Breast reconstruction can be done in a number of ways following a mastectomy. It can be carried out in most instances at the time of mastectomy (immediate reconstruction) or later on in a few months or longer (delayed reconstruction). Immediate reconstruction allows the surgeon to preserve the native skin of the breast whilst the breast tissue is removed from beneath the skin. This maintains the contours of the breast and all that is needed to restore the breast shape and size is to find body tissue or an implant or a combination of the two to fill out the skin envelope.
Types of breast reconstruction
There are various ways of reconstructing the breast. This may be achieved by the use of implants alone, transfer of body tissue to the chest with or without an implant. Tissue transfer may involve large areas of muscle from the back (LD flap) or the tummy (TRAM flap). Alternatively one may transfer just skin and fat from another part of the body to the chest along with the blood vessels nourishing the tissue and join the blood vessels to the blood vessels in the chest behind the ribs or in the armpit (microvascular surgery). The sites used are the tummy (Free TRAM flaps, DIEP flaps), buttock (SGAP flap), back (Free LD flap), thighs (TMG,TUG flaps).
Choice of reconstruction
The ideal reconstruction is one that meets the patients expectations with minimum risk. For small breasted women, implants alone may be sufficient. For women with large breasts any technique may be used. The choice is usually dependent on the patients preferences, need for corrective surgery to the opposite breast to achieve symmetry and the possibility of radiotherapy to the reconstructed breast. It is wrong to believe there is one reconstruction option for all patients.
Timing of reconstruction
The ideal time is immediately at the time of mastectomy ( immediate breast reconstruction) so that most of the native skin is preserved and the contours retained. If this is not appropriate or if the patient prefers the reconstruction may be delayed (delayed breast reconstruction).
Reconstruction may be done in two stages with an initial operation using tissue expanders followed by the definitive procedure. The second stage may involve replacing the tissue expanders with a fixed volume implant or the patients own tissues. The benefits of this approach is in the opportunity to revise the pocket in which the implant is to be placed, at the second operation.
Revision surgery of the reconstructed breast
Revision of the implant based breast reconstruction may be necessary where the breast has become hard and painful because of the effects of radiotherapy, infection,bleeding and smoking. The revision procedure may involve removing the scar tissue around the implant (capsulectomy) and replacing the implant with a new one or using a new form of reconstruction (LD, DIEP,TRAM).
Revision surgery may also be required after any form of reconstructive surgery in order to improve the shape. This may be reduction of a DIEP/TRAM flap which is too bulky, recreating the crease on the underside of the breast (inframammary crease), refashioning the scars, adjusting the position of the implant . These operations are short procedures and can be done as day cases
Are implants safe?
The safety of silicone implants has been well established following several reviews. Implants do not cause cancer, do not mask cancers from being detected and do not cause harm to the rest of the body as was once thought.
Why is Radiotherapy bad for the reconstructed breast?
Radiotherapy causes scar tissue which is coarse, thick and unpredictable and tends to shrink with time. As a result, the reconstructed breast will lose shape and become smaller and feel hard. This effect is seen regardless of the type of reconstruction but most noticeable where implants have been used. This would require revision surgery in 60% of the patients where the scar tissue is either removed or released and the implant replaced or a new reconstructive procedure used. In these situations, where radiotherapy is definite, it is useful to stretch the preserved skin envelope with a tissue expander for several months or longer before a definitive reconstructive procedure is carried out (this is called immediate-delayed reconstruction). There seems to be some early indication that lipofilling can be of benefit in making the breast feel softer. This involves removal of fat from some part of the body with liposuction and transferring it to the breast. Its role in the reconstructed irradiated breast is being studied and evaluated. The reconstructed breast that hardens and shrinks after radiotherapy will need revision surgery. The scar tissue will need to be removed in most of the cases and the breast reshaped with the addition of new tissue (LD Flap, DIEP Flap, TRAM Flap , SGAP Flap).
LICAP, IICAP, MICAP
Lateral, Inferior or Medial Intercostal artery perforator flap breast reconstruction
What is it?
These local flaps aims to restore the size and shape of your breast by replacing lost breast tissue from the cancer surgery with skin and fat taken from side of your chest wall and back. Muscle is not removed during this procedure therefore causing no affect to your arm or chest wall function.
Women choose to have this surgery as it allows for the appearance of a natural breast avoiding the need for a mastectomy or complex reconstruction.
Why I might need it?
If you’ve been diagnosed with breast cancer, we can help. We understand how hard cancer is on both your body and mental health – and right now all you probably want is to get back to some kind of normal life.
Traditionally, if you have a large tumour it would require a mastectomy with breast reconstruction. However, if your cancer is on the outer part of your breast occupying a quarter of your volume, you may be suitable for a LICAP thus avoiding the need for a mastectomy. Removal of such a large cancer leaves a large defect causing asymmetry. By choosing to have LICAP, this defect can be reconstructed at the time of your surgery to restore the size and shape, leaving you with a natural looking breast.
What are the benefits?
- It avoids mastectomy even for large tumours.
- One can avoid implant or other complex reconstruction as it uses your own tissue.
- It minimises the need for opposite breast symmetrising surgery as the natural shape of the breast maintained.
- Quicker recovery.
What does the procedure involve?
On the morning of your surgery, your consultant will draw markings on your skin to show where the incisions will be made. Your consultant will need to map out the underlying blood vessels to ensure a good blood supply to the flap being used to fill the defect in your breast- this will be done by using a hand held Doppler. A photograph may be taken from the neck down before and after your surgery for records and comparison. Your consultant will ask you to sign a consent form to show you are happy with this. This will remain anonymous.
The operation usually takes 3 hours. Once your tumour has been removed, your surgeon will use the tissue from the side of your chest wall and back to reconstruct the space left in your breast. All of the lymph node surgery (if required) will be performed through the same scar thus leaving you with no scars on your breast (unless your underlying cancer is close to the skin needing skin to be removed from the breast). You will be left with a long scar on the side of your chest going towards your back. Over time, this will fade and is mostly hidden under your arm and bra strap.
You do not need drains as a routine after this procedure unless it is combined with Axillary Lymph Node clearance. Drains are used to allow serous fluid to drain from the surgery site, to keep you comfortable. Your consultant will explain this to you.
What is the recovery period?
The usual recovery period for this procedure is 3-4 weeks. Your scar may feel tight but should relax after a few weeks. A physiotherapist will give you some gentle exercises to perform at home which are vital to ensure you regain full shoulder movement.
You will need to wear a soft breast support for the first week and then a soft, non-wired bra will be suitable for the following 3-4 weeks.
You will need to sleep on your back for the first 2 weeks. It is advised that you refrain from driving for the first 2 weeks and normal strenuous activities can be resumed gradually from 6 weeks.
What complications can happen?
- Bleeding / infection causing pain and swelling
- Blood clots in legs and lungs (Deep vein thrombosis & Pulmonary Embolism)
- Wound breakdown
- Flap failure
- Tightness in scar
- Altered sensation
- Shoulder stiffness