BREAST RECONSTRUCTION
What is Breast Reconstruction?
This
includes a number of surgical procedures whereby the breast lost to mastectomy
is reconstructed to approximately the same size and shape as the opposite
breast. Breast reconstruction is also feasible for bilateral mastectomies. A
complete breast reconstruction usually involves 3 – 4 operations done in sequence
and each one 3 – 6 months apart.
The first
operation in breast reconstruction can be done under the same anaesthetic as
the mastectomy or it can be done months to years later. The decision as to
whether a reconstruction procedure should be done simultaneously with the
mastectomy or not is taken by the patient in conjunction with advice from the
surgeon doing the mastectomy and the plastic surgeon considering the
reconstruction. In certain cases there is a great advantage to doing a
simultaneous reconstruction whereas it might not be advisable in others. This
needs to be discussed at length when the need for a mastectomy arises.
General Questions
Yes, we currently practice 4 different sets of techniques for breast reconstruction although the patient has input into deciding which technique will be used, the plastic surgeon’s assessment plays a large role.
The options are as follows:
1. The tissue expander technique: This technique involves placing a silastic balloon under the chest wall muscle. The balloon is then serially expanded with injections of sterile salt water through the skin into a filler valve over about 2-3 months. After 3 months the expander can usually be removed and a permanent breast implant placed under the chest wall muscle.
2. The TRAM flap: This technique involves raising a +25 x 15cm transverse ellipse of skin and fat from the lower abdomen. This is kept attached to one of the tummy wall muscles and tunneled upwards into the mastectomy site. The abdominal wound is then closed and the flap composed of muscle, fat and skin is shaped to achieve the optimal shape and size of the breast.
3. The tissue expander + TRAM flap technique: In this method, the tissue expander technique is used but instead of a permanent breast implant replacing the expander, a TRAM flap which has had the skin removed is inserted under the chest wall muscle without an implant being used.
4. The LD flap: This technique uses a ellipse of skin measuring +15 x 8cm raised from the same side of the back of the shoulder and remaining attached to one of the shoulder muscles. The muscle and skin paddle are then tunneled through under the arm into the mastectomy site and sutured into place over a permanent breast implant.
It is important to note that each of the 4 techniques is indicated in different situations i.e. previous surgery in the area, radiotherapy, underlying medical problems etc
Tissue
expansion
The first stage of breast reconstruction using tissue expansion involves placing the silicone tissue expander between the chest wall and the muscle on the front of the chest. This is usually done through the existing mastectomy wound or mastectomy scar. It is always done under general anesthetic and takes about 1 1/2 hours.
This is followed by placing a tube drain which exits through the skin under
arm. The procedure is moderately painful post operatively and usually requires
1 – 2 days of hospitalization followed by 2 weeks of convalescence with
restriction of activity. The subsequent inflation of the expander using a fine
needle through the skin under the arm into the filler valve is moderately
uncomfortable and is undertaken once every 2 weeks for 2-3 months. This can be
done in the office.
The second
stage usually involves removal of the tissue expander through the existing
mastectomy scar and replacing it with a permanent breast implant and is usually
done 3 months after the first stage. This is not a particularly painful
procedure and the patient can usually go home within 24 hours with no drain in
place. Recovery is much shorter and usually a week is sufficient.
The next
stage involves matching the opposite breast and may involve a breast reduction
or breast lift procedure which is discussed with the patient in good time. This
would be done under local or general anaesthetic and would take about 14 hours
in theatre. The recovery from this procedure usually takes 10 – 14 days.
The final stage of breast reconstruction involves a nipple / areola reconstruction using local skin and fat from the breast to reconstruct the nipple. This may be done under general or local anesthetic and takes about 1 hour.
The recovery is very
quick and patients usually go home on the same day. For reconstruction of the
areola we prefer a tattooing with skin matching pigments. This is usually done
by a professional tattoo artist whom we recommend. These tattoos tend to fade
with time and can be revised fairly easily.
TRAM flap
The TRAM flap procedure is technically a more complicated one. In some cases it is necessary to do a small operation a few weeks before the actual reconstruction to tie-off 2 sets of blood vessels in the lower tummy wall. This is not always necessary. At the first stage procedure, under general anesthetic, the abdominal tissue is raised and the mastectomy site re-opened.
This procedure can also be done at the same time as the mastectomy. This is a much longer and technically involved procedure taking up to 4 hours under general anaesthetic. The recovery phase takes about 2 – 3 weeks and requires major restriction of physical activity thereafter.
LD flap
The LD flap
procedure is of moderate technical complexity (somewhere between the tissue
expansion technique and the TRAM flap technique). This requires the raising of
the skin and muscle on the upper back on the same side which is then tunnelled
through under the arm to cover a permanent implant on the chest wall. This
usually takes 2-3 hours in theatre and requires hospitalisation of 2 – 3 days
thereafter. The recovery phase also takes 2 – 3 weeks.
The above
named procedures all carry a small risk. The tissue expansion technique is a
small risk for bleeding and infection. This is uncommonly seen as precautions
are taken to prevent this. The problems with later hardening of the breast due
to the permanent implant or radiotherapy will be discussed with each patient.
As regards
the TRAM flap procedure, not only is bleeding and infection a risk but in 10 –
15% of cases, variable amounts of tissue which has been transferred to the
breast may lose some blood supply. This tissue becomes non-viable and may have
to be removed surgically. This is not a big risk and does not threaten
significantly the final outcome of the procedure. The LD flap method carries
the same general risks but is far less likely to develop blood supply problems.
One should also remember that the TRAM flap procedure effectively leaves the
patient with a tummy tuck as well which also carries the risks of a tummy tuck.
The main
advantage of the tissue expansion technique is that it is technically a little
easier, carries less risk of complications and does not cause any more scarring
than the original mastectomy. The new breast mound carries the same sensation
as the skin does after the mastectomy.
The main
disadvantage of the tissue expansion technique is that it requires a permanent
breast implant which also carries a certain risk (see breast augmentation) and
that the breast mound reconstruction is more cosmetically (appearance)
acceptable in TRAM flap reconstructions.
The main
advantage of a TRAM flap procedure is that it provides a breast mound with
often very good appearance, texture and no need for a synthetic breast implant.
It is important to remember however, the skin brought up from the tummy into
the breast does not have sensation (remains numb). There is also additional
scarring across the lower tummy as for a tummy tuck. The risk of tissue loss
due to poor blood supply is 10 – 15% which is not the case for the tissue
expansion technique.
The LD flap
carries a risk involved with the presence of a breast implant but is an
extremely reliable procedure of moderate technical difficulty. It is especially
useful in cases where there has been radiotherapy to the chest wall.
Before surgery please do not take any products that contain Aspirin or large doses of Vit.E for3 weeks pre-operatively. If you take any form of over-the-counter medication, please notify your doctor well before the operation.
Smokers should stop smoking completely at least 2 weeks before the operation.
Please
report any signs of a cold, infection, boils or pustules appearing within 3
weeks of surgery.
The night
before and the morning of surgery we recommend a hair shampoo with Betadine or
alternative. Arm pits should be shaved closely on the day before surgery.
It is
extremely important that you limit the use of your arms for 2 – 3 weeks post
operatively. Do not lift your arms above shoulder level. Keep you elbows to
your sides. Do not lift anything heavy or drive a car until 2 – 3 weeks after
surgery.
In the
first 24 hours we recommend bedrest although the patient may go to the bathroom
with assistance. If you are comfortable on your side this is permissible,
however do not attempt to sleep on your stomach for 4 weeks after surgery.
The breasts
are usually bandaged until the drains (if present) are removed at 24 – 48
hours. The bandages will then be replaced until 5 – 6 days post surgery. Do not
wear a brassiere until you have been given permission to wear one.
It is
extremely important to be very patient as regards the final outcome. The final
appearance and shape and softness of the breast may take up to a year and a
half to develop.
Scars may
be pink or even raised in areas for 18 – 24 months after surgery. Treatment of
the scars may be necessary with special tape, creams or injections to achieve
the best scars. Please avoid getting overheated and do not sit in the sun for 2
weeks after surgery. Please wear loose fitting clothes that are easy to slip on
and off with minimal use of your arms. Do not wear tight sweaters.
Finally
please avoid large crowds and any persons who have colds or flu for at least 6
weeks after surgery. After 3 weeks you can resume most normal activities except
for tennis, golf, swimming or strenuous exercise which can be resumed usually
after 2 months.
We also
strongly recommend wearing adhesive paper tape over the scars for 3 months post
surgery. You will be shown how to do this.
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