Breast Reconstruction after Mastectomy for Breast Cancer
Indications
Breast cancer affects about 1 in 12 women in the UK. Surgery
has tended to become less radical over recent years; but
still a significant proportion of women with breast cancer
will undergo mastectomy. In addition to women with invasive
breast cancer, a group of women with widespread precancerous
changes in their breasts and women with a strong family
history of breast cancer will also undergo some form of
mastectomy.
Breasts are a focus of femininity in our society; the loss
of a breast combined with the diagnosis of cancer can, understandably,
have a deep psychological impact. Breast reconstruction
offers some compensation by restoration of loss of body
image associated with surgical treatment.
All patients undergoing mastectomy should have the opportunity
to discuss breast reconstruction with a reconstructive surgeon
prior to their mastectomy. Unfortunately this is not the
case for many patients in the UK today. Patients should
be aware of the reconstructive options available prior to
their cancer operation. For some patients reconstruction
may not be desired; for example the prospect of additional
surgery with scarring on other parts of the body and the
prospect of multiple operations may not be wanted. Other
patients are unable to think about reconstruction, whilst
still coming to terms with the diagnosis of breast cancer
- in these patients reconstruction is not indicated.
If a patient wishes breast reconstruction and is medically
fit for it then most reconstructive surgeons would be happy
to offer breast reconstruction. The patients age and the
presence of cancer spreading to other parts of the body
are not contra-indications to breast reconstruction in an
otherwise fit, informed and motivated patient. It is important
to remember that breast reconstruction should not interfere
with the patients cancer treatment which may include surgery,
radiotherapy and chemotherapy.
Anaesthetic
Breast reconstruction is carried out under general anaesthetic.
Technique
Their are several questions to be answered and options to
be considered in a woman undergoing mastectomy and considering
breast reconstruction.
• Should the reconstruction
be immediate (at the same time as the mastectomy) or delayed?
• Is the opposite breast
easily matched by the breast reconstruction or will it need
to be surgically modified for a symmetrical result?
• Does the patient wish
a breast made only out of her own tissues or is she happy
for a breast implant to be used?
• What is the medical
condition of the patient?
• Is the patient fit
enough for long reconstructive operations? Is a more simple,
if less aesthetic, operation more sensible?
• What operations has
a woman had previously? (e.g. extensive abdominal scarring
may preclude the use of abdominal tissue for breast reconstruction).
• What does the patient
wish for from breast reconstruction? What "price"
is she prepared to pay?
Immediate or Delayed Breast Reconstruction
In the UK many women have no option but delayed breast reconstruction
because they never meet a plastic surgeon prior to their
mastectomy.
The decision for immediate reconstruction should be a joint
decision between cancer surgeon, plastic surgeon and patient.
For example, a patient overwhelmed by the cancer diagnosis
might be best served by a delayed reconstruction; a woman
with a strong body image might wish immediate reconstruction.
Immediate reconstruction has some theoretical advantages;
the psychological trauma of cancer surgery can be lessened
by immediate reconstruction of the removed tissue; much
of the breast skin envelope can be preserved and the shape
which this helps to maintain will give a better result.
The disadvantages of immediate reconstruction include perhaps
an increased incidence of complications; a concern that
if reconstructive procedures develop complications then
additional, necessary, breast cancer treatment might be
delayed. In patients who are due to receive postoperative
radiotherapy then most surgeons would avoid the use of breast
implants for fear of complications.
Delayed reconstruction also has some advantages - the procedure
may be carried out without interfering with cancer treatment;
the complication rates are probably less; the patient may
have come to terms with her diagnosis. However; patients
forced to live with their deformity may suffer psychologically
as a result of disturbed body image; conversely some patients
will come to terms with their appearance and not go on to
reconstruction.
The decision about timing in breast reconstruction may be
very difficult and demands good communication between the
cancer surgeon, reconstructive surgeon and patient - the
decision need to be individualised for each patient.
Surgical Techniques
Surgical techniques for breast reconstruction can be divided
up into:
• Reconstructions using
breast implants and tissue expanders
• Reconstructions using
only the patient’s own tissues (autologous reconstruction)
• Combinations of implant
and autologous reconstruction
• Matching operations
on the other breast
• Nipple-areolar reconstruction
Breast Reconstruction Using
Breast Implants and Tissue-Expanders
Silicone breast implants offer the simplest type of breast
reconstruction. An implant can be placed under the mastectomy
flaps to produce a breast mound. However, the results are
not aesthetically good and the complications, particularly
implant extrusion are high. This complication can be reduced
by placing an implant under the muscles of the chest wall,
but again only a limited breast mound can be produced. Implant
only reconstructions are rare today. The results of implant
only reconstructions were improved by the use of tissue
expanders. Tissue expanders are silicone balloons which
are placed at the site of the missing breast. Ideally the
expander should be placed underneath the muscle of the chest
wall. A length of tubing with a one-way valve is connected
to the balloon. The whole device is buried under the skin.
Through the valve sterile salt-water solution is injected
in stages. Over a period of, on average, three months the
balloon is gradually inflated. Inflating the balloon stretches
the overlying skin and muscle and creates a new breast envelope.
When the envelope has been created the expander can be removed
and replaced with a breast implant to produce a better shaped
breast. Some tissue expanders have been designed to be both
tissue expander and breast implant such that when the desired
shape has been achieved the inflations are simply stopped
and the reconstruction is achieved.
This type of breast reconstruction is usually avoided in
patients who have undergone radiotherapy, unless additional
tissue is brought in.
Autologous Breast Reconstruction
Autologous breast reconstruction is used when the local
tissues are not satisfactory; this usually means there is
a shortage of local skin or the tissues are scarred by surgery
or radiotherapy. Autologous reconstruction involves importing
tissue from elsewhere in the body to reconstruct a breast
using just the patients own tissues or in combination with
a silicone implant or tissue expander. The imported tissue
is known as a "flap"; although various flaps have
been used the two most popular are the latissimus dorsi
flap and the TRAM flap.
Breast Reconstruction Using the Latissimus Dorsi Flap
The latissimus dorsi is a large fan shaped muscle which
lies across the mid-back. This can be separated from its
normal attachments and swung to the front of the chest to
recreate missing tissues and create a breast. A tunnel under
the skin is created to deliver the flap to where it is needed.
The muscle is normally used together with an attached piece
of overlying skin known as the "skin paddle".
The skin paddle is used to recreate the skin that was removed
during the mastectomy and the underlying fat and muscle
to recreate the missing breast. Unfortunately the reconstruction
of a breast using only the latissimus dorsi flap is only
possible with very small breasts; usually the procedure
needs the addition of a silicone breast implant or tissue
expander to produce a satisfactory breast reconstruction.
Latissimus dorsi breast reconstruction leaves a significant
scar on the back; this scar is usually placed transversely
so that it can be hidden by the bra’ strap, other
orientations are possible.
Breast Reconstruction Using
a TRAM Flap
TRAM is an acronym derived from Transverse Rectus Abdominis
Myocutaneous flap. The rectus abdominis is one of a pair
of abdominal muscles that run from the rib-cage to the pubic
region on either side of the mid-line (the "six-pack"
of athletic individuals). "Transverse refers to the
orientation of the skin paddle that is taken with the muscle
to rebuild the breast and "Myocutaneous" means
a flap containing muscle and skin.
The TRAM flap provides sufficient tissue for breast reconstruction
using a patients own tissues only; the aesthetic result
can be impressive. The TRAM flap can be swung up to reach
the mastectomy defect like a pendulum of a clock. A tunnel
under the skin is created to deliver the flap to where it
is needed. The skin paddle is used to recreate the skin
which was removed during the mastectomy and the underlying
fat is shaped to recreate the missing breast. The muscle
itself is not used to rebuild the breast; a strip of muscle
is necessary to keep the blood vessels supplying the flap
alive. An alternative technique for TRAM flap breast reconstruction
is known as a "free flap". In this operation the
TRAM flap is completely separated from all of its bodily
attachments; it is fixed into the mastectomy defect to reconstruct
the breast and its blood supply is restored by joining up
its blood vessels to others in the arm-pit or just inside
the rib-cage. This is a very major operation and needs surgeons
skilled in micro-surgery to reestablish blood flow in the
flap.
Nipple-Areolar Reconstruction
Reconstruction of the nipple areolar complex is usually
performed at least six weeks after the main breast reconstruction.
Many operations are available for rebuild the nipple prominence
and include rearranging the local skin (local flaps) and
grafting nipple tissue from the unaffected side. The pigmented
areola can be recreated using skin grafts from other areas,
such as the groin or by tattooing the area to match the
normal side.
Length of Operation
The length of the operation varies hugely depending upon
timing and the type of reconstruction carried out. Some
simple reconstructions may take 1 - 2 hours; others make
take several hours and more than one operation.
Time in Hospital
The time in hospital is also very varied, from 1 - 7 days.
Post-Operative Discomfort/Limitations
Implant and expander breast reconstructions are intermediate
operations whose postoperative recovery is similar to that
experienced by patients undergoing cosmetic breast augmentation.
Autologous breast reconstruction is a major operation and
significant postoperative discomfort can be anticipated;
the TRAM flap is a particularly major procedure. However,
modern pain relief techniques should provided good control
of pain.
If a tissue expander has been used then this will need to
be inflated, this usually means a weekly trip to the surgeon
when saline is injected into the one-way valve of the expander.
Overall implant only reconstructions offer the simplest
reconstruction but the least aesthetic result. TRAM flap
offers excellent aesthetic results but has significant complications
and is a very major procedure.
Implant reconstructions can rarely match the other breast;
even combined implant and autologous reconstruction struggle
to produce the natural droop seen in most breasts. In these
patients matching procedures to reduce and/or lift up the
unaffected side (breast reduction/mastopexy) may be required.
Time Off Work
The amount of time of work is also very varied; after a
TRAM flap a patient may be off work for 6 - 8 weeks.
Risks and Complications
General anaesthesia is safe; but in a tiny proportion caries
a very small risk.
General Complications
Bruising, swelling and bleeding which may be heavy and need
a blood transfusion and a return to the operating theatre
to stop; chest and wound infection, unsatisfactory scarring
(keloid or hypertrophic); leg vein thrombosis (clot).
Specific
Complications
Silicone implant reconstructions have the same complications
as silicone breast augmentation. Flap reconstructions have
additional complications including death of all or part
of the flap; abnormal fluid collections at the flap donor
sites (seroma) and risk of injury to structures where the
flaps are harvested from. TRAM flaps can be complicated
by hernias or weaknesses in the abdominal wall - sometimes
a plastic mesh is needed to reinforce the abdominal wall
after a TRAM flap has been used.
