Plastic surgeons treat all disorders of size and shape of breasts. They also combine with general surgeons in the management of patients with breast cancer where radical surgery and reconstruction is in the patient's best interest.

BREAST RECONSTRUCTION

Plastic Surgeons are frequently involved with general surgeons in primary reconstruction of the breast after mastectomy. It seems likely that as patient awareness improves, there will be an increasing requirement for reconstruction and plastic surgeons should be part of the teams treating breast carcinoma. Reconstruction of the breast is sometimes complex involving microsurgery procedures and therefore requires the facilities of specialist centres. 

WHAT IS BREAST CANCER?  

Breast cancer is the most common form of cancer affecting women in the UK, with 40000 new cases diagnosed every year; and most women diagnosed with breast cancer are cured. Cancer occurs when normal cells stop responding to the control systems used to co-ordinate the function of cells. These 'rogue' cells start to multiply abnormally forming cancerous tumours. The reason why these cells stop functioning normally is the subject of a great deal of research, but is a combination of environmental, lifestyle and genetic factors.

The treatment of breast cancer is directed at eliminating all of these 'rogue' cells, whether by cutting them out at an operation, or by killing them with radiotherapy and chemotherapy. Which type of treatment you require depends on the type of breast cancer, whether the cells have spread outside their normal position within the breast, or whether they have spread outside the breast. Your breast surgeon will discuss the options available for you and help guide your decision.   

WHAT IS MASTECTOMY?  

About 40% of women diagnosed with breast cancer require or choose to undergo mastectomy, the surgical removal of the entire breast. The breast is positioned between the skin of the chest and the chest wall muscles, and consists of milk ducts, glands, fat and some connective tissue holding all of these together. The glands produce milk, which runs via the ducts to the nipple. As the nipple is connected to the entire breast and the cancer can involve the ducts, the nipple must be removed as part of the mastectomy.  

Mastectomy is recommended for women with certain types of breast cancer. The details should be discussed with your breast surgeon, but generally if cancer is present in 2 or more areas of the breast, if the breast has been previously irradiated, if a large tumour is found in a small breast or if the tumour is likely to recur, mastectomy is recommended. In addition, on discovering cancer within one breast, many women prefer to have that entire breast, or even both breasts, removed to minimise the chance of breast cancer in the future.  

WHY BREAST RECONSTRUCTION?  

If mastectomy is your best treatment option, you will have to decide what to do about your missing breast. Until fairly recently, a flat chest was the only option. and for some women today still prefer to accept a flat chest. Many women feel radically changed by their cancer experience, and some feel that their flat chest is an acknowledgement of their post-cancer persona.

A simple option is to wear a breast prosthesis. This provides the appearance of a natural breast and provides a better fit in clothing. It can help to minimise the un-balanced or lop-sided feeling that the missing breast creates. This option can also be used temporarily if you are undecided about breast reconstruction, or if your reconstruction needs to be delayed for radiation treatment.  

Breast reconstruction is the process of recreating a breast mound aiming to match the remaining natural breast. It has been shown to improve mental health, emotional well-being, energy level and satisfaction with breast appearance after mastectomy. Reconstruction is performed by a reconstructive plastic surgeon. The main procedure is the creation of the breast shape and volume, either at the same time as the mastectomy, or at a later date. It may be necessary to undergo one or two subsequent smaller procedures, aimed at slightly altering the shape of the breast or creating a nipple and areola (the darker skin around the nipple).   

TIMING OF RECONSTRUCTION

One of the first choices you will have is whether to undergo immediate or delayed reconstruction. Immediate reconstruction is performed during the same operation as the mastectomy. Delayed reconstruction involves only performing the mastectomy at the first operation. After you have fully recovered and any additional necessary treatment has been completed, a second operation is performed to reconstruct the breast. These are generally a few months apart.   Here are some advantages and disadvantages of each type of procedure :        

Immediate Reconstruction      

Advantages        
Better cosmetic results        
Smaller breast scars        
One anaesthetic and recovery period        
One hospital stay        
Lower psychological impact - no time without a breast shape      

Disadvantages        
Longer anaesthetic and recovery time        
Longer wait for surgery as 2 surgical teams are involved        
Increased risk of infection        
Distortion of reconstructed breast if radiotherapy is required        

Delayed Reconstruction      

Advantages        
Staggered surgery resulting in easier and shorter recovery after each procedure
Time to consider whether reconstruction is right for you without delaying cancer treatment        
Less to deal with at once     

Disadvantages        
Longer breast scars        
Difficult to obtain excellent cosmesis        
More time off work due to multiple operations        
Multiple hospitalisations  

Any type of mastectomy and reconstruction will result in scarring of the breast. The shape and size of the scars, however, vary between immediate and delayed reconstruction.

During immediate reconstruction, it is often possible to perform a 'skin-sparing mastectomy'. This involves removing the nipple and the entire breast contents, but leaving most of the breast skin behind. The scars after immediate reconstruction are either a circular scar around the nipple and areola (darker skin around the nipple) or a relatively small straight line scar.

In contrast, delayed reconstruction requires the skin hole left after mastectomy to be stitched up. It is not possible to use this skin for reconstruction as, during the months between the two procedures, it would shrink and scar to the muscle underneath resulting in hard, non-malleable skin and a very poor cosmetic result of the breast surface following reconstruction. More skin is, therefore, removed at the time of mastectomy, resulting in a long scar across the chest wall. Although this scar will fade in time, it will always be present, even after reconstruction.   

TYPES OF RECONSTRUCTION

There are 2 main types of reconstruction: prosthetic and autogenous. Prosthetic reconstructions use artificial implants to recreate the breast mound whereas autogenous reconstructions use tissue from elsewhere in the body to recreate the breast.  Which option is most suitable for you depends on the characteristics of your remaining natural breast, the quality of reconstruction required and the type of surgery you are prepared to undergo to achieve your reconstruction.  

Prosthetic reconstructions involve making a space between your ribcage and 'pec' muscles and inserting an implant into this space. The overlying skin is then sutured together to close the wound. The implants are usually expandable implants, which are slowly enlarged over 3 to 6 months to give the desired shape and size. These will be covered in more detail in the Expander / Implant chapter of this disk.  

Autogenous reconstructions involve moving tissue from your back, buttocks or abdomen to the site of your breast and reshaping the tissue to form the new breast mound. As the tissue is alive and natural, it provides the most natural shape and feel to the reconstructed breast at the expense of undergoing surgery and creating scars in healthy parts of your body. In contrast to prosthetic reconstructions, there is a full-size breast mound immediately after the operation, although it is likely to change shape and size slightly over the first few months following reconstruction.  

Nipple reconstruction is performed as a final stage of breast reconstruction, after the breast has reached its final shape and size, and when you are happy with your reconstruction. As there are inevitably changes that occur in the breast following reconstruction, creating a nipple too early would result in a poor match between the two sides.   

HOW DO THE DIFFERENT TYPES OF RECONSTRUCTION COMPARE?        

Prosthetic Reconstruction      

Advantages        
Short and relatively simple surgery        
Short anaesthetic and recovery time        
No operating on healthy tissue or extra scars        
No missing tissue missing elsewhere in the body      

Disadvantages        
Slow reconstructive process with expansion of implants        
Less symmetrical shape match with remaining natural breast        
Less natural breast texture        
Unsuitable for reconstructing large breasts        
Artificial material is more likely to become infected     

Autogenous Reconstruction      

Advantages        
Most natural feel        
Most durable        
Best cosmetic result        
No artificial materials      

Disadvantages        
Major operation        
Extra scars        
Possible complications from surgery at other body sites        
Longer hospital stay

WILL IT BE NECESSARY TO OPERATE ON THE OTHER BREAST?

Although a good match can often be achieved by reconstructing the affected breast alone, the best symmetry is obtained by also considering surgery to the unaffected breast. For some women, reconstruction gives an opportunity to address any concerns with shape or size of breasts, and it is possible to complete reconstruction with bigger, smaller or less drooping breasts than before. The options can be considered as follows:

No surgery to the unaffected breast

Many women feel that performing surgery to a healthy breast is unacceptable and would prefer reconstruction that best matches the existing breast without any change. 

Remove the remaining breast and reconstruct both breasts

Women at high risk for breast cancer may decide that it would be preferable to remove as much breast tissue as possible so that they do not need to worry about breast cancer in the future.  In this case creating excellent symmetry between the two breasts with any reconstructive technique is relatively easy.    

Enlarge the remaining breast

Breasts containing implants are generally less affected by gravity and appear fuller in the upper half of the breast.  Inserting an implant to enlarge the healthy breast can reduce the difference in shape and improve symmetry, especially with implant based reconstructions.    

Reduce the remaining breast

Creating a new large breast requires a large volume of tissue, which almost always limits the reconstructive options to only a TRAM or DIEP flap. Performing a breast reduction on the unaffected breast can widen the choice of suitable reconstructive options or reduce the amount of  tissue needing to be moved to make the breast.  In addition, if large breasts have been causing problems, breast reduction can be helpful.  

Lift the remaining breast

Over time, gravity has an effect on all breasts.   As the breast tissues become less elastic, breasts hang lower on the chest, the nipples hang lower on the breasts and the areolae (darker skin surrounding the nipples) become larger. Women with 'droopy' breasts may prefer a breast lift for the unaffected breast, and a reconstruction to match the new position.   

WHAT IS A FLAP RECONSTRUCTION?

A 'flap' is a volume of living tissue transferred from one site in the body to the breast, along with the blood vessels keeping it alive.  The 2 main techniques for transferring tissue in this way are either to keep the blood vessels attached, but to rotate the tissue around the blood vessels to its new position (pedicled flap), or to completely detach the tissue and blood vessels from the body, move the whole block of tissue to its new site, then re-connect the blood vessels to other vessels near the breast using microsurgical techniques (free flap).  

Written by James Seaward SHO in Plastic Surgery and Author of www.optionsforbreastreconstruction.com  

Areas:

> Latissimus Dorsi Breast Reconstruction