Breast reconstruction surgery

Breast reconstruction surgery involves the creation of a new breast(s) following removal of the breast or part of the breast (usually after a mastectomy for breast cancer). The operation can be performed either at the same time as cancer surgery (immediate reconstruction) or after cancer surgery (delayed reconstruction), and will depend on the type and stage of the cancer and the preference of the patient.

Mr Sherif Wilson MB, ChB, MS, FRCS (Plastic Surgery) is the lead clinician for breast reconstruction at Southmead Hospital in Bristol. Mr Wilson undertakes breast reconstruction in the NHS and privately from the Nuffield Bristol Hospital.

Techniques

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 or after 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 reconstruction following a mastectomy.

This procedure can involve:

• The use of your own tissues imported to the chest from another part of the body (a flap)
• Implanting an artificial prosthesis
• 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 reconstruction

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. 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

Delayed reconstruction occurs once a patient has fully recovered from a mastectomy (usually after several months). 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 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

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

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, similar to a breast augmentation procedure.

Advantages of Latissimus Dorsi Flap reconstruction:

• 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 reconstruction:

• 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

The skin and fat of the lower abdomen is often the ideal tissue for breast reconstruction, making an abdominal flap reconstruction a popular option. A large amount of skin and volume can be replaced in order to achieve a very natural look and feel. An added bonus if that the removal of excess skin and fat from the abdomen results in a Tummy tuck (abdominoplasty) for the patient.

This is probably considered to be the gold standard 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 lose 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.

Testimonials

Sherif invites his clients to leave a review about the service he provided on Google (Bristol and Gloucester), as well as Doctify, RealSelf and I Want Great Care.

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