Candidates for Breast Reconstruction Surgery
The vast majority of women who undergo mastectomy are candidates for breast reconstruction. However, not every woman wants to immediately undergo more surgery and so prefers to delay the decision. In addition, some women are perfectly happy with a bra-filling prosthesis and do not want reconstructive surgery. Moreover, some women have invasive breast cancer for which delayed reconstruction is the safest option. The majority of women do choose breast reconstruction in order to restore body shape, symmetry and their sense of femininity.
Mastectomy and Immediate Reconstruction
Women who are due to undergo skin-sparing mastectomy and do not need radiation therapy may consider immediate one-stage reconstruction. After removal of the breast tissue, an implant or the patient’s own tissue is used to restore breast volume. If an implant is used, Mr Karri may elect to use a special type of material, known as acellular dermal matrix (ADM), to provide an additional layer of coverage over the implant.
For patients wishing to use their own tissue, the lower abdomen, inner thigh or buttock are potential donor sites. Nipple reconstruction if desired, is usually performed 3 months later.
Immediate reconstruction does offer a number of potential advantages including better aesthetic outcome and psychological benefit. The goal of breast reconstruction is to create a breast that looks and feels natural as possible.
Whatever the situation, women are encouraged to discuss their options with Mr Karri. In this way, they can be reassured they have all the necessary information to make a fully informed choice.
Correcting Previous Breast Reconstruction
Breast reconstruction techniques have evolved over the years with patients benefitting from shorter recovery and improved results. As a result, some patients who underwent breast reconstruction with older techniques now seek improvement of their reconstruction or correction of a problem. Some of the issues Mr Karri can correct include;
- Implant related problems e.g. incorrectly positioned implants, implants placed too wide, capsular contracture, incorrectly sized implants, implant rippling
- Failed breast reconstruction
- Conversion of implant-based reconstruction to autologous reconstruction
- Correction of divots / contour defects
Lumpectomy Reconstruction With Fat Grafting
For patients who have undergone lumpectomy and radiotherapy, Mr Karri can reconstruct the defect with fat grafting.
Fat grafting involves harvesting fat from the abdomen or hips, and then injecting the fat into the site of the breast lumpectomy defect. The injected fat eventually becomes part of the native breast tissue.
Mastectomy and Immediate Implant-Based Reconstruction
Immediately after a skin-sparing mastectomy an implant is inserted into the empty breast envelope. The upper half of the implant is placed under the pectoralis major muscle whereas the lower half is covered by a specially prepared material called acellular dermal matrix (ADM). The ADM is sutured to the inframammary fold, thereby creating a pocket in which the implant comfortably sits.
The ADM is derived from pig skin and has had all the cells removed leaving a collagen scaffold. Over time it becomes incorporated into the native tissue and and provides an additional soft-tissue layer covering the implant.
Implant-based reconstruction can also be undertaken for delayed breast reconstruction. In this situation as there is no breast pocket, a flap of skin and muscle is taken from the back and transferred to the chest, whilst still attached to its blood supply. The flap of skin and muscle is used to recreate the breast pocket, into which the implant is placed.
An alternative method to create a breast pocket is to use a tissue-expander to expand the chest skin. The tissue-expander is inflated at regular intervals over a period of months and once the correct size has been achieved, it is replaced with an implant. An expander cannot be used if the chest skin has received radiotherapy and either flap of skin and muscle from the back will be required or another option should be considered.
Autologous Breast Reconstruction
This refers to breast reconstruction in which the new breast is made from the patient’s own tissue. Women typically choose this type of breast reconstruction if they are not candidates for implant reconstruction, want to avoid a silicone implant or have excess tissue in an area which can be used for the breast reconstruction. Autologous breast reconstruction is preferable for women with larger breasts as the reconstructed breast appears more natural.
The main advantage of autologous breast reconstruction is that the breast looks and feels very much like a natural breast. The surgery itself is more technically demanding and therefore longer (about 6-8 hours) and recovery will take longer as well (typically 4 – 6 weeks).
Autologous breast reconstruction should be considered a two stage-procedure. The first stage involves creation of the breast mound, whereas the second stage involves aesthetic refinement e.g. shaping the normal breast to match, creation of the nipple and possible contour adjustment with fat grafting.
Autologous breast reconstruction options are named according to the blood vessels supplying the donor tissue or the site from where the donor tissue is harvested from;
Deep Inferior Epigastric Perforator (DIEP) flap
This is the most common autologous breast reconstruction method, in which skin and fat from the lower half of the abdomen is used to reconstruct the breast mound. Microsurgery is used to connect the blood vessels in the donor tissue to blood vessels at the chest or armpit. The soft consistency of the abdominal skin and fat is ideal for recreating a breast. The skin and fat removed from the abdomen is the same tissue that would be removed with a tummy-tuck, and many women are attracted the to idea of breast reconstruction and tummy tuck at the same time.
Transverse upper gracilis (TUG) flap
The skin, fat and muscle from the inner part of the upper thigh are used to reconstruct the breast mound. Microsurgery is used to connect the blood vessels in the donor tissue taken from the upper inner thigh to blood vessels in the chest or armpit.
This method of breast reconstruction may be preferable in those patients with insufficient abdominal tissue for a DIEP flap or require a small breast mound.
Women who are seeking breast reconstruction can be easily overwhelmed with choices and information. To help you make an informed decision, Mr Karri will discuss all your available options. Empowered with this information, you can feel confident about the choices you make.
The risks of breast reconstruction depends on the type of reconstruction undertaken but some risks include;
Scars / poor scarring – in some patients the scars may be red and raised and take a number of months to settle.
Infection – may require treatment with antibiotics and/or further surgery.
Haematoma – bleeding within the breast pocket causing the the breast to become swollen and tender. A return to the operating theatre may be required to evacuate the blood and the breast may take longer to settle.
Implant malposition – with an implant-based reconstruction the implant may become incorrectly positioned.
Capsular contracture – with an implant-based reconstruction the scar tissue that normally forms around the breast implant thickens and contracts, causing deformity and pain in the breast.
Limited lifespan of breast implants – breast implants are not designed to last forever. Therefore all women should expect replacement of their implants during their lifetime.
Breast implant rupture or leakage
Need for revision surgery
Risks of general anaesthesia, such as feeling sick and vomiting, deep vein thrombosis, shivering and sore throat.