BREAST RECONSTRUCTION FOR CANCER
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Breast Reconstruction Overview
Oncoplastic Procedures
Implant based Reconstruction
Using the Tummy
Using the Back
Nipple Areola Reconstruction
Breast Reconstruction Overview
The decision to have breast reconstruction or not can be a difficult process, especially when you are dealing with your diagnosis and treatment. Ultimately the decision is yours and should be made on what is best for you and your health. Although all women having a mastectomy should have breast reconstruction discussed there is no right or wrong about your personal choice.
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Breast reconstruction can be performed at the time of the mastectomy (known as primary or immediate reconstruction) or at a later date (secondary or delayed reconstruction). If in doubt you can always have reconstruction at a later date. In general terms, a breast can be reconstructed using an implant or tissue from the patient’s own body ( autologous tissue reconstruction ). Sometimes a combination of the two procedures can be used, but the type of procedure used will really depend on what is best for the patient and can be discussed during a consultation.
Further information about breast reconstruction is below.
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Immediate Reconstruction
This is when the reconstruction is done at the same time as the surgery for your breast cancer. There are advantages and potential disadvantages of planning an immediate reconstruction. It must always be remembered that reconstruction can still be performed on the majority of patients at a later date after all of the cancer treatment is completed.
Advantages Of Immediate Reconstruction
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As there is no delay between cancer treatment and reconstruction, for some patients this means that the psychological effects of having a mastectomy and therefore losing a breast are reduced
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A reconstruction using the patient's own tissue will only involve one operation, and therefore recovery should be quicker.
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Immediate reconstruction can result in a far more natural result for the patient, especially if the mastectomy is carried out through the nipple. This means that all of the breast skin can be saved and used for the reconstruction giving a more natural cosmetic result.
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Stephen McCulley can sometimes build a nipple at the same time as a mastectomy. This is true of the reconstructions using the tummy or back but not with implant-based reconstruction.
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Disadvantages Of Immediate Reconstruction
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Understanding the surgical process of breast reconstruction and deciding to have immediate treatment, that may lengthen your hospital stay, will inevitably add further pressure at an already difficult time.
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You may have complications from your additional surgery at a time when you are awaiting other treatments for your cancer such as radiotherapy and chemotherapy. This does not mean that your cancer treatment will be affected, but could mean additional surgery to ensure that complications are treated quickly if they occur.
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If you unexpectedly need radiotherapy this can affect the result of your reconstruction. Indeed, if we know you will definitely need radiotherapy after surgery then we may recommend delaying reconstruction.
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The complication rate of immediate reconstruction is slightly higher than the delayed reconstruction.
DELAYED RECONSTRUCION
Delayed Reconstruction
This is when breast reconstruction is performed after all of the cancer treatment has finished, and maybe months or years later. There is no time or specific age limit, and should only be carried out when the patient is ready, both physically and mentally, for further surgery.
Some patients choose to have a delayed reconstruction, others are recommended it, and some patients who did not initially want to have a reconstruction sometimes decide after a period of time that they are ready to have surgery.
Advantages Of Delayed Reconstruction
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It will avoid the strain of being treated for any possible complications following reconstruction surgery at the same time as undergoing cancer treatment, such as radiotherapy or chemotherapy.
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Avoids the possible effects of radiotherapy (firmness, shrinking, and deformity) impacting on the reconstruction. The cosmetic result of immediate reconstruction can be superior to delayed reconstruction. However, if you add radiotherapy to an immediate reconstruction it will have the opposite effect.
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You will not have to deal with the surgery or any decisions relating to the reconstruction at the time of cancer diagnosis and treatment.
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This form of surgery has a slightly lower complication rate than compared to immediate reconstruction.
Disadvantages Of Delayed Reconstruction
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You will need to live with the effects of the mastectomy until the reconstruction is performed. This can be for a number of months or up to a year, depending on the individual case.
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The cosmetic result is potentially not as good. This is because an immediate reconstruction of the skin of the breast is often kept and used to cover the reconstruction giving a more natural result. If a delayed reconstruction is performed using your own body tissue then skin needs to be added to the breast from the back or tummy. This skin does have a slightly different appearance and the scars on the reconstructed breast will be longer.
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The skin difference is less obvious in delayed implant-based reconstruction as the skin is stretched with the inflatable balloon device first (just as with immediate reconstruction).
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If you have had radiotherapy it is unlikely you will be offered implant type reconstruction, as the complications are too high. You will need some tissue from the back or tummy moved to help reconstruct the breast.
RADIOTHERAPY AND BREAST RECONSTRUCTION
Radiotherapy and Breast Reconstruction
Radiotherapy is a very important part of the treatment for certain breast cancer patients, usually, those who only have part of the breast removed (breast-conserving surgery), as it has been shown to reduce the chances of breast cancer recurring in the remaining breast tissue. There is also evidence to show that the combined efforts of breast-conserving surgery and radiotherapy can be as effective as a mastectomy.
However, certain patients that have a mastectomy have also been shown to benefit from radiotherapy. It’s likely to use can be predicted in some patients but it will often only be known if radiotherapy is needed after the mastectomy is performed and cancer analyzed.
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When carried out, radiotherapy can damage normal tissue as well as cancer cells. It can result in changes to the patient's skin colour and cause firmness and shrinkage in healthy breast tissue. It can also have the same effects in tissues that have been used to reconstruct a breast. If a silicone implant is present then it can cause an alarming rise in potential complications of capsule formation (firmness from scar tissue) or infection.
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The problems associated with having radiotherapy can impact on when to have a breast reconstruction and the particular method to use.
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If radiotherapy is planned or has already been given then implant reconstruction should be avoided in the majority of cases.
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When radiotherapy is almost certainly planned you may be recommended to delay reconstruction until all of your treatment is completed. There is nothing more disappointing for the patient and Stephen McCulley to see a good reconstruction be adversely affected by radiotherapy.
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If radiotherapy is a possibility then it is acceptable to take either the cautious route of a delayed reconstruction or proceed with immediate reconstruction and deal with radiotherapy problems if they occur.
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It must be emphasized that not all patients get strong adverse effects from radiotherapy. This can make definitive advice difficult, however, Stephen McCulley will guide you as much as possible on the best course of treatment for you, based on your individual case.
ONCOPLASTIC SURGERY
Oncoplastic Surgery Procedures
Oncoplastic breast surgery uses plastic surgery techniques to treat breast cancer. Through this process our Team can remove cancer and also improve the appearance of the affected area at the same time. Stefano Pompei has 25 years of experience in this field of breast cancer surgery.
Therapeutic Mammoplasty
This uses breast reduction techniques to both excise cancer and re-shape the breast. This means that even if a large area of the breast is removed the final shape following surgery can still be very good, if not better. For this type of procedure, both breasts are usually operated for achieving a natural symmetry. The same excision, but without these reconstructive techniques may leave an obvious contouring defect in the breast. This technique is only suitable for patients that can be treated by breast-conserving methods and those with enough breast tissue left after a wide local excision in order to adequately re-shape the breast. As with most breast-conserving surgery, the patient is usually advised to have radiotherapy following surgery.
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In terms of recovery, the patient is likely to have the same experience as with a standard breast reduction with breast-conserving surgery.
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Other Oncoplastic Techniques
The other group of oncoplastic techniques involves using skin and fat from the back or lateral chest area to ‘fill’ the hole left by the cancer removal. This method leaves the breast the same size as before, and usually the same shape as well.
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IMPLANT BASED BREAST RECONSTRUCTION
The Procedure
This form of reconstruction involves placing an implant under the chest wall muscle and skin. In many cases is usually done as a two-stage operation. Firstly an inflatable balloon (tissue expander) is placed under the muscle. This is inflated with a series of injections of saline water to stretch the skin. A permanent implant is then inserted 3-6 months later.
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With an appropriate selection of patients, Implant reconstruction can be offered also as a single-stage operation. This has the advantage of maintaining the breast skin and allowing more natural appearance of the breast. It requires the use of special materials to be used in addition to the implant to help support the implant internally. This is either a synthetic-made material or a specially prepared animal-derived biological meshes. If one-stage implant reconstruction is an option this will be discussed with you.
Advantages of using Implants
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When carried out as an immediate reconstruction it only adds a little extra surgery time to the original mastectomy operation.
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This technique avoids additional scarring on the rest of the body.
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For a lot of patients, the implant will create a very pleasing and natural breast shape.
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The recovery rate for the operation is relatively quick.​
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Disadvantages of using Implants
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The shape of the breast can appear less natural in matching the other breast.
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There are two operations for the patient to undergo and therefore involve more recovery.
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There are some issues associated with having implants, including the implant causing the breast to harden (usually in 20% of patients) and a small risk of infection resulting in implant loss.
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The implant tends to give less symmetry over the years, as it will not change in shape or size in the same way as the normal breast.
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Smoking
If you are a smoker, try and stop for six weeks before and five days following surgery as it can reduce the chances of complications.
Surgical Recovery & Final Outcome
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Length of stay in hospital is usually 3-4 days for both operations (which will be done over 4-6 months).
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The length of surgery is usually between 1-2 hours after the completion of the mastectomy.
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Time-restricted to bed is normally 1 day.
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Time to walking: the patients should be able to walk 1-2 days after the procedure , and walk without any discomfort after a week.
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Time to exercise: patients should be able to restart exercise after 4 weeks of recovery avoiding preferably chest/arms.
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Time to full recovery: patients should be able to return to work by 4-6 weeks.
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Driving – Patients should avoid driving at least until drains removal. Normally It may take up to 2-3 weeks to recover sufficiently.
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Dressings – patients will wear dressings on the breast for 2-3 weeks.
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Bras & clothing – patients are advised to use elastic/sports bra for the first 8 weeks. The bra should feel comfortable, whilst still providing support. You will need to have two bras at home that can be worn on rotation.
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There is around a 3-8% risk of fluid collection in the reconstructed breast and an infection occurring. This would need to be treated immediately.
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As with any implant surgery, in Breast Reconstruction there is up to a 20-30% risk of the implant becoming ‘firm’ ( Capsular Contracture ) as well as there being some asymmetry to the opposite breast. This event is statistically more frequent inpatient submitted to Radiotherapy.
RECONSTRUCTION USING THE ABDOMINAL AUTOLOGOUS TISSUE
The Procedure
Using tummy skin and fat is one of the most successful procedures to reconstruct the breast.
This involves the removal of the skin and fat from the lower tummy (the same tissues as taken
during a tummy tuck operation) which is then used to reconstruct the breast. The tummy
skin and fat is the closest like for like replacement of the breast. It is, for this reason, it can
produce very life like reconstructions. However, most importantly this type of ‘own body
tissue reconstruction will last a lifetime. This is done by re-attaching this tummy tissue into
the breast with microsurgery. If this is done as an immediate reconstruction at the same time
as the mastectomy, then the breast skin is usually kept and the tummy tissue is used to give the breast shape and to form a nipple. However, if it is done at a later date (delayed reconstruction) then the tummy skin is also used for the new breast skin. With an experienced team, this operation has now become reliable enabling rapid patient recovery and shorter hospital stay.
The blood vessels are the ones that are re-attached in the breast area with microsurgery to keep the tummy flap alive. These blood vessels pass through the tummy wall muscles to get to the skin and fat. When all the muscle is left behind the flap is called a DIEP (Deep Inferior Gastric Artery flap). However, in some cases, the muscle around these blood vessels needs to be partially removed also. This then becomes a TRAM flap (Transverse Rectus Abdominis Muscle flap).
Advantages of using The Tummy
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Using the patient’s own tissue ( skin and fat) to reconstruct the breast means it will closely resemble a normal breast in the texture and movement.
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The new breast will naturally ‘droop’ like normal breast tissue and therefore should achieve the same shape as the other breast.
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Generally, the results of this type of reconstruction improve over time as the breast changes in size and shape.
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This type of reconstruction is regarded worldwide as one of the most successful and stable over the years in 95% of patients.
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The patient’s tummy will have a flatter and slimmer appearance following surgery.
Disadvantages of using The Tummy
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Although much faster it is still a big operation taking 4-6 hours to perform, with a 2-3 month recovery period.
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The operation has a 3-5% failure rate, but this depends on risk factors including, obesity, smoking, past surgical procedures, other illnesses, and whether radiotherapy has been used to treat cancer.
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A scar will be left on the tummy from where the skin and tissue has been removed.
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Although uncommon, patients might experience some pain, weakness, or bulge in the tummy. There is also a slightly greater risk of general complications such as pneumonia and blood clots following surgery.
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Patients will experience some numbness on the skin of the lower tummy.
Surgical Recovery & Final Outcome
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Length of stay in hospital – usually 5-7 days.
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Length of surgery – usually between 4-6 hours.
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Time-restricted to bed – 2 days.
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Time to walking – patients should be able to walk after 3-4 days of recovery, and then walk without discomfort after 10-14 days.
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Patients should be able to return to work by 4-6 weeks.
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Dressings – patients will wear dressings on the breast and tummy for 2 weeks.Bras & clothing – patients are advised to wear a pressure garment for 4-6 weeks.
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There is around a 6% risk of experiencing problems with the tummy – pain, bulging in the tummy, skin infection, fluid collection, wound breakdown, and the possibility of having a hernia.
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There is a 5% chance of experiencing reconstruction problems – lumps in the tissue, part or total failure of the reconstruction succeeding.
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There are few long term problems associated with this type of surgery, apart from the tummy remaining weaker than before surgery.
USING TISSUE FROM THE BACK
Using tissue from the back
This reliable method shows excellent results for breast shape in both immediate and delayed reconstruction. It is normally proposed when some added skin or muscle coverage is requested.
Latissimus Dorsi Flap
This is the most common method in which muscle and skin from the back is placed into the breast. A definitive implant or a tissue expander is then placed behind the muscle to give volume.
Advantages
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This method can result in excellent breast shape and can be used in both immediate and delayed reconstruction. This is a very reliable form of surgery that only carries a very low risk of reconstruction failing. The operation can be safely carried out in conjunction with radiotherapy treatment.
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Overall, this is one of the most common forms of reconstruction and regarded by many as the standard procedure to use when opting for breast reconstruction.
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Disadvantages
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This is a quite intensive operation that will require up to a week’s stay in hospital and then up to 2 months in recovery. The scar on the patient’s back. There is a 2% risk of the implant becoming infected and therefore needing to be treated. There is also the chance of fluid collecting in the back (seroma) which would need to be removed. As with any procedure involving implants, there are certain risks associated with having them.
MINI LATISSIMUS DORIS FLAP
Mini Latissimus Dorsi Flap
This method is used for when only part of the breast has been removed (as with breast-conserving surgery) and therefore a part of the muscle with or no skin is removed from the back and placed into the breast to fill in the hole. This procedure is not normally used with a mastectomy.
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Advantages
This method can result in excellent breast shape and can be used in both immediate and delayed reconstruction. The operation is highly reliable. As much of the original breast remains intact there is a good sensation in the overall breast.
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Disadvantages
It’s important for the patient to consider whether a mastectomy might be planned for the future, as this procedure will use up one of the major reconstructive tools (muscle from the back) and could therefore not be used at a later date. Radiotherapy will still be required (as with most breast-conserving surgery treatment).
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Surgical Recovery & Final Outcome
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Length of stay in hospital – usually 5-6 days.
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Length of surgery – usually between 3-4 hours.
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Time to walking – patients should be able to walk after 2-3 days, and walk without any discomfort after 10 days.
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Time to exercise – patients should be able to exercise after 6 weeks of recovery.
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Dressings – patients will wear dressings on the breast and back for 2 weeks.
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Bras & clothing – patients are advised to wear a pressure garment for 4 weeks.
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There is around a 5% risk of experiencing problems with the back – stiffness in the shoulder, fluid collection, and possibly infection around the implant following surgery.
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There is a moderate risk of having long term problems – implant firmness and poor symmetry compared to the other breast.
FLAP NIPPLE AREOLA RECONSTRUCTION
The procedure
Nipple /Areola complex reconstruction is a minor procedure with good cosmetic results.
Nipple reconstruction can often ‘finish’ a breast reconstruction. It is a relatively minor operation performed under local anesthesia. However, it is not essential and some patients elect not to have it done – as with all areas of breast reconstruction, the decision lies with the patient.
Nipple reconstruction is more commonly performed some months after reconstruction is complete. The best option will depend on the individual patient case. There are broadly two different ways to perform the surgery. The advantages of the surgery are that there is no need for general anesthesia and can be treated as a day case. The nipple can shrink over the first 6-9 months and therefore tends to be made larger to start with.
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Flap Based Nipple Reconstruction
Normally the preferred method is to reconstruct the nipple using small pieces (flaps) of skin on the reconstructed breast which are ‘wrapped’ around themselves to make a nipple.
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Nipple Share Reconstruction
This takes half of the nipple from the opposite breast which is then grafted onto the reconstructed breast (similar to a skin graft).
With both techniques, the areolar (colored disc around the nipple) is then created with the use of a tattoo around 8-12 weeks following surgery. The tattoo is done using pigments to best match the color of the opposite nipple. Patients should be aware that the process might need repeating over time.
Prosthetic Nipples
Another option is to have a rubber molded nipple made. This can achieve a very realistic result as it will be molded on the opposite nipple.
Smoking
If you are a smoker, try and stop around the time of the procedure as it can reduce the chances of complications.
Surgical Recovery & Final Outcome
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Length of stay in hospital – day case.
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Length of surgery – usually 30-45 minutes.
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The patient will not need to spend any time in bed and will be able to walk straight away following surgery.
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Time to exercise – patients should be able to exercise after 2 weeks.
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Dressings – patients will wear dressings on the nipple and breast for 2-3 weeks.
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There is a 2% chance of experiencing part or total nipple reconstruction failure.