Breast reconstruction is most often recommended for patients who have undergone a mastectomy (surgical removal of a breast) due to cancer or a pre-cancerous condition , but these techniques are also used to correct other breast deformities.
What are the benefits?
Using a number of different techniques, surgeons can create a breast that closely matches the shape, size and feel of the breast that was removed.
Many women feel insecure about breast abnormalities, or the condition of the breasts after a mastectomy, and in restoring a normal appearance; breast reconstruction often helps women to feel more confident and feminine, so that they can continue their lives normally.
What will happen at the consultation?
During the consultation, you and your surgeon will discuss the changes that you would like to make in your appearance. Your doctor will explain the procedure, including what kind of anaesthesia he will be using. At this time, he will also ask about your medical history and perform an examination. You should stop smoking 6 weeks prior to surgery and 2 weeks afterwards.
How is the procedure performed?
There are two alternatives to consider; immediate breast reconstruction and delayed breast reconstruction. Immediate breast reconstruction is performed at the same time as the mastectomy, while delayed breast reconstruction is postponed until a later post-surgery date. There are risks and benefits to both immediate and delayed reconstruction, so it is important that you talk with your doctor before your mastectomy to decide which method is best for you.
During immediate reconstruction the breast surgeon, who removes the breast, teams up with a plastic surgeon, who creates the new breast. Immediate reconstruction has several potential emotional and aesthetic advantages. Some patients find that waking up from a mastectomy with two similar breasts helps to alleviate the grief caused by losing a breast.
Immediate reconstruction can also preserve a greater amount of skin and reduce scarring. Scars are easier to conceal when less skin is removed during the mastectomy. And, of course, when the reconstruction is performed immediately following the surgery, there is only one recovery to deal with. However, in some cases, it is better to complete your treatment e.g. radio/chemotherapy before having a reconstruction.
Though immediate reconstruction offers many benefits, it is not for everyone. Some patients do not want the added stress of thinking about different reconstruction techniques while they are coping with a cancer diagnosis.
Since breast reconstruction can be performed weeks or even years after having a mastectomy, choosing a delayed reconstruction allows patients to take their time exploring their choices. Delayed reconstructions also allow patients to complete other treatments such as chemotherapy or radiation before thinking about breast reconstruction.
What are the different types of breast reconstruction?
Having a breast removed can cause great emotional strain. For patients whose mastectomy was due to cancer, the absence of a breast can be a daily reminder of their struggle with a serious disease. Breast reconstruction can give patients a physical appearance similar to that before their mastectomy, or, when it is used to correct deformity, it can create symmetry in the body that was lacking before the surgery. Breast reconstruction can help restore women\'s self-confidence, femininity and sense of wholeness, so that they can go on with their lives.
There are two major types of breast reconstruction; breast implants and flap reconstruction:
The simplest breast reconstruction technique, implants are silicone shells filled with either silicone gel or a saline solution. Breast implants are typically inserted through the use of a tissue expander. In this technique, a silicone balloon or bag is surgically placed beneath the chest muscle. Through a valve buried under the skin, the surgeon injects a sterile saline solution into the bag, expanding it. The ?expander? stays in place for several weeks or months, during which time weekly or twice-weekly injections are administered. Once the skin has expanded sufficiently, the bag is replaced with a permanent implant during a second surgery. A one-stage expander can also be used.
A third surgery may be recommended to reconstruct the nipple and areola. In order to ensure proper placement of the nipple, this operation is normally performed about three months after implant surgery, giving time for the new breast to settle into its permanent position. The nipple is usually fashioned from a small piece of skin drawn from the breast mound. About six weeks later, the nipple and areola will be coloured to match the other side using a medical tattoo technique.
This technique creates a new breast using a section of muscle, fat and skin taken from another area of the body. It requires a longer hospital stay and more recovery time than implant reconstruction, and it also leaves scars at both the breast site and the donor site. But because the new breast is made of natural tissue, it looks, feels and ages more like a normal breast -- which many patients prefer. In addition, the use of natural tissue eliminates the complications that can arise when foreign objects such as implants are inserted into the body. Flap reconstruction may also be recommended when the skin won\'t expand enough to cover an implant.
Flap reconstruction may be performed using a pedicle flap or a free flap. The pedicle flap allows the tissue used in reconstruction to remain attached to its original blood source. The tissue is moved to the breast area through a tunnel under the skin. In the free flap technique, the flap tissue is completely removed and reattached to the breast area, where its blood vessels are connected to those in the chest area through microsurgical techniques.
Types of flap reconstruction:
Transverse rectus abdominis musculocutaneous flap (TRAM)
The TRAM procedure can be performed as either a pedicle flap or a free flap. A section of muscle, fat and skin is surgically removed from the abdomen and used to form the new breast. Sometimes referred to as ?tummy-tuck? reconstruction, this procedure flattens the stomach and reconstructs the breast simultaneously. After the surgery, the abdominal muscles are weakened, and in rare cases, this weakness can cause a hernia. If you are considering future pregnancy, be sure to tell your doctor because this sort of abdominal weakness can affect future pregnancy.
Deep Inferior Epigastric Perforator flap (DIEP)
Similar to TRAM but does not remove any muscle and, therefore, decreases the complication of abdominal weakness.
In this technique, a section of the latissimus dorsi (the back muscle arising from the top of the hip to the arm just below the shoulder) is removed with some overlying fat and skin to form a new breast. This tissue is often quite thin, so a small implant may be required as well.
If the abdominal or latissimus tissue is unsatisfactory, a flap can be taken from the upper, middle or lower part of the buttock.
How long does the operation take?
Normally, each of the operations in the implant process takes from one to two hours. Flap reconstruction surgeries take longer, from five hours for back operation to 8 hours for DIEP. Free flap procedures are often longer than pedicle flap procedures because of the careful microsurgery needed to reconnect the blood vessels.
How long do I have to stay in the hospital for?
Tissue expansion and implants require 1-2 days in hospital. Patients having flap reconstructions should expect to stay in the hospital from 5 to 7 days.
What can I expect afterwards?
All of the initial reconstruction procedures are done under general anaesthesia, so you?ll sleep through the entire surgery. A morphine drip can be set up afterwards, controlled by the patient, to control the pain.
After surgery you will be tired and sore for one to two weeks. Your doctor can prescribe pain medication to relieve any discomfort. You should also expect some swelling and bruising, which could last for several weeks. Some procedures require the insertion of drains for 2-3 days remove excess fluid from the surgical site. Your stitches will dissolve.
Recovery time varies depending on the type of procedure, but usually takes between one and two months. Recovery from flap procedures generally takes longer than recovery from implant procedures. You should be able to engage in light activities by the end of the first week, including taking short walks to reduce the risk of blood clots in the legs. Refrain from heavy lifting, sexual activity and rigorous sports for three to six weeks. Patients who have had the DIEP flap procedure should refrain from heavy lifting for at least three months, since the abdominal wall is weaken by the procedure and further strain could result in a hernia.
What are the long-term results?
Most patients report that breast reconstruction enhances their appearance and contributes to their quality of life. Scars will never completely disappear, but they do fade with time. You should also be aware that a reconstructed breast may not duplicate the other breast exactly; it may seem firmer and have a slightly different shape. For most patients, these factors do not detract from their overall satisfaction with the replacement of a lost breast.
What are the risks?
The most common problem following implant surgery is capsular contraction, a tightening of the scars around the implant. In this situation, a second surgery can be performed to loosen the scar tissue. Other complications associated with implants include infection around the implant, necessitating its removal, and leaking, hardening, or shifting of the implant. You should know that implants may deteriorate over time and may eventually need to be replaced. With all free flap procedures there is a risk that the blood vessels will not reattach sufficiently, constricting blood flow and causing the death of the flap tissue. TRAM flap procedures can result in abdominal hernia, loss of feeling in the skin below the navel, and a permanent weakening of the abdominal muscles. As with any surgery, breast reconstruction incurs the risk of swelling, bleeding, infection, fluid collection, drug reactions, keloid scarring, and numbness.
All of these complications are increased if you smoke or are too overweight.