Breast Reconstruction

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Breast reconstruction is surgery to recreate the breast after it has been removed by cancer surgery (mastectomy). This allows a woman to retain her breast after cancer treatment, which is important for her appearance and emotional well-being.

Reconstruction may be performed right after breast cancer surgery during the same operation (immediate reconstruction) or months or years later (delayed reconstruction). The breast can be replaced with either implants or your own flesh (flap) from another part of your body.

Not all techniques are suitable for everyone, and your plastic surgeon will assist you in making this decision during your consultation. Some techniques may require multiple surgeries over several stages to achieve the final outcome. Depending on your breast shape, your surgeon may also recommend surgery to the normal breast to match the size and shape of the reconstructed side – either a breast reduction, breast lift or breast augmentation. During the final stage of breast reconstruction, a nipple and areola is re-created on the reconstructed breast, if these were not preserved during the mastectomy.

The decision to have breast reconstruction is very personal. While some people choose to have breast reconstruction after a mastectomy, many don’t. The latter group may choose to use an external breast prosthesis, which is a “silicone breast” worn inside a bra to imitate the shape of a breast under clothing.

The Procedure

There are several options for breast reconstruction:

• Breast implants
  These are silicone or saline implants placed beneath the breast skin after the breast gland has been removed. The implants may be placed under the chest muscle (pectoralis major muscle) or above it. Sometimes, the implant may be covered with an additional skin substitute layer, known as an acellular dermal matrix (ADM). ADMs may be manufactured from human or animal sources, and provide additional support and coverage of the implant.

Depending on the stage of your cancer and quality of your skin, your surgeon may recommend implant reconstruction as a two-stage procedure. In the first stage,
a temporary implant (tissue expander) is inserted first. This is slowly filled with saline during periodic visits to the plastic surgeon after surgery, allowing the overlying breast skin time to recover after surgery before it is fully stretched out again. The expander is removed and replaced with the final implant several months later after the chest tissues have relaxed and healed sufficiently (typically 3-6 months after mastectomy).

• Autologous tissue flap
  A piece of flesh containing skin, fat and/or muscle is taken from another part of your body and transferred to the chest to rebuild the breast. Because a large volume of tissue is moved from a faraway part of the body, the blood supply of the transferred unit (flap) has to be preserved in order for it to survive. When the flap can be transferred with its blood vessels still attached, it is called a pedicled flap. However, if the flap has to be detached from its blood supply to be moved up to the chest, it is called a free flap as the blood vessels must be reconnected by microsurgical vessel repair to restore blood supply.

Flaps are most easily taken from areas where there is excess flesh, such as the lower abdomen (Figure a). However, in slimmer women, other options include flaps from the back (Figure b), thigh, or buttocks.

 

Reconstruction with an abdominal flap

 

Reconstruction with a back (latissimus dorsi muscle) flap

 

• Sometimes, surgeons may recommend a combination of implants and flap, e.g. when a flap cannot provide sufficient volume to match the normal breast size.

• In the final stage of breast reconstruction, a nipple and areola can be re-created on the reconstructed breast, if these were not preserved during the mastectomy. This final surgery also provides the opportunity for minor revisions to improve the cosmetic outcome of the reconstruction, such as the use of fat grafting to fill out depressions and irregularities. 

Your surgeon will help you in choosing the most suitable approach based on your existing breast appearance, body shape, cancer treatment plan and personal expectations.

After the Surgery

Dressings and/or bandages will be applied over the incisions. Small tubes (drains) will be placed to remove excess blood and fluid for several days. Painkillers and antibiotics will be prescribed to control the pain and minimize the risk of infection. A post-surgical support bra will be supplied to you which must be worn at all times to minimize swelling and support your reconstructed breast as it heals.

If you have had implant-based reconstruction, you will generally be discharged within a couple days of surgery. In contrast, as flap-based reconstruction involves more operative sites, you will typically stay in hospital for at least one week to monitor the health of your reconstructed breast and to ensure that you can get about safely and independently before discharge.

Throughout your recovery period, a physiotherapist will attend to you regularly to teach you graduated exercises for your arm, shoulder, and trunk to regain strength and range of motion in the affected areas. It can take a few months before you are able to get back to sports and strenuous activities.

Understanding the Risks

As with any major surgery, breast reconstruction carries risks such as:

• Anaesthesia-related risks
• Bleeding
• Hematoma (accumulation of blood under the skin)
• Seroma (an accumulation of fluid under the skin)
• Damage to underlying important structures
• Wound infection
• Lung infection
• Failure of the reconstruction, e.g. due to flap loss or implant infection
• Poor wound healing or wound breakdown
• Poor scarring
• Blood clots
• Breast asymmetry
• Long-term implant problems e.g. implant leak or rupture, malposition, wrinkling of the overlying skin (rippling), painful tight scar tissue around the implant (capsular contracture)


You may need to undergo revision surgery to correct these problems. The subject of risks, as well as potential complications of surgery are best discussed on a personal basis between you and your plastic surgeon.