Breast Reconstruction is also known as: Breast Surgery.
Breast Reconstruction Surgery Overview
Living with the diagnosis of breast cancer is difficult, but as many women have proven, the disease is surmountable. Current medical technology offers you amazing ways to restore your physical and emotional well-being.
You probably will have, or have already had, a mastectomy, involving removal of breast tissue together with skin and the nipple-areola complex. Sometimes your breast surgeon will advise you that the skin of the breast or the nipple complex can be preserved. This is beneficial for your reconstruction. While this medically necessary removal is undoubtedly for the best, like many women in your situation, you may feel a great loss.
Considering what you are going through, the decision to opt for reconstructive breast surgery may be complex, and only you can make that decision. Many women opt for breast reconstruction not only because they wish to restore their whole body image, but also because it may allow them to bring a worrying time to a close. Opting for breast reconstruction can help you make a positive start to a new period in your life.
Breast reconstruction techniques have gained momentum in the past few years. Breast implant shapes and other options have also improved considerably. Although reconstruction can never make up for the loss of one’s own breast, the results are generally very good.
The following can provide you with information on current techniques and options in breast reconstruction. The important part is that you know your options and make the best decision for your own personal well-being.
The timing of reconstructive breast surgery
The question of whether reconstruction is carried out in the same operation as the mastectomy, or at a later stage, depends very much on your personal situation. Immediate reconstruction means that the procedure begins at the same time as the mastectomy. Delayed reconstruction can be carried out weeks or even years afterwards. It is important to know that, whichever method of reconstruction you choose, it may involve various stages before the end result is achieved.
One advantage of immediate reconstruction is that when you wake up from the anaesthetic, the reconstruction process has already begun. This means that you avoid the experience of having only one breast, or none if the mastectomy was performed on both breasts. Another advantage of immediate reconstruction is that it means one less time undergoing anaesthesia and surgery.
In addition, costs may be reduced when the first stage of reconstruction is combined with the mastectomy. At the same time, you should realise that the length of time the operation takes is increased and there is a slightly greater risk of complications. Moreover, the time required for you to accept the reconstructed breast and for convalescence may be longer than in the case of reconstruction at a later stage.
An advantage of reconstruction at a later stage, often called “delayed” reconstruction, is that you give yourself more time to make a well-considered decision. In fact, you can work on your recovery in two phases. You can begin by concentrating entirely on follow-up treatment, such as radiotherapy, chemotherapy, or both. You will also need time to cope with the whole course of the disease, a process that will require a great deal of energy. After this phase, you can prepare yourself for the restoration of your natural bodily contours.
Your surgeon will discuss with you the best timing depending on your situation and your wishes. Allow plenty of time for these discussions. The decision to have breast reconstruction carried out is an important one, leading you into a new phase of life.
Medical and emotional aspects, as well as financial considerations, play a part in weighing whether to opt for immediate or delayed reconstruction. Talk to your surgeon about the options relevant to your own situation.
There are various ways to reconstruct the breast. Here again, the choice you make depends on a variety of personal details such as your state of health, the shape and size of your breasts, your remaining skin and tissue, your wishes and your lifestyle. In breast reconstruction, every situation is unique – after all, you are unique.
Breast reconstruction can be carried out with the aid of a breast implant, by using your own tissue, or by a combination of the two.
A breast implant is a breast-shaped silicone elastomer casing or envelope that can be filled with various materials. Silicone gel and a saline (salt-water) solution are the most well known and most extensively researched fillers. The breast implant is implanted under the chest wall muscle to make a new breast.
In the method using your own tissue, the plastic surgeon uses your own fat, skin and muscle tissue, from your back or abdomen. The TRAM flap uses abdominal tissue. For the Latissimus Dorsi flap, tissue from the back is used.
What about a TRAM flap?
TRAM stands for Transverse Rectus Abdominus Muscle. The particular feature of this method is that it uses a section of abdominal skin, fat and muscle to create a breast mound. This method is particularly suitable for women with surplus fat in the area of the lower abdomen. It will get rid of the roll of fat, but you will probably be left with a sizeable scar on your abdomen, and weaker abdominal muscles.
This method is suitable for women who have enough abdominal tissue. It is suitable for plump women as well as for slim-to-average women because the breast size is normally in balance with the body shape. In other words, slim-to-average women with less abdominal tissue normally have smaller breasts, so less tissue is needed. If you are extremely slim, the TRAM flap method is less suitable, since you probably have too little abdominal tissue for this method to be possible. The TRAM flap may be less suitable if you have already had abdominal surgery, with resultant scars.
In any case, the surgeon will begin by checking whether you are in good health and that you have no problems with your circulation. This means that women who smoke will usually be advised against the TRAM flap method. You need to bear in mind that this method involves a major operation. Good general health and strong motivation are important preconditions.
Tissue is cut from the lower abdomen and is transplanted to the chest wall. When the blood supply remains connected, it is called a pedicled TRAM flap. When the flap is completely cut away and re-attached in the breast region by microsurgery, it is called a Free TRAM flap.
The advantage of the TRAM flap method is that your own tissue is used to fashion a new breast, and the breast changes with the body habitus over the long term. Because the tissue is comprised of skin and fat it has the appearance and texture of a normal breast. Another advantage of the TRAM flap is that your stomach will be flatter after this operation. It is potentially a one stage procedure although secondary procedures may be necessary, such as nipple reconstruction, reduction or re-shaping of the reconstucted breast and/or reduction or lifting of the opposite breast. This method may be chosen when other options are not possible; for example, if a large breast needs to be reconstructed and the remaining skin is no longer sufficiently elastic as a result of radiotherapy.
The operation to reconstruct a breast using abdominal tissue can take a long time – around 3 to 4 hours under general anaesthetic for the pedicled TRAM flap, and even a little longer for the free TRAM flap. You may need to have a blood transfusion. You can donate your own blood prior to the procedure (autologous transfusion). If there are problems with circulation to the flap it may mean you have to return to the operating room. Complete loss of the flap may result if the circulation is interrupted. You will have to stay in hospital for several days (up to 10 days).
You will not be able to resume your normal daily activities until six to eight weeks after the operation. However, some women report that it takes a whole year for their life to return to normal. There is usually a greater risk of more immediate complications than in the case of reconstruction using a breast implant. The most devastating complication is loss of the abdominal flap. You may continue to have problems with your abdomen for some considerable time after this operation. The abdominal muscles remain weakened, which can cause problems if you take part in any sport. If you are considering becoming pregnant after your reconstruction, you should discuss this thoroughly with your surgeon.
What about the Lat Dorsi method?
With the Lat Dorsi method, the surgeon transplants a section of skin and muscle from the back, under the arm, to the breast area to be reconstructed. As this flap of skin is usually thinner than a flap from the abdomen, this method of reconstruction is often carried out in combination with a breast implant. This creates greater volume and gives the new breast a more natural shape.
The advantage of the dorsal muscle method is that, just as with the abdominal method, the patient’s own tissue is used to fashion a new breast. It is also the method indicated if the skin on the chest has been damaged, for example by radiotherapy.
Like the abdominal muscle method, surgery using the dorsal muscle method represents a major operation. You will usually have to spend longer in hospital and take a bit longer to recover than in the case of reconstruction using a breast implant. You will have a scar on your back, though this will usually be covered by your bra. The reconstructed breast will also have more scars than is the case with a breast implant. With this method too, you will have to take a slight difference in colour of the skin into account.
This method is a solution for women for whom an implant cannot be inserted easily because they have too little surviving breast tissue or their breast tissue is no longer sufficiently elastic (as a result of radiotherapy, among other things). It is a reliable method that is suitable for many women and causes relatively little trouble and pain.
The operation using the dorsal muscle method takes around 3 hours under general anaesthetic. You will have to stay in hospital for another 3-5 days afterwards and you may have drains in left your back for some days. You can resume your normal daily activities about 3-4 weeks later. You may experience slight temporary weakness in your shoulder muscle and may have some difficulty in moving your shoulder initially.
What about using a breast implant
The simplest way of having a breast reconstructed is with the aid of a breast implant. However, this can only be done under certain conditions. The skin must be healthy and undamaged and must be sufficiently supple to allow room for a breast implant. In addition, the chest wall muscle must be intact to provide coverage for the implant. This method is primarily suitable for the reconstruction of smaller breasts in thinner women. It is also suitable in bilateral reconstruction as you are not trying to match up with a natural breast. The advantage of this method is that it is not a complicated operation and no extra scars are created. The recovery period is considerably shorter although drains may have to be left in for a few days. The disadvantage is that this method is not suitable for the reconstruction of larger breasts. There are also the potential problems associated with an artificial implant such as leakage, capsular contracture, infection and extrusion.
A breast implant consists of a silicone elastomer envelope that is usually filled with a soft cohesive silicone gel that has a shape retaining memory. These implants can also be filled with a saline solution. Different shapes and sizes of implants are available and your surgeon will help you decide what is appropriate.
Breast reconstruction using an implant can be done in two ways: with or without a preceding period of expanding or stretching. If your surgeon decides in favour of a preceding period of skin and muscle stretching, reconstruction is carried out in two stages.
If there is too little tissue available for a breast implant to be inserted straight away, it is stretched for a certain period, using an expander. The expander is gradually filled with a saline (salt water) solution postoperatively, thereby stretching the skin, similar to what occurs naturally to your abdominal skin during pregnancy. This creates the room needed for the permanent prosthesis. Some months later the expander is replaced with a permanent implant. While this means that usually two operations are required, no additional scarring is caused since the scar sites from the mastectomy are used.
The expander is regularly filled with saline solution through a port (an integral part of the expander itself). Filling is done with a fine needle, directly through the skin and is painless. Some patients may experience a slight feeling of tightness in the breast, but this quickly passes. With the aid of this procedure, the skin is gradually stretched. The desired volume is usually achieved after four to eight weeks. It is important for the expander to remain in place for several months, to ensure that the tissue remains stretched. The expander can be replaced with a permanent implant at any stage after expansion, provided any adjuvant therapy has been finished. The surgeon will help you to choose any definitive size or shape. Your wishes and preferences of course play an important part here.
The advantage of this method is that the surgeon can reconstruct your breast without additional scarring or a major operation. This means that your body has to undergo less of an assault. In comparison with reconstruction with the aid of your own tissue, the operation involving the expander is considerably shorter, as regards the time required both for the operation and for you to recover. One disadvantage is that you have to undergo two operations. While the regular filling of the expander does not involve much physical stress, it does make demands on your time. The final aesthetic result may not be as satisfactory as methods using your own tissues.
The expander/ implant reconstruction can have problems of its own. The expander may become exposed, infected, shift, deflate or encapsulate. This may involve premature removal of the expander. If infection occurs the expander may have to be removed and the expanded breast pocket then shrinks. If this occurs you may have to resort to a latissimus dorsi flap at a later date.
A precondition for employing the expander method is that the skin on your breast is healthy. This means that the method is less suitable for women who have had to undergo, or are likely to undergo radiotherapy. This method is particularly suitable for women who opt to have breast reconstruction at the same time as the mastectomy. It is also especially suitable for women with small or medium-sized breasts or those having both breasts removed. Larger breasts are often reconstructed by using an implant in combination with a method using the patient’s own tissue.
In a mastectomy, the nipple is often removed as well, since it may contain cancer cells. The nipple can be reconstructed using skin from the nipple of the other breast, provided that it is big enough or by raising the skin of the reconstructed breast, to create a little “button”. Operations to reconstruct the nipple and areola are carried out only when breast reconstruction has been completed.
The areola (the skin around the nipple) can be reconstructed using skin from the groin or labia. The skin is somewhat darker here and resembles that of the areola. It can also be reconstructed by tattooing the surrounding skin. This is a simpler method giving a very satisfactory result. In every case, the operation involved is minor and relatively painless.
An evolving trend is the recognition that in many cases, skin of the breast or indeed the nipple can be preserved at the time of mastectomy. The resultant reconstruction is made easier if this is the case and aesthetic result is often much better than after a complete mastectomy. Prior to your surgery you need to discuss this aspect with your breast surgeon. It may be that the type or location of tumour precludes saving the skin or nipple of the breast.
Making the breasts symmetrical
Often the breasts are not symmetrical following breast reconstruction. The shape of the healthy breast can be corrected in such a way that it forms a more attractive whole with the reconstructed breast. Women, who are already a bit older, have had children and have breast-fed them, often have slightly drooping breasts. Reconstructed breasts are a little firmer and more erect, like young women’s breasts. Your surgeon may recommend that you have your other breast lifted slightly (mastopexy), reduced, or enlarged using an implant.
You should realise that absolute symmetry is almost impossible to achieve. Even two healthy breasts almost always differ slightly from each other. Even after breast correction, the difference will become slightly greater again over the years as the skin slackens as a result of aging. If you definitely do not want the other, healthy, breast to be operated on, then you should make this clear in your discussions with the surgeon. It may influence the choice of method of breast reconstruction. Check out our FAQ page for more information.
*The images on this page are used with permission from the Australian Society of Plastic Surgeons. Complete patient education pamphlets are also available.