Breast Reconstruction

Breast reconstruction is a surgical procedure to restore the appearance of a breast for women who have had or are about to have a mastectomy to treat breast cancer. The surgery attempts to rebuild the size and shape of the breast and, if you wish, the nipple and areola (the darker area surrounding the nipple) at a later date. Most women who have had a mastectomy can have reconstruction.

Breast reconstruction surgery before pictures                after breast reconstruction surgery pictures
Before                                    After
 

Immediate reconstruction is reconstructive surgery that is done at the same time as the mastectomy. The benefit with immediate reconstruction is that the chest tissues are undamaged by radiation therapy or scarring and your natural breast skin is retained. This helps to shape the reconstruction more like your natural breast and minimise scarring.

Delayed reconstruction is surgery that is done at a later time following a mastectomy. For some women, this may be advised if radiation is likely to follow mastectomy. This is because radiation therapy that follows breast reconstruction increases the risk of complications and adversely affects the cosmetic result. Some women find it difficult to decide about reconstruction at the time of a cancer diagnosis or prefer not to have a more major operation at this time. Delayed reconstruction can be carried out at any time after a mastectomy.

Types of Breast Reconstruction

Several types of operation are available for breast reconstruction but you may not be suitable for all types of procedure.

Tissue expansion and silicone implant alone

Expander Implant

This operation is most suitable for women with small to moderate size breasts with minimal ptosis (breast droop). It is usually performed as a two stage procedure (Two operations separated by 3 - 6 months).

A tissue expander, like a balloon, which has a silicone shell, and a chamber into which saline (salty water) can be injected to gradually fill the implant is placed beneath the skin and chest muscle. The purpose of this is to stretch the skin and muscle over a period of time to accommodate the subsequent silicone implant.

Once healing of the surgical wound has occurred, usually between 2- 4 weeks after surgery, tissue expansion can begin. Through a valve mechanism beneath the skin, saline is injected at regular intervals to fill the expander over time. This is usually carried out several times as an outpatient at intervals of two to three weeks. It is left that size for a few months to achieve maximum stretching of the tissues. The expander is removed in a second operation, and a permanent silicone implant is then put in its place.

Latissimus dorsi flap with or without an implant (back operation)

This type of reconstruction moves tissue from your back and transfers it to the front of your chest in place of the breast tissue removed at mastectomy. It is more suitable for moderate to large breasted women and gives a more realistic shape and feel to the reconstruction than implant only reconstructions. It is however a more complex operation requiring a longer recovery period and leaves a scar at the donor site (on the back).

The Latissimus dorsi flap operation involves moving a flap of muscle, fat and overlying skin from the back. The flap and its blood supply is tunnelled under the skin just below the armpit. It is then put into position to make a new breast shape. Often, there is not enough tissue to form a whole breast, so an implant may be put behind it to match the size of the other breast. Sometimes a larger area of tissue is taken from the back, which is called an autologous latissimus dorsi flap, so that no implant is used. This gives a more natural feel to the breast reconstruction and avoids any potential complications associated with implants.

Any type of breast reconstruction using muscle, fat and skin flaps is a major operation and needs a hospital stay of around five days. This type of operation leaves scars both from where the skin and muscle flap is taken (donor site), and on the reconstructed breast. The scar on the reconstructed breast is round, oval or eliptical and the scar on the back is either diagonal or straight, so a bra strap will mostly cover it.

This type of reconstruction generally has few problems and can make a small or moderate size breast very well. However, it cannot always match a very large breast. To give a good match, some women with large breasts may need to have a breast uplift procedure (mastopexy) or breast reduction of the other breast at a later time.

TRAM (transverse rectus abdominis muscle) flap and DIEP (deep inferior epigastric artery) flap

The TRAM flap procedure uses tissue from the lower abdominal wall (tummy tissue). The tissue from this area alone may be enough to create a breast shape, and an implant may not be needed. If there is insufficient tissue to recreate a breast then this procedure would not be suitable for you. The skin, fat, blood vessels, and at least one of the abdominal muscles are moved from the abdomen to the chest area. There are two types of TRAM flaps:

  1. Pedicle flap involves leaving the flap attached to the underlying muscle and to its original blood supply and tunnelling it under the skin to the breast area.
  2. Free flap means that the surgeon cuts the flap of skin, fat, blood vessels, and muscle free from its original location and then attaches the flap to blood vessels in the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels.

The DIEP flap procedure uses fat and skin from the same area as the TRAM flap but does not use the muscle to form the breast mound. The procedure is done as a "free" flap meaning that the tissue is completely detached from the tummy and then moved to the chest area. This requires the use of a microscope (microsurgery) to reconnect the tiny vessels to vessels either in your axilla (armpit) or behind your ribs.

I offer all of these breast reconstructions at the Nuffield Health Taunton Hospital other than abdominal based flaps (TRAM and DIEP reconstructions). I will be able to advise you which types of reconstruction you would be suitable for as you may not be suitable for all the different types of reconstruction.

Nipple and Areola Reconstruction

The decision to have your nipple and areola (the dark area around the nipple) reconstructed is dependent on your wishes. Many people having a breast reconstruction decide to have a nipple and areola reconstruction but not all. They are considered the final phase of breast reconstruction. This separate surgery is done to make the reconstructed breast more closely resemble the original breast. It is usually done after the new breast has had time to heal (3 - 6 months after surgery) and is carried out as a day case.

Tissue used to rebuild the nipple and areola is taken from your own body, such as from the newly created breast.

Tattooing can be done to try and match the colour of the nipple of the other breast and to create the areola. This is done a minimum of six weeks after nipple reconstruction to allow the scars to fully heal.

Planning Your Surgery

After reviewing your medical history and overall health, I will help you decide which reconstructive options are best for your age, health, body type, lifestyle, and goals.

Breast reconstruction after a mastectomy can improve your appearance and renew your self-confidence. However, keep in mind that the desired result is improvement, not perfection.

Breast reconstruction at the same time as a mastectomy cannot recreate the exact appearance of your natural breast, however I will endeavour to mimic your natural breast as closely as possible.

You will be shown photographs of reconstructions and subsequently be able to discuss any issues further. If you would like to talk with someone who has had your preferred type of surgery this can often be arranged.

If we are planning to do a reconstruction at the same time as your mastectomy, we will need to do a short operative procedure under General Anaesthetic called a Sentinel Node Biopsy on your axilla (armpit). This ensures that your lymph nodes do not have cancerous cells in them. This procedure will take place 2-3 weeks before your planned mastectomy and reconstruction. If the lymph nodes are free of cancer we will be able to do your reconstruction at the same time as your mastectomy. If the lymph nodes contain cancer cells there is a high chance that you will need radiotherapy to your chest wall. I therefore prefer to do your reconstruction at a later date as a delayed procedure after your mastectomy and chest wall radiotherapy.

After Breast Reconstruction Surgery 

You are likely to feel tired and sore for a week or two after implant reconstruction and longer after flap procedures. You will be given painkillers to control your discomfort.

Depending on the type of surgery you have undergone, you should go home from the hospital in 3 - 5 days. You can shower (not bath) with your dressings on as they are splash proof. You will need to wear a soft bra (not too tight) for six weeks after the surgery and you should bring this with you into hospital. You may require regular drainage of fluid from your back (back flap operation only) in the outpatient department. You should not drive for 2 - 6 weeks depending on the operation you have undergone. Generally you will need 4 -12 weeks sick leave depending on your recovery and type of work you do but you may need longer.

You should be up and around in 2 - 4 weeks. If implants are used without flaps, your recovery time may be less.

Some things to remember:

  • Reconstruction does not restore normal sensation to your breast, but some feeling may return.
  • It may take as long as 1 - 2 years for tissues to completely heal and for scars to fade, but the scars never go away entirely.
  • Follow your surgeon's and physiotherapist's advice on when to begin stretching exercises and normal activities. As a rule, you'll want to avoid any overhead lifting, strenuous sports, and sexual activity for six weeks following reconstruction.
  • Women who have reconstruction months or years after a mastectomy may go through a period of emotional readjustment once they have their breast reconstructed. Just as it takes time to get used to the loss of a breast, you may feel anxious and confused as you begin to think of the reconstructed breast as your own.

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