Breast cancer affects about 1 in 12 women in the UK and Ireland. Surgery has tended to become less radical over recent years; but still a significant proportion of women with breast cancer will undergo mastectomy. In addition to women with invasive breast cancer, a group of women with widespread precancerous changes in their breasts and women with a strong family history of breast cancer will also undergo some form of mastectomy.

Breasts are a focus of femininity in our society; the loss of a breast combined with the diagnosis of cancer can, understandably, have a deep psychological impact. Breast reconstruction offers some compensation by restoration of loss of body image associated with surgical treatment.

All patients undergoing mastectomy should have the opportunity to discuss breast reconstruction with a reconstructive surgeon prior to their mastectomy. Unfortunately this is not the case for many patients in the UK today. Patients should be aware of the reconstructive options available prior to their cancer operation.

For some patients reconstruction may not be desired; for example the prospect of additional surgery with scarring on other parts of the body and the prospect of multiple operations may not be wanted. Other patients are unable to think about reconstruction, whilst still coming to terms with the diagnosis of breast cancer - in these patients reconstruction is not indicated.

If a patient wishes breast reconstruction and is medically fit for it then most reconstructive surgeons would be happy to offer breast reconstruction. The patients age and the presence of cancer spreading to other parts of the body are not contra-indications to breast reconstruction in an otherwise fit, informed and motivated patient. It is important to remember that breast reconstruction should not interfere with the patients cancer treatment which may include surgery, radiotherapy and chemotherapy.

Anaesthetic

Breast reconstruction is carried out under general anaesthetic.

Technique

Their are several questions to be answered and options to be considered in a woman undergoing mastectomy and considering breast reconstruction.

• Should the reconstruction be immediate (at the same time as the mastectomy) or delayed?
• Is the opposite breast easily matched by the breast reconstruction or will it need to be surgically modified for a symmetrical result?
• Does the patient wish a breast made only out of her own tissues or is she happy for a breast implant to be used?
• What is the medical condition of the patient?
• Is the patient fit enough for long reconstructive operations? Is a more simple, if less aesthetic, operation more sensible?
• What operations has a woman had previously? (e.g. extensive abdominal scarring may preclude the use of abdominal tissue for breast reconstruction).
• What does the patient wish for from breast reconstruction? What "price" is she prepared to pay?
  

Immediate or Delayed Breast Reconstruction

In the Ireland many women have no option but delayed breast reconstruction because they never meet a plastic surgeon prior to their mastectomy.

The decision for immediate reconstruction should be a joint decision between cancer surgeon, plastic surgeon and patient. For example, a patient overwhelmed by the cancer diagnosis might be best served by a delayed reconstruction; a woman with a strong body image might wish immediate reconstruction.

Immediate reconstruction has some theoretical advantages; the psychological trauma of cancer surgery can be lessened by immediate reconstruction of the removed tissue; much of the breast skin envelope can be preserved and the shape which this helps to maintain will give a better result. The disadvantages of immediate reconstruction include perhaps an increased incidence of complications; a concern that if reconstructive procedures develop complications then additional, necessary, breast cancer treatment might be delayed. In patients who are due to receive postoperative radiotherapy then most surgeons would avoid the use of breast implants for fear of complications.

Delayed reconstruction also has some advantages - the procedure may be carried out without interfering with cancer treatment; the complication rates are probably less; the patient may have come to terms with her diagnosis. However; patients forced to live with their deformity may suffer psychologically as a result of disturbed body image; conversely some patients will come to terms with their appearance and not go on to reconstruction.

The decision about timing in breast reconstruction may be very difficult and demands good communication between the cancer surgeon, reconstructive surgeon and patient - the decision need to be individualised for each patient.

Surgical Techniques

• Surgical techniques for breast reconstruction can be divided up into:
• Reconstructions using breast implants and tissue expanders
• Reconstructions using only the patient’s own tissues (autologous reconstruction)
• Combinations of implant and autologous reconstruction
• Matching operations on the other breast
• Nipple-areolar reconstruction

Breast Reconstruction Using Breast Implants and Tissue-Expanders
Silicone breast implants offer the simplest type of breast reconstruction. An implant can be placed under the mastectomy flaps to produce a breast mound.

However, the results are not aesthetically good and the complications, particularly implant extrusion are high. This complication can be reduced by placing an implant under the muscles of the chest wall, but again only a limited breast mound can be produced. Implant only reconstructions are rare today.

The results of implant only reconstructions were improved by the use of tissue expanders. Tissue expanders are silicone balloons which are placed at the site of the missing breast. Ideally the expander should be placed underneath the muscle of the chest wall. A length of tubing with a one-way valve is connected to the balloon. The whole device is buried under the skin.

Through the valve sterile salt-water solution is injected in stages. Over a period of, on average, three months the balloon is gradually inflated. Inflating the balloon stretches the overlying skin and muscle and creates a new breast envelope. When the envelope has been created the expander can be removed and replaced with a breast implant to produce a better shaped breast. Some tissue expanders have been designed to be both tissue expander and breast implant such that when the desired shape has been achieved the inflations are simply stopped and the reconstruction is achieved.

This type of breast reconstruction is usually avoided in patients who have undergone radiotherapy, unless additional tissue is brought in.

Autologous Breast Reconstruction
Autologous breast reconstruction is used when the local tissues are not satisfactory; this usually means there is a shortage of local skin or the tissues are scarred by surgery or radiotherapy. Autologous reconstruction involves importing tissue from elsewhere in the body to reconstruct a breast using just the patients own tissues or in combination with a silicone implant or tissue expander. The imported tissue is known as a "flap"; although various flaps have been used the two most popular are the latissimus dorsi flap and the TRAM flap.

Breast Reconstruction Using the Latissimus Dorsi Flap

The latissimus dorsi is a large fan shaped muscle which lies across the mid-back. This can be separated from its normal attachments and swung to the front of the chest to recreate missing tissues and create a breast. A tunnel under the skin is created to deliver the flap to where it is needed. The muscle is normally used together with an attached piece of overlying skin known as the "skin paddle".

The skin paddle is used to recreate the skin that was removed during the mastectomy and the underlying fat and muscle to recreate the missing breast. Unfortunately the reconstruction of a breast using only the latissimus dorsi flap is only possible with very small breasts; usually the procedure needs the addition of a silicone breast implant or tissue expander to produce a satisfactory breast reconstruction.
Latissimus dorsi breast reconstruction leaves a significant scar on the back; this scar is usually placed transversely so that it can be hidden by the bra’ strap, other orientations are possible.

Breast Reconstruction Using a TRAM Flap

TRAM is an acronym derived from Transverse Rectus Abdominis Myocutaneous flap. The rectus abdominis is one of a pair of abdominal muscles that run from the rib-cage to the pubic region on either side of the mid-line (the "six-pack" of athletic individuals). "Transverse refers to the orientation of the skin paddle that is taken with the muscle to rebuild the breast and "Myocutaneous" means a flap containing muscle and skin.

The TRAM flap provides sufficient tissue for breast reconstruction using a patients own tissues only; the aesthetic result can be impressive. The TRAM flap can be swung up to reach the mastectomy defect like a pendulum of a clock. A tunnel under the skin is created to deliver the flap to where it is needed. The skin paddle is used to recreate the skin which was removed during the mastectomy and the underlying fat is shaped to recreate the missing breast.

The muscle itself is not used to rebuild the breast; a strip of muscle is necessary to keep the blood vessels supplying the flap alive. An alternative technique for TRAM flap breast reconstruction is known as a "free flap". In this operation the TRAM flap is completely separated from all of its bodily attachments; it is fixed into the mastectomy defect to reconstruct the breast and its blood supply is restored by joining up its blood vessels to others in the arm-pit or just inside the rib-cage. This is a very major operation and needs surgeons skilled in micro-surgery to reestablish blood flow in the flap.

Nipple-Areolar Reconstruction

Reconstruction of the nipple areolar complex is usually performed at least six weeks after the main breast reconstruction. Many operations are available for rebuild the nipple prominence and include rearranging the local skin (local flaps) and grafting nipple tissue from the unaffected side. The pigmented areola can be recreated using skin grafts from other areas, such as the groin or by tattooing the area to match the normal side.

Length of Operation

The length of the operation varies hugely depending upon timing and the type of reconstruction carried out. Some simple reconstructions may take 1 - 2 hours; others make take several hours and more than one operation.

Time in Hospital

The time in hospital is also very varied, from 1 - 7 days.


Last Editorial Review: 20/9/2010