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
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.
Breast reconstruction is carried out under general anaesthetic.
Their are several questions to be answered and options
to be considered in a woman undergoing mastectomy and considering
- 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
- 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
- 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 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 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
breast implants offer the simplest type of breast reconstruction. An
implant can be placed under the mastectomy flaps to produce a breast
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
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.
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.
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