconstruction.
What about nipple reconstruction?
Once the breast mound has been reconstructed, the decision then remains as to how to replace the nipple and surrounding areolar area.
Some patients are quite happy to not have any form of nipple replacement. Others use a 'stick on' prosthesis, which looks extremely natural and realistic. To form a more permanent replacement, many techniques have been used; some specialists use small pieces of cartilage under the skin to form a new nipple mound. More commonly, small cuts are made in the new nipple area. The skin is then stitched together in such a way as to form a raised area, resembling a nipple.
The areola can be replaced with a small skin graft, placed around the new nipple. A common and very effective alternative is to use tattooing to replace the dark areola area.
Your specialist will be able to discuss all options with you, tailoring the final procedure to your wishes.
Which option of breast reconstruction is best for me?
This is a very difficult question that can only be answered by both you and your specialist. Once all the information is gained, your specialist can discuss further options with you, and possible plans. The decision making process often involves many members of a team, including Breast surgeons and Plastic surgeons. There may be more than one possible option and you should carefully weigh up the pros and cons of each option. Some options may not be available, due to your health or other circumstances.
Never be afraid to ask more questions, and always be sure that you are clear about what treatment you are having and what to expect from it. If you are unsure about your treatment, you are always entitled to ask for a second opinion.
Other SurgeryWise articles
You may also be interested to read our article on breast cancer
Other useful links:
breastreconstruction.org - Breast Reconstruction support site
breastcancercare.org.uk - Breast cancer support site
Any procedure involving skin incision can also result in unfavourable scarring, wound infection, or bleeding. This list of risks is not exhaustive, and you should discuss possible complications with your specialist. Whilst these risks will seem very worrysome, and indeed can be serious, it should also be borne in mind that many people have no postoperative problems whatsoever.
The information provided is for guidance only and you should discuss matters fully with your specialist before deciding if this is the right procedure for you. Please also read our disclaimer