Breast Reconstruction

f you require a full mastectomy then we will discuss the option of reconstruction with you. Breast reconstruction is not an essential part of your cancer treatment and is not right for everyone. It can however make a big difference to many women and aid with their recovery. We are fortunate today to have a range of options available. Reconstruction can be done at the time of mastectomy or as a delayed procedure.
The three most widely used methods are:

1. Implant
2. Latissimus dorsi flap with an implant
3. TRAM flap

1. Implant: An implant is a bag filled with saline or silicone gel that can be inserted under the chest wall muscle at the time of mastectomy. This is suitable for someone with a small breast who does not want a larger flap procedure. The limitations of the method are that the implant tends to have a "plastic feel". It is difficult to match a large breast size. The implant will have a limited lifespan and may need to be changed in the future requiring more surgery.

Complications of implants, include:

• Capsular contracture or hardening of the implant
• Infection
• Shift or migration - the implant can move so that the shape of the breast changes
• Leak - the implant capsule can rupture causing leaking into the tissue and a change in the size of the breast.

Any of these problems may require removal or replacement of the implant.

2. Latissimus dorsi flap: This involves using one of the back muscles to provide additional tissue to cover the implant. The muscle is released from its distal attachment and rotated anteriorly through the axilla. The blood supply is maintained through the proximal attachment. As this muscle is not very big it is usually insufficient to replace the volume of the breast and an implant is used to create the desired size and shape. This method does provide a more natural "droop' to the breast. It produces a scar on the back and may result in some weakness of the shoulder.

Possible complications include:

Flap necrosis: if the blood supply to the muscle is damaged or simply inadequate some or all of the flap may die. This is uncommon and this particular flap is considered to be one of the most durable and reliable options available.

Infection

Seroma formation: Particularly at the back where the muscle is harvested. This will require drainage with a thin needle under local anaesthetic. It will settle down over a period of 3 - 4 weeks.

Implant complications as listed above although these are less common thanks to the added protection provided by the muscle flap.

3. TRAM flap: This is the transverse rectus abdominus myocutaneous flap and involves using the abdominal fat and skin for reconstruction. The flap is supplied by a blood vessel running through one of the abdominal wall muscles and this is rotated superiorly under the abdominal skin to reach the mastectomy defect. It avoids the need for an implant and tends to give an excellent long-term result. An advantage for some is the tummy-tuck resulting from harvest of the flap.

Possible complications include:

1. Flap necrosis - if the blood supply to the transposed tissue is insufficient then the tissue will die and will have to be removed.

2. Fat necrosis - areas of the fatty tissue in the flap can die causing tender, hard areas. If this affects small parts of the tissue it may settle down over a few months but if larger areas are affected this tissue will need to be removed surgically.

3. Decreased skin sensation - there may be numb areas of skin and the reconstructed breast will not feel the same as your original breast tissue.

4. Abdominal incisional hernia - moving the abdominal muscle can produce weakness and bulging of the abdomen and may need to be repaired surgically.

View case example

Flap procedures require 4 - 5 hours in theatre and about 5 - 6 days in hospital. It may take 6 weeks or longer to fully mobilise and get back to regular exercise and activities.

Breast reconstruction usually involves more than one operation. The aim of the initial operation is to create an adequate breast mound. It may be desirable to consider a procedure to the other breast to achieve good symmetry. This might be a reduction or a breast lift depending on the appearance of the breast and patient preference.

Nipple reconstruction is done at a later date and is a relatively minor operation. The nipple is recreated using local tissue or alternatively with a graft from the healthy nipple. The areola is usually tattooed to match the other side