Breast Reconstruction
Breast Reconstructions are performed by Mrs Sue Jones, Breast Oncoplastic Surgeon.
For Patients undergoing free TRAMS or DIEP reconstructions, Sue Jones is helped by John Pereira, consultant plastic and reconstruction surgeon.
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Wherever possible we strongly believe in breast conservation. Removal of the lump along with radiotherapy to the breast has been shown to be every bit as safe and effective as mastectomy. However, in certain circumstances, particularly with either widespread pre-cancerous disease or multifocal cancer we will advise mastectomy. A simple mastectomy will leave the chest wall on that side flat and able to accommodate an external prosthesis, which in a bra or clothes will look, and feel, normal. However, some women feel an external prosthesis is not enough and may wish to consider a breast reconstruction. Reconstruction can be performed either immediately or months or years after mastectomy. Immediate surgery has many advantages; you will avoid ever living through a period with a flat chest wall, the surgery is all over at one sitting and indeed it is often technically easier to reconstruct immediately. Delay may mean the use of an expandable prosthesis so the ultimate volume of the new breast may take several months to achieve. When using the most complex tummy flap (TRAM) we usually advise an interval between mastectomy and reconstruction. However, the simple forms of reconstruction can be easily fashioned immediately or later on.
At the time of advising a mastectomy women are often overwhelmed at the advice and its implications and find it very difficult to focus attention and understanding of the details of reconstructive surgery. It is devastating enough to comprehend the reasons for needing a mastectomy and the impact on your life, your family's life, your future and the impact of your diagnosis on your ultimate life expectancy. You may also need to take on board the possible need for further treatment such as chemotherapy and radiotherapy. On top of which you will be asked to consider the idea of reconstruction and even then not just a simple yes or no, but when and what sort. Therefore some Surgeons delay discussion on reconstruction and would always perform reconstruction as a delayed procedure to give the woman and her family time to fully consider all the implications and choices.
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That said we believe by ensuring time is available for several sessions of discussion and counseling, where appropriate, there are some women who, despite the complexity of the all the issues, will wish to proceed immediately.
What are the options? As with any commodity the most complex/expensive/intricate the operation usually the better the long term outcome cosmetically, but some breasts are better suited to one form of reconstruction than others by virtue of the size and degree of protuberance or droop. A simple implant would be the ideal solution for a petite small breasted woman, but would in no way be able to offer a good match for the large breasted woman with significant droop or ptosis. Conversely a tummy flap (TRAM) will produce an excellent reconstruction for a large breasted woman, but is probably an unnecessarily large and extensive operation for women with smaller breasts.
In short, although the purpose of this is to explain the details of the various reconstructive procedures, when it comes down to it, the size, shape, droop of the breast, the age, general health, associated diseases and smoking habits of the patient usually indicates the best individual choice.
What does a reconstruction aim to achieve? Reconstruction will not reproduce the breast that is lost. It produces a mound that simulates as far as possible the removed breast in shape, size, protuberance and volume as possible. It will not have the same sensation; indeed in some cases there will be an island of skin that is without any sensation.
Symmetry may be produced, particularly if the aim is for symmetry in a bra. However, without the support and uplift of a bra the normal, untouched breast may be much more droopy, or more ptotic, than the reconstructed side. If symmetry without a bra is to be achieved, surgery on the other breast may need to be contemplated. This surgery may be in the form of an uplift or a reduction or both to the other side.
Generally, however, most women are content with symmetry in a bra, achieving a good cleavage visible with low cut necklines. Disparity, particularly with a view to degree of droop without a bra, is generally acceptable to most women.
It is, however, important to discuss these issues at the outset so a clear idea of the final results and expectations are understood. Changes to the opposite breast can always be considered at a later date.
Some women take the opportunity to "trade in" the breasts they have always hated for being too large or too small. The large breasted lady may opt for a smaller reconstruction and a later reduction to the other side. Similarly the 32AA cup woman may opt for a bigger reconstruction and an augment on the other side to give her the 36B cups she has always desired.
What forms of reconstruction are there?
1. Simple implant.
2. Implant and muscle flap (usually from the back) - latissimus dorsi
3. Using fat and skin +/- muscle from the abdomen (TRAM or DIEP). Usually no implant.
Why do we need a muscle flap?
It is not normally possible to remove the breast and put an implant in under the skin. The implant will act as a foreign body, much like a splinter, and work its way out. The wound will break down and the implant will be extruded. In order for the implant to "take" it needs to be covered by something else other than skin. This something else is a layer of muscle.
Beneath the breasts is a large muscle, the pectoral muscle, beneath which lie the ribs. There is a potential space here that can be created and an implant can be simply inserted behind the pectoral muscle. The space is not large. A simple implant can be used beneath the pectoral muscle to reconstruct a small breast. If a larger breast is to be reconstructed an implant can be inserted which can be gradually expanded over the months via a small tube which lies under the skin. Injections of saline can be repeatedly instilled into this tube to gradually inflate the prosthesis so expanding this potential space behind the pectoral muscle. Simple implants placed behind the pectoral muscle give good results for smaller breasted women .
Even with expandable prostheses large breasts are always significantly more protuberant than the other breast because of the confines of the subpectoral space. However, with a good uplifting bra this may not be a problem if symmetry in a bra is the ultimate goal.
Simple implants add little to the time or complexity of the operation of mastectomy. Recovery time is little more than if mastectomy alone has been performed. Expandable prostheses will need several outpatient attendance's in the months following surgery for gradual inflation.
Why use muscle flaps from elsewhere?
To create a larger pocket and avoid the need for inflation other muscles can be used to protect the implant.
Usually we use the large back muscle called the latissimus dorsi. It is ideally suited as its blood supply comes from a leash of vessels in the axilla (armpit). The whole muscle can be lifted from the back and swung on its blood supply through the axilla into the breast pocket. No vessels are divided and the muscle thereby remains healthy and able to sit in the front instead of the back, protecting the implant that is placed beneath it. As well as the muscle, an island of skin is also taken from the back to become an island in the front to exactly match the skin removed during mastectomy. This island of skin will be numb as its nerve supply is disrupted. The bigger pocket for the implant makes a more ptotic breast and is suitable for small to moderate to fully large breast volumes.
Latissimus dorsi flap reconstruction's do add to the operating time of mastectomy, generally two to three hours extra operating time. Recovery time is greater, but surprisingly there is no significant long-term deficit to back or shoulder movements after repositioning the muscle.
Because internally there is quite a large raw area left when the muscle is lifted from the back, there is a significant incidence of fluid build up, or seroma formation, that requires drainage for a few weeks after the operation. This is a painless outpatient procedure taking approximately ten minutes on a weekly basis for usually no more than three or four weeks. There is a scar on the back, usually placed beneath the bra line, or such that a low cut dress at the back will not show the scar.
Generally speaking most breasts, except very large ones, can be reconstructed with this method. It is a safe and reliable procedure with few complications and does not add excessively to surgery or recovery time.
What sort of implant is used? Is silicone safe?
Generally with simple implants or latissimus dorsi and implants, the prostheses used are textured silicone/saline implants. As in most countries in Great Britain we use silicone and recent major scientific reviews have confirmed it is perfectly safe.
As with any artificial material introduced into the body there is a risk of infection and rejection. Antibiotic cover is given for forty-eight hours to avoid problems with infection. Rarely infection can be a problem and necessitate removal of the implant. Several months later a further implant can be reinserted, after everything has settled down.
What is a TRAM and a DIEP and why use one if implants are so good?
The tummy tuck operation uses the excess fat and skin that makes for the spare tyre some can feel in the lower abdominal wall. The skin and fat and sometimes a small patch of muscle are taken away and transposed to form a breast mound. The blood vessels are divided in the groin and hitched onto blood vessels between the ribs, so opening up a new circulation of blood into the new "breast". The beauty of this operation is that all the tissue is natural and usually implants are not needed at all. As you change weight the new "breast" does likewise. Although numb the tissues feel normal, because they are.
The downside to the tummy tuck is that it is a long and complex operation, the scar on the abdomen is not insignificant (although you do gain a flat tummy!) and the recovery time is similarly more protracted. Because of the new blood vessel join up there is a small risk that the blood may not flow freely in which case the new breast will not be nourished and may die. We know that certain people are at more risk of blocking the new blood supply and these groups would be advised against this procedure: smokers, patients with diabetes, high blood pressure, autoimmune disease such as rheumatoid, thyroid disease, heart conditions, vascular disease and people taking certain medications.
It would not be advised if future pregnancies were contemplated and may not be possible if there has been previous abdominal surgery.
There was a small risk of hernias, or ruptures, of the abdominal wall after this operation, but nowadays very little or sometimes no muscle is taken (the DIEP), so hernias should become less common.
TRAM reconstruction is usually performed as a delayed procedure because it is undertaken by Mr Roger Smith, Consultant Plastic Surgeons at Queen Victoria Hospital, East Grinstead, using operating microscopes
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