Breast Reconstruction after Cancer
Breast cancer (mamma carcinoma) is the most common tumour forming disease while simultaneously being the most common form of death in women between 30 and 60 years of age. The diagnosis must be made as early as possible because it is only in the early stages of its development that a cure is possible. Guidance for patients on on how to examine their breasts, regular participation in screening programmes and modern diagnostic imaging techniques (mammography, sonography, computer tomography and magnetic resonance imaging) all help to assist in early discovery. But despite all this assistance, in many cases the breast must be partially or completely removed in order to eliminate the malignant tumour. After partial or complete removal (mastectomy) of one or both breasts, reconstructive surgery, which covers a wide range of techniques, makes the reconstruction of a new breast possible (reconstructive mammoplasty). This involves attempting to recreate the outward aesthetic appearance of healthy breasts in terms of shape, volume, contour and consistency in order to be as indistinguishable as possible from natural breasts.
Basically, there are two breast reconstruction options as follows:
- Using the body’s own tissues (tissue flap reconstruction / fat grafting)
- Using breast implants
In some cases both options are combined. In other words, as well as using the body’s own natural tissues, an implant or expander is also inserted in order to achieve optimum results.
Breast reconstruction can either be performed at the same time as the mastectomy, which is called primary reconstruction, or at least 6 months afterwards, known as secondary reconstruction. Breast surgery is also possible several years later. However, chemotherapy and radiotherapy should have been completed before reconstruction begins. For many women, the delaying of the reconstruction gives them the opportunity to come to terms with what they have just been through and the time between helps them to think over what lies in front of them more factually and more clearly. Apart from that, for many who are affected, it is of extreme importance to be well-informed of breast reconstruction surgery techniques and to be professionally advised before taking the decision to going ahead with the surgery.
The above mentioned advice comes in advance of the breast amputation surgery and is in the form of an extensive consultation in which the operating surgeon gives the patient detailed information on the breast reconstruction options. The final-decision on whether primary or secondary reconstruction is performed initially depends on the patient’s own wishes. Despite this, the extent of the tumour can influence the eventual decision. If a tumour is in its advanced stages, then one can expect a long phase of radiotherapy after surgery. In this case, primary reconstruction can therefore be ruled out. The patient is also informed that after breast reconstruction she may also have to expect follow-up surgery in order to perform any necessary scar or shape revisions.
Normally, two operations are necessary for a breast reconstruction. In the first operation, the breast wall and breast mound are reconstructed and in the second operation the nipples are positioned. A third operation may be required in order to optimize the symmetry of both breasts. In this case, the breast tissues are tightened or the differing-sized breast reduced. Should there be a lack of skin in the affected breast and skin expansion is necessary, then a further surgery date should be made for the insertion of a tissue expander.
Breast Reconstruction Using Body’s Own Tissue
A successful method of breast reconstruction is to use the body’s own tissue (autologous breast reconstruction). The most common methods are as follows:
- Latissimus dorsi flap
- TRAM flap (Transverse Rectus Abdominis Myocutaneous flap)
- DIEP flap (Deep Inferior Epigastric Perforator)
- SGAP flap (Perforator flap from the buttocks)
- Gracilis flap (gracilis myocutaneous flap from inner thigh)
- Additional forms of local and free tissue flap surgery
- Fat transfer (lipofilling)
The advantages of using the body’s own tissue structures are that there is the absence of any foreign-body / immune reaction and the results are very natural. However, the removal of tissues from another part of the body leaves scarring in that particular area. The areas that are suitable for tissue removal are the lower abdomen, back, buttocks and inner thighs. Exactly which of these areas comes into question depends on each individual case and will be explained to you in a detailed consultation.
Breast reconstruction using tissue flap surgery can be either what’s known as local or pedicle flap, or free flap. Flap is the term used for the area of tissue that is to be moved from one part of the body to another. A local or pedicle flap consists of the tissue and its blood supply, whereas a free flap is cut from its blood supply and must be reconnected to the blood supply after the flap is moved. This technique is performed using microsurgery, which allows for precise suturing of the blood vessels. We work using a surgical microscope that enables even the smallest of vessels and nerves to be seen, mobilized and sutured.
This procedure also allows tissue flaps that are distant from the breast to be used in a breast reconstruction. Despite this method, there is always the risk that the blood circulation in the flap is not adequate enough and part of the flap, or all of it in extreme cases, is lost. Apart from that, in many tissue flap operations, the sensation, or in other words normal feeling in the breast, is lost.
Latissimus Dorsi Flap
One well-established procedure in breast reconstruction is to use the pedicled latissimus dorsi flap technique. It is mainly used when there is a large area of damage to the breast tissue and a radical removal of the breast (mastectomy) is necessary. The latissimus dorsi flap is a pedicled flap of skin and underlying fat tissues from the broadest and largest back muscle, the latissimus dorsi muscle. This reconstruction method involves the complete (or partial) elevation of the back muscle including skin and underlying tissue. It is tunnelled under the skin below the armpit and used to build the breast. Although microsurgery is used, there is no need to disconnect and reconnect the blood vessels because they are intact throughout the procedure.
The loss of function in the latissimus dorsi muscle is compensated for by other muscles. The wounds on the back are closed immediately. There will be a horizontal or diagonal scar on the back that can be covered well with a bra. The latissimus dorsi flap procedure is suitable for women who are lightly overweight and those that have small breasts because they usually have an adequate amount of skin tissue available to be used in reconstruction. Should there not be an adequate amount of skin available, then the tissue is stretched with the help of a tissue expander in order to be able to insert an implant, or an implant is inserted during the tissue flap surgery itself.
TRAM Flap
Another breast reconstruction procedure is the TRAM Flap (transverse rectus abdominus muscle flap). This skin and muscle flap is well-suited for breast reconstruction. There is usually enough surplus tissue below the navel to allow for the removal of a flap of skin, fat and muscle. The TRAM flap technique also simultaneously involves a tummy tuck because the required tissue is taken from this area. The scar that remains runs horizontally and lightly curved across the abdomen and can be covered with appropriate clothing. As the grafted tissue is similar to the breast tissue, the breast has a natural looking form and matches the other breast well. One disadvantage of this procedure is the weakening of the abdomen especially if it is not a microsurgically reconnected free tissue TRAM flap, but a pedicled TRAM flap with the muscles and its own blood supply. Since high blood loss sometimes occurs in a TRAM Flap procedure, a transfusion may be necessary.
DIEP Flap
The DIEP flap method (Deep Inferior Epigastric Perforator Flap) is a microsurgical reconstruction, which is, in a sense, a further development of the free TRAM flap that enables the aesthetic building of breasts using the body’s own tissue without the need for implants. This method also uses a flap from the lower abdomen. However, in contrast to the TRAM flap, only the abdominal fat tissue is taken, not the muscle. The necessary blood vessels from the muscle are connected to the blood vessels in the chest using microsurgery to ensure the blood supply. The advantage of this variation is that the abdomen is hardly weakened. However, this procedure is lengthy and complex. The operation itself takes up to six hours, making a stay of up to 2 weeks in hospital necessary. However, as a rule, this is the same for most free tissue flap surgery.
SGAP Flap
The free SGAP flap technique (Superior Gluteal Artery Perforator Flap) is a similar microsurgical technique to the DIEP flap, but the tissue flap is not taken from the lower abdomen, it is taken from the buttocks. There are two types of GAP flaps: the upper SGAP flap and the lower IGAP flap. This technique is preferred when, among other reasons, the abdomen is already heavily scarred or when there is too little lower abdominal fat available for a reconstruction. This procedure is often used when there has been amputation of both breasts because tissues are available from both buttocks. As no muscle is taken using this method, there is no impairment in movement. The scar is easy to camouflage being above the buttocks in an SGAP and in an IGAP flap it is in the crease of the buttocks. Any visible deformation of the buttocks when there is removal from both sides is not to be feared. The SGAP technique is demanding because the vessels are generally smaller and anatomical variations are more common than in the other procedures.
Breast Reconstruction using Fat Transfer / Fat Grafting (lipofilling)
A further option available for breast reconstruction is to use the body’s own fat, so-called lipofilling. This fat-transfer procedure is based upon taking fat from one part of the body, such as the hips or buttocks, and transplanting it in another part of the body. In recent years, lipofilling, techniques for the harvesting, preparation and transplantation have been improved to the extent that there is sufficient knowledge on the reliability of the technique available to reduce any complications to a bare minimum. Read more on breast reconstruction using fat grafting at Breast Augmentation by Lipofilling.
Breast Reconstruction using Implants
Silicone breast implants have been used in reconstructive breast surgery since the 1960‘s. This operation is less stressful for the patient than tissue flap surgery. The operation itself is not as demanding as others and the hospital stay is considerably shorter. Implants are best suited for women with small to medium sized breasts. For women with large breasts, a lift or reduction to the other breast may be necessary in order to improve symmetry. Breast implants are sometimes used in combination with the above described flap techniques if those techniques alone do not guarantee satisfactory results.
A breast implant can be positioned either under the pectoral muscle (subpectoral) or under the skin (sub cutaneous). The insertion of the implant under the muscle is more complicated because the pectoral muscle must be partly released from the ribcage. The implant position that best suits you is established pre-operatively and can be determined by factors such as the thickness of the breast envelope (skin and tissue that covers the breast), sports activities you are involved in etc.
The breast implants are filled with a silicone gel and can optimally recreate the breast shape. The special gel also retains the desired shape very well and feels real and natural. However, one risk associated with silicone implants is the possible development of so-called capsular-fibrosis. This is not the normal thin, soft tissue around the implant, but the forming of hard palpable tissue, which can cause deformation and hardening of the breast and require replacement of the implant. Some patients worry that the implant could burst due to external causes and the gel could leak out. However, modern silicone implants are made using a multi-layered shell and the filling is made in such a way that any danger of a leak does not exist. There is such a wide range of implants available that, as a rule, satisfactory results can be targeted to suit the individual.
After removal of the breast there is a taught, flat area of skin left over which can be built up using an implant. If, after breast removal, there is enough skin remaining, then the implant can be inserted straight away. If the remaining area of skin, known as a breast-skin envelope, is insufficient enough, then it must be stretched over a period of weeks using a tissue expander. This is inserted in a 1-hour-long operation under general anaesthetic. The expander is an empty balloon-like plastic shell with a port built into the front. The port is accessed through the skin with a needle and a saline solution is injected in stages until a new breast mound emerges. The filling of the expander is done on an out-patient basis at regular intervals. Once the expansion of the skin is complete, the expander is swopped for an implant. This procedure is performed under general anaesthetic and is in conjunction with a short stay at the clinic.
Further Operative Measures
The results of a breast reconstruction do not always completely fulfil the patient’s wishes and how she imagined it. Therefore, further surgery to the healthy breast may be required in order to achieve desired symmetry and natural appearance. However, one should wait for at least 3 months after breast reconstruction before any symmetry-correcting surgery is performed. The reconstructed breast normally sits slightly higher than the healthy one and needs some time to settle. However, should an acceptable result not appear within this time, then there are a few corrective procedures available.
A breast lift (mastopexy), breast augmentation (mamma-augmentation-plasty) or a breast reduction (reduction mammoplasty) can be performed. In a breast reduction, the skin, fat and glandular tissues are removed and the breast lifted. Breast augmentation is achieved by an implant or by grafting of the body’s own fat tissues.
Nipple reconstruction
Reconstruction of the nipples is the final stage of breast reconstruction. The newly formed breast only takes its on complete form once the nipple has been restored. The nipple should be optically natural to the eye and surrounded by a suitably coloured areola, which also matches the size and shape on the breast on the other side. The reconstruction of the nipple and the restoration of the areola are directly related to each other so together they are medically termed as Nipple-Areola-Complex (NAC). However, a functional reconstruction of the NAC including sensitivity or breast feeding function is not possible.
There are a few techniques available for the reconstruction of the nipple and areola. A highly successful option is to form the nipple using a skin graft from the newly constructed breast itself (local tissue flap surgery). To do this, small flaps are built up and sutured in such a way as to create a new nipple. A third method is to remove a part of the nipple from the healthy breast and graft it onto the reconstructed breast (nipple-sharing).
Just as important as the reconstruction of the nipple is the formation of the areola. This is often done with the help of a skin graft from another area of the body such as the inner thigh or the upper eyelid. After transplanting it, the skin appears darker and resembles the areola on the other breast. A good optical adjustment to match the other breast in terms of natural colour is the tattooing of the areola.
There are also actually stick-on nipples available from medical supply stores. For the main part, these are used so that a nipple appears on the operated side when wearing swimwear or a t-shirt etc. If no further operation is desired and the breasts should only optically match when in swimwear or in summer, then this also an option.