Breast reconstruction

Breast reconstruction is achieved through several plastic surgery techniques that attempt to restore a breast to near normal shape, appearance and size following mastectomy.

Current evidence suggests that breast reconstruction, either at the time of (immediate) or after (delayed) cancer treatment, has no adverse effect on the outcome of a patient's cancer. According to guidance from the National Institute of Clinical Excellence, all patients should be offered immediate breast reconstruction following a mastectomy.

Options:

Breast reconstruction can involve:

  1. The use of your own tissues imported to the chest from another part of the body (a flap),
  2. Implanting an artificial prosthesis or
  3. A combination of the above two options.

Your choice of reconstruction is dependent on your aspirations balanced against your perspective regarding the risks involved.

Immediate vs. Delayed:

One of the first choices confronting patients is whether to undergo immediate or delayed reconstruction. Immediate reconstruction is performed during the same operation as the mastectomy. Delayed reconstruction occurs once a patient has fully recovered from a mastectomy (usually after several months).

The benefits of immediate reconstruction are:

  • The skin of the breast can be preserved
  • Smaller breast scars
  • Only one anaesthetic and recovery period
  • Only one stay in hospital
  • No period of time without a breast

The benefits of delayed reconstruction are:

Staggered surgery, resulting in an easier and shorter recovery following each procedure Time to consider whether reconstruction is right for you without delaying the cancer treatment so less to deal with at once.

The drawback of immediate breast reconstruction is that after mastectomy the removed breast is analysed by the pathologist who will assess the need for subsequent radiotherapy. Radiotherapy will change the size and shape of a reconstructed breast as well as increasing the risk of complications. For these reasons many surgeons prefer to do a delayed reconstruction and import normal tissue into the breast region, which has not, been altered by radiotherapy. A period of time after mastectomy will also allow you to make a more informed and considered choice as to whether you wish to have further surgery and if so how involved you would like that surgery to be.

Implant-based reconstruction

When a breast is reconstructed using an implant alone a silicone implant is inserted under the skin and muscle of the chest to replace the breast volume that has been removed at the time of mastectomy. The main disadvantage of implant-based breast reconstruction is that it is impossible to create a breast with a natural shape and feel.

Latissimus Dorsi flap reconstruction

One type of flap transfer for breast reconstruction uses the latissimus dorsi muscle from the back along with an overlying patch of skin. In this procedure, the muscle is transferred to the breast area by swinging it around the ribcage so that it lies at the front of the body. Using this procedure skin removed at the time of mastectomy is replaced along with some volume. Some patients will also need an implant to further augment the volume.

Advantages of latissimus dorsi flap

  • Can use your own tissue for small or medium breasts
  • Reliable flap due to good blood supply
  • Achieves better breast droop and profile than implant alone

Disadvantages of latissimus dorsi flap

  • Frequent formation of seroma (collection of fluid) at donor site in back.
  • Often needs implant or expander to increase breast volume
  • Scar on back will be visible in low cut dresses and swim suits.
  • Needs to be sufficient spare skin on back
  • Not suitable for serious athletes especially climbers or swimmers.

Abdominal flap reconstruction

The skin and fat of the lower abdomen is often the ideal tissue for breast reconstruction. A large amount of skin and volume can be replaced in order to achieve a very natural look and feel. Removal of excess skin and fat can often be a welcome bonus for the patient, resulting in a "tummy tuck". When first described the operation involved tunneling the lower abdominal flap with the underlying rectus abdominis muscles beneath the upper abdomen to the chest – a pedicled TRAM flap.

Free DIEP flap – this variant uses the same blood vessels as the TRAM flap, but they are carefully dissected out from the muscle when the flap is raised and DIEP flap contains no muscle. This procedure involves hooking up all the tiny blood vessels of the flap with those in the new site, and is carried out with use of a microscope, hence the name 'microsurgery'.

This is probably considered to be the gold standard breast reconstruction. It produces the best shape of breast while attempting to preserve the tummy muscles. In addition many patients are pleased to have had a tummy tuck at the same time. These benefits however have to be balanced by the fact that if the microsurgery to the blood vessels fails the flap can loose its blood supply and the whole flap can be lost. This will occur in about 3-5% of patients.

All breast reconstruction is a process and many patients will need further procedures to adjust their reconstruction. These are usually minor procedures such as liposuction to reduce the size of the flap, scar revisions, lipofilling or nipple reconstruction. That said, autologous reconstruction is durable and once a satisfactory result is achieved it tends to be static and permanent.

  • The British Association of Aesthetic Plastic Surgeons
  • The British Association of Plastic, Reconstructive and Aesthetic Surgeons
  • The Royal College of Surgeons of England