Breast Reconstruction

Breast Reconstruction

Breast Reconstruction Surgery

About 15% of women decide to have a reconstructive surgery after mastectomy. Many women decide that they would rather stay flat. Perhaps because they can’t face more surgery, or perhaps because the feel that that their post cancer survival-body is to be celebrated, and that their scars are battle scars.

Many women wear prosthetics in their bras to achieve a ‘normal’ appearance, and others are ‘flat-and-proud’, choosing to reclaim their bodies with beautiful tattoos. If this is the right decision for you, I salute you!

Types of Breast Reconstructions

Generally speaking, there are two types or reconstructions; reconstruction using your own tissues (known as autologous reconstructions) or reconstruction using a silicone implant.

Implant based reconstruction

As the name implies this reconstruction uses silicone implants to recreate the breast. Most Oncoplastic breast surgeons – myself included – are trained to do this type of reconstruction achieving excellent cosmetic results. It is probably the most common type of immediate reconstruction that is performed.

Advantages of Implant Based Reconstructions:

• Can be done at the same time as the cancer operation
• Avoids having a flat chest
• Cost effective
• Shorter surgery compared to autologous reconstruction (see below)
• Less visible scars
• Nipple can be preserved sometimes.

Disadvantages of Implant Based Reconstructions:

• Silicone implants are a foreign material
• 5% general risk of infection and loss of implant
• Risk of implant rupture and silicone leakage
• Not durable long term
• Sequela of implants that hinder the appearance of the new breast
• Implant animation – i.e. the implant moves when you flew your chest muscles
• Rippling – the appearance of folds on the skin over the implant
• Implant capsule formation and capsular contracture. The body forms a layer of scar tissue around the implant (capsule). In some patients this capsule hardens over time causing the implant and breast to change shape.
• Chest wall and muscular pain
• Need for further surgery to correct the above

Autologous breast reconstruction

Autologous means using your own tissues to reconstruct the breast. Tissue from other parts of your body is borrowed and moved into the chest to create a new breast. In my opinion, this by far the best form or reconstruction of the breast.

These reconstructions are performed by reconstructive plastic surgeons. The “spare parts” or tissue used are called flaps. The flap may come from nearby areas attached to its the blood supply. This is called a pedicled fap e.g. TRAM flap or Latissimus Dorsi (LD) flap.

If they come from a part of the body further away, they are called free flaps and the blood vessels that keep this tissue alive are cut and reconnected to vessels in the chest using microsurgery. Common examples of free flaps used in breast reconstruction include the DIEP, TRAM and Gracillis flap.

The advantages of Autologous Breast Reconstructions are:

• They feel more like real breast tissue
• It is your own tissue – thus no risk of complications or issues related to having foreign material in your body
• May grow and shrink in proportion to changes to your body weight
• A durable reconstruction
• They often look better than implant-based reconstructions long term

Disadvantages of Autologous Breast Reconstructions are:

• Extensive surgery – usually 10-12 hours
• Longer recovery
• Donor site (site where tissue comes from) complications and side effects
• Costly when done privately
• Often long waiting list when done in the public hospital system
• Often difficult to organise as an immediate reconstruction
• Some women may not be suitable for this type or reconstruction

Timing of Reconstruction

Once you have decided that you want to have a breast reconstruction, the next question that you and your care team need to answer is when will be the best time to do it?

It is possible for some women to have reconstruction performed at the same time as the mastectomy (immediate reconstruction) or later, after recovery from surgery and completion of any associated treatments (delayed reconstruction).

This will depend on your circumstances, and what treatments are recommended for you.

If you need to have radiotherapy, then your care team is likely to recommend that you have delayed reconstruction. This is because radiotherapy cause your skin to shrink, which could pull your reconstructed breast out of shape.

Immediate reconstruction is more likely to be available to women in general good health with early-stage disease.

Immediate Reconstruction

The benefits of immediate reconstruction are:

• The cosmetic results are usually better
• More of the skin of your breast can be preserved, perhaps including your nipple
• The scarring on the breast itself is usually less
• You will not have to spend any time ‘flat’

Immediate reconstruction may be an option if you are not recommended to have radiation therapy.

When radiation is not anticipated, immediate reconstruction is very often the preferred option. For most women it yields more natural-appearing results compared with delayed reconstruction.

Immediate reconstruction may not be advisable for you if you have other health problems such as obesity, high blood pressure and diabetes – it might be better to wait.

If you are a smoker the risk of complications increases significantly, and most plastic surgeons will be reluctant to offer you a reconstruction until you become and remain a non-smoker.

The risk is that if there are complications with your surgery, then there could be knock-on effects such as delaying chemotherapy, which is best avoided.

If you are recommended or are suitable to have neoadjuvant therapy – in other words chemotherapy (and sometimes radiotherapy) up front, before cancer removal – then surgery to remove the cancer and immediate reconstruction can be planned while you are having the cancer treatments.

You have time to come to terms with your diagnosis, time to view your options and make a better-informed-decision.

If you can’t make up your mind about having breast reconstructive surgery, then your best bet is to wait. You can have your reconstruction in the future, and still get a great result.

Delayed Reconstruction

The benefits of delayed reconstruction are:

• Less risk of delay to your life saving cancer treatments
• More time to explore your options and make your mind up
• As the cancer is gone and you have had time to recover from the cancer therapies, the operation focuses purely on reconstruction and your recovery from surgery is in theory less complicated

If radiotherapy is recommended for you, then my strong recommendation is that you wait for at least 12 months until you have your reconstructive surgery, to allow your body and skin to heal. Radiotherapy can compromise the appearance of both implant-based and tissue–based reconstruction because it causes scaring of the tissues that manifests as skin tightening and stiffening of the soft tissues, meaning that your reconstruction can become misshapen.

Post mastectomy radiotherapy is usually recommended for women at higher risk of their breast cancer coming back e.g. Currently, post mastectomy radiotherapy is recommended to women who have 4 or more lymph nodes involved, a tumour more than 5 cm in size, or cancer in their skin or chest wall.

However, there is growing evidence that supports the notion of giving radiotherapy in a neoadjuvant setting 6 to 10 weeks prior to definitive cancer surgery, where breast reconstruction can be performed with minimal compromise to the cosmetic appearance of the reconstructed breast.

Benefits of Breast Reconstruction

Women who have had breast reconstructive surgery say that they feel more like their normal self again, improving their self-image, self-confidence and reconnects them with their sexual self. Emotionally, women say that they feel ‘whole’ again and that reconstructive surgery enables them to move on from a painful period in their lives.

It can feel overwhelming to think about breast reconstruction in the face of a cancer diagnosis. There is so much information to process. You breast surgeon should help to guide you. The better informed you are the happier you will be with your decision. Any woman considering breast reconstruction needs to understand what’s available to her, with the pros and cons of each approach clearly explained and understood. Your plastic surgeon needs to give you realistic expectations for what can be they can and can’t achieve and will explain what the best timing is for you to have your reconstruction.

Even though you might just want to get the cancer out of you as soon as possible, try not to rush into important decisions. Your outcomes are very unlikely to change if you take an extra week or two to get yourself to a point where you can make well informed decisions. You are more likely to feel happier with your choices if you do so.

Although treatments related to survival, such as radiotherapy, may limit the choice of reconstructive surgery available to you, it is important that you don’t compromise your cancer treatment on that basis. Having said that, for many women, reconstructive surgery is part of recovery and return to normal living and is an important component of your care plan.

Remember the decision to have breast reconstructive surgery is very personal. There are no right or wrong choices, just the one that’s right for you.