Breast Reconstruction in Surgery

What is Oncoplastic Breast Reconstruction?

Oncoplastics is a term given to the combination of performing breast cancer surgery and achieving acceptable cosmetic results.

Level 1 Oncoplastic techniques

Level 1 oncoplastics is performed after removing a breast cancer lump. The residual defect needs to be closed otherwise a residual deformity in the breast will result. This type of oncoplastic reconstruction is routine with all breast conserving surgery and requires use of the breast tissue to be remodelled under the skin so as to fill the defect.

Level 2 Oncoplastic techniques

These are performed after a mastectomy has been performed. If a patient requests a breast reconstruction post mastectomy then a form of reconstruction needs to take place. These can range from the use of breast implants, your own muscle and fat or a combination. Each technique has it pro’s and con’s and the decision on which type to chose will be discussed with you by Dr Green.

Is reconstruction the same as breast enhancement?

Breast reconstruction surgery post mastectomy is NOT the same as a breast enhancement.

Breast enhancement is a cosmetic procedure done to increase the size of a women’s breast. An enhancement uses an implant under the breast to push it forwards and enhance your natural breast shape. Breast enhancement IS NOT performed by Dr Green and would require a referral to a cosmetic plastic breast surgeon.

Breast reconstruction surgery is performed after a mastectomy (removal of the breast). This is usually performed as a result of breast cancer treatment or as a prevention technique against breast cancer (in genetically at risk patients). In a reconstruction the aim is to try and re-create your breast after it has been removed as close as possible to its natural shape as you require.

What is the aim of the reconstruction?

Breast reconstruction is performed after a mastectomy has been performed, as part of breast cancer treatment or prevention. The aim is to restore your breast to a shape that you are satisfied with. Your natural breast shape is the best breast shape you have. This can be enhanced by cosmetic techniques. However, once a mastectomy has been performed it is very difficult to reconstruct a breast that looks identical to the natural form.

Breast reconstruction surgery can result in a breast shape that is cosmetically pleasing to you. The aim can be to give the best ‘out of bra look’ or settle for a pleasing result in a bra or tight top.

Photo caption: Subcutaneous mastectomy and expander reconstruction. Fig 1 shows ‘out of bra’ look. Fig 2 shows ‘in bra look’.

What is the best type of reconstruction?

There are multiple different options for breast reconstruction surgery. There is not one type of reconstruction that is the best. The best reconstruction depends on the following things:

Your expectations

After a breast has been removed (mastectomy) it is very difficult to reconstruct a breast that is better than what you had originally. The aim of reconstruction is to reconstruct your breast to some extent that is cosmetically pleasing to you and is as close to your natural breast as possible.

It is important to decide if you are after a ‘normal’ shape out of a bra or if you after a ‘normal’ shape whilst wearing a bra or tight top.

To achieve the most natural out of bra breast it is usually necessary to use some of your own body tissue borrowed from a different site to reconstruct the breast. This is called an autologous breast reconstruction. Abdominal muscle and fat back muscle and fat are two common options. Whilst the results are often very pleasing the surgery is very extensive with a long recovery. Additionally the site where muscle and fat was borrowed from will be weakened. This will have implications on you if you are active and athletic resulting in a noticeable weakness.

Many women surveyed about reconstruction are not prepared to undergo this type of reconstruction. They are looking for shape and ‘something there’. Implant based reconstruction is the most common choice to give a good shape with lower-risk surgery. The cosmetic results are very good. Especially when wearing a bra or tight type a natural shape can often be achieved. This surgery is does not result in any residual muscle weakness from donor sites. This is by far the most common type of breast reconstruction surgery performed.

Extent of surgery

Breast reconstruction surgery can range from relatively painless and straightforward to complex, challenging with a prolonged recovery period.

The recovery period and long-term effects need to be thought of when considering reconstruction options.

When using autologous tissue (TRAM reconstruction) to achieve as close to the ‘perfect’ breast there is a considerable recovery period and residual weakness of muscle. The surgery itself takes several hours and requires a prolonged hospital stay whilst the reconstruction is healing. A TRAM reconstruction can result in a very pleasing cosmetic breast and the borrowed muscle and fat form the abdomen gives a ‘tummy tuck’ at the same time. Unfortunately the borrowed muscle does result in a weakened abdominal wall. For many people this will not be a problem. However, if you are active and use your abdominal muscles regularly there will be a noticeable weakness.

Implant based breast reconstruction surgery is much less complicated. Here a saline or silicone filled implant is placed under your pectoral muscle to recreate the breast shape. This procedure is quite quick and gives a good cosmetic outcome especially while wearing a bra. Recovery is fast and doesn’t delay any cancer treatment so is the most common immediate reconstruction at the time of your cancer surgery. Patients are mobile and returning to normal activities usually within a few weeks from surgery.

The impact your cancer treatment has on reconstruction

Most importantly when deciding what form of reconstruction to embark it is essential that you DO NOT delay your cancer treatment. Post cancer treatment you may require chemotherapy or radiation therapy and this is critical for a good prognosis.

Reconstruction becomes difficult if you are going to need chemotherapy post-surgery. In this circumstance the option is to either delay your reconstruction until after the chemotherapy is completed or to choose a form of reconstruction like a tissue expander/implant reconstruction that has a quick recovery period and will not delay your treatment. An autologous reconstruction is unwise if chemotherapy is likely due the delay in treatment. This can still be offered as a delayed procedure.

Radiation therapy makes any reconstruction challenging. If radiation is planned an immediate reconstruction will likely not be offered due the risk of complications. A delayed autologous reconstruction would be advised.

Immediate v delayed reconstruction

In circumstances where undergoing a reconstruction may delay your cancer treatment or there is an unacceptably high infection risk, delayed breast reconstruction surgery will be offered. So long as you do not need radiation therapy you will still have all the possible options available to you and obtain a satisfactory reconstruction by delaying the reconstruction.

In some circumstances you will be advised for a delayed reconstruction. Similarly if you’re unsure of if you want a reconstruction it is a good idea to delay the decision and complete your cancer treatment. Here a delayed reconstruction would be a sensible option. Gr Green will discuss this with you in detail at the time of your consultation.

What is an Expander based versus autologous tissue reconstruction?

Tissue expander reconstruction would be the most common and least complicated form of breast reconstruction. In some reported series up to 85% of women request this type of breast reconstruction surgery in Brisbane hospitals.

Expander

After the breast is removed your pectoral muscle is lifted off your ribs and an empty expander is placed. An expander is effectively an empty breast shaped balloon that will be covered by your pectoral muscle and your breast skin. Once recovered from the surgery the expander is slowly filled with saline until the desired shape and volume is achieved. Then a second procedure is performed about 3 months later to switch the expander to a permanent silicone implant that has a softer, more natural shape than the expander will.

Autologous Reconstruction

Autologous breast reconstruction surgery involves using your own tissue to reconstruct the breast. A common form is a TRAM reconstruction. Here some of the muscle and fat from your lower abdomen is used to replace the breast tissue that was removed. This form of surgery gives the most natural looking and feeling breast. Also the removal of excess abdominal fat and muscle results in a flatter lower abdomen.

This form of reconstruction is technically very challenging. There is a prolonged hospital stay after the surgery whilst all the wounds heal and ensure that the donated muscle and fat remain alive and healthy. After the surgery there recovery is prolonged and will require some time off normal activities. The down side to this form of reconstruction is that the removed muscle results in a significant weakness to the anterior abdominal wall. Many people would not realise the weakness. However, especially in young active patients they will notice the weakness and may even notice a bulge in the lower abdomen. This form of surgery has the highest risk but does give the most natural reconstructive outcome.

Tissue expander reconstruction

This is the most common form of breast reconstruction surgery performed. A good cosmetic result can be achieved with a relatively natural appearing breast especially when wearing a bra. The recovery from this form of reconstruction is not significantly longer than the recovery for a standard mastectomy for breast cancer.

This form of reconstruction is performed in two stages:

Stage 1 – Placement of expander and expansion

The expander is placed empty in a deflated state. It is paced under your pectoral muscle. The aim is to cover the expander completely by muscle. This is a tight space and that is why the expander is placed empty. The muscle and skin is closed over the top of the expander. There will be some drains placed to take away excess fluid. Most people stay in hospital for a few days to a week.

Once the wounds are healed the expander is slowly filled with saline. This slowly stretches the muscle and skin and creates the space for a permanent implant to be places. How long this takes depends on what size you are trying to achieve. The expansions are performed in the rooms and usually 50-100ml is placed at a time on a 1-2 weekly basis.

Stage 2 – Placement of permanent implant

Once the expander is fully expanded it will feel very hard and often sit a little high on your chest. This will be corrected at the second stage.

Once all your breast cancer treatment is completed the second stage is planned. A minimum of 3-months is allowed after expansion to ensure the space created is fully formed.

A second quick operation is performed where the expander is removed and the permanent implant placed. This is a silicone implant that is breast shaped and has a much softer, natural feel than the expander. At this operation small adjustments can be made to the position of the implant so as it sits in the desired position.

Single stage implant reconstruction

This is an implant-based breast reconstruction surgery where no expander is used and a permanent implant is placed initially. This cannot be performed on all patients. The space under the muscle is a limiting factor. If you have larger breast there will be insufficient space to put a full size implant under the muscle. An expander will be required for larger breasts.

This type of procedure is sometimes used for prophylactic (cancer prevention) surgery and reconstruction, where there is no cancer treatments planned.

More recently the use of artificial tissue is being used to allow a single stage reconstruction in larger breasts. Here the muscle is lifted off the chest wall and the artificial tissue is added to create more space. If this is being considered Dr Green will discuss more about the artificial tissue that is used.

Potential complications

All operations can have complication. Whilst it is not planned there are some complications that can be minor and then there are those that can be more severe and require further surgery. Below is a list of some of the potential complications associated with breast reconstruction surgery. This is not an exhaustive list but is some of the more common problems that may be occur in a few patients.

With implant reconstruction artificial material is being placed. Your body’s natural response is to try and remove it. Steps are taken to avoid this but in some cases the reconstruction can fail resulting in a very poor reconstruction outcome. This will definitely require further surgery.

Secondly, it is important to be realistic about what can be achieved. Your natural breast is the best you have. Once it is removed it is very difficult to reconstruct an identical breast. Your expectations need to meet what is possible and Dr. Green will emphasise this point.

Below are some of the complications associated with implant-based breast reconstruction surgery:

 

Common (up to 10% of cases)

Uncommon (up to 5% of cases)

Rare but important (less than 1% of cases)

  1. Seroma – fluid collection.
  2. ‘Dog ears’ on wound needing correction.
  3. Numbness over chest wall.
  4. Implant movement – to high, slip into armpit.
  5. Rippling of implant (capsular contraction).
  1. Wound edge necrosis (dying skin).
  2. Nipple necrosis (dead nipple needing excision).
  3. Wound infection.
  4. Infected implant – needing removal.
  5. Loss of implant and failed reconstruction.
  6. Poor cosmetic result. 
  1. Anaesthetic complications.
  2. Very poor cosmetic result.
  3. Further reconstructive surgery to salvage.
  4. Replacement of implant inside 10 years. 

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