What is breast reconstruction surgery?
The purpose of breast reconstruction is to reform or reshape one or both breasts after a mastectomy or lumpectomy.
- A mastectomy is a surgical procedure during which a surgeon removes the entire breast, usually including the nipple and areola, to treat or prevent breast cancer.
- A lumpectomy is the removal of a breast section that contains a smaller tumour.
Breast reconstruction which takes place at the time of mastectomy or lumpectomy is called immediate reconstruction. But at times a person might choose to undergo reconstruction after the mastectomy has healed and after the radiation treatment is completed. This is called delayed reconstruction.
What happens during immediate reconstruction?
- Step 1 – You will be under general anaesthesia during your mastectomy and immediate reconstruction.
- Step 2 – Your breast surgeon will usually make an oval-shaped incision over the nipple area. In some people with certain early breast cancers, the nipple could be preserved on the breast. This is performed by using incisions at the bottom of the breast or near the nipple. However, the nipple-sparing mastectomy or areola-sparing mastectomy depends on the stage and location of your breast cancer.
- Step 3 – From the incision, your surgeon will remove all of the breast tissue of that breast. They may also remove few or all lymph nodes under your arm, depending on the stage of cancer.
- Step 4 – The plastic surgeon will then reconstruct the breast or breasts. Generally, a breast may be reconstructed with an implant or with your own tissue from another part of your body.
After reconstruction, your breast surgeon will attach temporary drainage tubes to your breast. This is to make sure that any excess fluid has to be removed during healing. Your chest will be wrapped with a bandage.
What are the options for breast reconstruction surgery?
There are many factors that can help to determine the suitable type of breast reconstruction; the two main options are given below:
- Breast reconstruction with implants:
There are two types of implants used in breast reconstruction. When reconstructing a breast with implants, the surgeon will insert silicone or saline implants underneath the skin or muscle, to replace the previous breast tissue. Saline-filled implants use sterile saltwater inside implant. Whereas, Silicone-gel filled implants are made of a type of rubber. Saline-filled implants are the most common implant type, but many people think that silicone implants feel more like a natural breast. Your plastic surgeon may recommend a two-stage procedure. The first stage is to place an implant expander and the second stage is used to complete the tissue reconstruction.
Stage 1 – A surgeon places a tissue expander or an expandable balloon underneath the remaining breast after the surgery. The expander is a temporary saline implant that gradually stretches the remaining tissue.
Stage 2 – After the person has fully healed following surgery, a surgeon will inject salt water gradually into the expandable balloon on a weekly basis. This balloon gradually grows, stretching the overlying skin and muscle until the breast reaches a size that is comfortable for the patient.
When the chest tissues heal and the surgeon has added enough saline to the tissue expander to prepare for the implants, they will perform the second procedure to insert the implants. The surgeon will remove the tissue expanders and replaces them with either a silicone or saline implant. They will usually reopen the original scar. This means that the procedure will not leave any scars on the chest. In some cases, a surgeon could place a permanent saline or silicone implant during the mastectomy, without the use of a tissue expander.
Things to keep in mind for Breast reconstruction with implants:
- Recovery time with implants is shorter than with tissue flap reconstruction.
- No implant will last forever. Your implant will likely need to be replaced.
- Silicone implants will need monitoring with MRIs every few years to detect rupture.
- Your body may have problems with the implants, such as infection, scarring, and implant rupture.
- Future mammograms may be harder to perform with implants.
- An implant may affect your ability to breastfeed.
- Tissue flap surgery:
Breast reconstruction with flap surgery is a complex procedure that is performed by a plastic surgeon. The surgeon will take tissue from another part of the body and move it to the chest to rebuild the breast. The surgeon removes this tissue from the abdomen, buttock or inner thigh. There are two methods available for this surgery:
- Free flap surgery: A surgeon removes the tissue and the blood vessels completely. They stitch the blood vessels to other blood vessels in the chest at the needed site of placement. These blood vessels are very small, so the surgeon has to use a microscope to sew them together in a procedure called microsurgery.
- Pedicle flap surgery: A surgeon will not remove the transplanted tissue from its blood vessels entirely. Instead, the tissue remains attached to the body, and the surgeon rotates this into the chest to form the breast. A surgeon will use tissue from the abdomen or back for pedicle flap surgery.
Things to keep in mind for Breast reconstruction with Tissue flap surgery:
- Tissue flaps generally look and feel more natural than implants.
- The size of the tissue flaps can adjust with the rest of your body as you gain or lose weight.
- You will not need to replace tissues as you would likely need to replace implants.
- Surgery generally takes longer than implant surgery, with a longer recovery time.
- It will leave multiple surgical site scars because multiple areas of your body will be operated on.
- Some people may experience muscle weakness or damage in the tissue donor area.
Some people choose to use a prosthetic breast from either inside their bras or attached to their bodies. These artificial body parts look and feel like natural breast(s) and provide the body with balancing weight to support its posture. They can start wearing prosthetics after the body has fully healed.
What factors are considered before breast reconstruction surgery?
Choosing to undergo breast reconstruction surgery is a personal choice including the type of surgery to have and when to have the surgery. The reconstruction process can help a person find their self-confidence again and feel better during their cancer recovery.
However, the following are some factors that help a person and their surgeon to decide the best kind of breast reconstruction:
- The person’s body type is considered because slimmer people may not have enough tissue elsewhere on the body to perform skin flap surgery
- The location, severity, and types of cancer
- Age, overall health and whether they smoke or not
- The other cancer treatments, such as radiation therapy or chemotherapy, that the person may have received
- The number of surgeries a person is willing to have
What are the complications of breast reconstruction surgery?
The risks and complications a person may experience during breast reconstruction surgery:
- Bleeding or blood clots
- Complications with anaesthesia
- Fluid build-up in the breast or at the donor site (for skin flap surgery)
- Extreme fatigue
- Slow or disrupted wound healing
The additional complications that can occur after breast reconstruction surgery may include:
- Tissue death, or necrosis, which may develop in the skin, fat, or tissue flap
- A loss of muscle strength at the donor site (for skin flap surgery)
- Changes in breast or nipple sensation
- A need for more surgical procedures if complications occur
- Uneven breasts
- Problems with the implant, such as movement, rupture, leakage, or scar tissue
- A need to have the implants removed
The following are small surgeries that may be required according to the medical condition of the patient:
- Minor revision surgeries usually take place several months to several years after the mastectomy and implant or flap reconstruction, and well after any additional treatments such as chemotherapy or radiation therapy.
- Nipple reconstruction may be necessary: During this procedure, a surgeon sews together small pieces of skin on the reconstructed breast to form a bump that resembles a nipple. A person may then choose to have this nipple and the skin around it tattooed to form the appearance of an areola. Some people choose not to have the nipple reconstructed, and instead get a 3D nipple tattoo that uses shading to make it appear as an elevated nipple.
- Other revision surgeries may include fat grafting, during which a surgeon performs liposuction on the trunk or thighs to obtain fat, which they will then inject around the reconstructed breasts to improve the appearance. A person may require several sessions of fat grafting because the body will absorb some of the fat over a period of time.
They will require minimal recovery time as it is a daycare procedure.
What is the outcome and recovery for breast reconstruction surgery?
- A person will spend several days in the hospital after both implant reconstruction and flap reconstruction as breast reconstruction is major surgery.
- A person will require stitches and drainage tubes following the surgery.
- During the initial recovery period, a doctor may advise you to wear an elastic support bra to reduce swelling.
- Reconstructed breasts will not resemble the person’s natural breasts or provide the same type of sensation. However, with time, some sensation may return.
- Both types of surgeries will make a person unable to perform daily activities for 2 months.
- People will need more than one surgery to fully reconstruct the breast(s).
- Skin flap surgery will need a longer recovery time than reconstruction using implants.
- You may still need to have mammograms after breast reconstruction.
- If you need to have mammograms, use a mammogram facility that has experience taking and reading mammograms of reconstructed breasts, and inform your mammogram technician if you have any implants.
People might experience the following in the initial months of recovery from breast reconstruction surgery:
- Pain, bruising, swelling, or soreness in the breasts and at the area from which the surgeon removed tissue during skin flap surgery, such as the abdomen, back, or buttocks
- Restrictions on movement, such as lifting the arms overhead