Any woman that has to have a mastectomy for breast cancer or DCIS (ductal
carcinoma in-situ) has the option of breast reconstructive surgery. It is
only very rarely that a breast reconstruction is not advisable. Breast
reconstructive surgery can often be carried out at the same time as the
mastectomy (which we feel is preferable), but sometimes it is better to have
the surgery a few months later. Equally women who have had a mastectomy many
years before can have breast reconstructive surgery.
A breast reconstruction should not be thought of as a way of restoring the
breast back to the way it was before, as this is rarely possible. The main
benefit of this type of surgery is to enable a woman to confidently and
comfortably wear any type of clothes including low-cut tops and swimming
costumes, and to produce a normal look with a natural cleavage at all times.
A breast reconstruction should look indistinguishable from the other side in
a bra, but is never quite the same as the other side when undressed.
Nonetheless most women greatly prefer it to a mastectomy without
reconstruction.
There are two main types of breast reconstruction operation.
The simpler types use a silicone prosthesis to create
the new breast, while more complicated operations use
tissue from other parts of your body such as the back
or lower abdomen. Everybody is different, has specific
medical needs and has individual preferences. It is
therefore important to carefully discuss which type
of reconstruction operation is most suitable for you
and to be aware of the advantages and disadvantages
of each. We often like you to be seen by both a breast
consultant surgeon and a plastic surgeon before you
make up your mind. A large collection of photographs
are available to show you the type of look that you
will get.
Breast Reconstruction - Detail
It is still necessary for some women with breast cancer, recurrent breast cancer or extensive ductal carcinoma in situ to require a mastectomy. This leaves a flat scar over the chest wall as shown in. Women undergoing such a procedure will be provided with an external prosthesis that fits inside the cup of a bra. This will nearly always look quite natural when fully clothed and nobody will be able to see any difference or realise that it has been necessary to have a mastectomy. External prostheses can, however, be a problem especially when wearing lower cut blouses and tops, and with swimming costumes. Moreover, patients complain that prostheses are heavy and in the summer they are hot and sweaty and uncomfortable. External prostheses can move around, particularly when you bend forwards, which is of course disconcerting. Overall external prostheses are good but are not convenient or desirable for all women.
Many women who now undergo mastectomy opt to have breast reconstructive surgery. This can be carried out at the same time as the mastectomy (immediate reconstruction) or some time later, often after about 12 months (delayed reconstruction). Breast reconstruction aims to give you a more natural breast although it is never really possible to get back to your original appearance before the mastectomy. The most important aspect of the breast reconstruction is that it provides a natural cleavage which allows a woman to wear practically any tops that she would like and in addition it should look perfectly natural in a swimming costume. The size of the reconstructed breast can usually be matched with the other side but the shape of the breast without a bra is often different. It is very difficult to make the reconstructed breast have the same amount of natural droop as the normal side. For this reason we always say that we aim to produce a new breast with a natural cleavage that looks identical to the other side in a bra. However, it is important to realise that once you take your bra off the two sides will be different. In particular, the reconstructed breast is likely to sit up and be more pert than the normal breast. Most reconstructed breasts do not at first have a nipple but it is also possible at a later date to have a small operation to provide a natural appearing nipple.
There are two principle types of breast reconstruction. The first type uses a silicone prosthesis to provide your new breast while the second type uses natural tissue from another part of your body. In many cases these two techniques are combined so that a silicone implant is used in conjunction with tissue from another site.
In brief, the principle reconstructive techniques that you might be offered if you were considering reconstruction are:
1. reconstruction using a solid silicone implant
2. reconstruction using an expanding silicone implant
3. reconstruction using tissue from the back (latissimus dorsi flap)
4. reconstruction using tissue from the lower abdomen (DIEP flap) or even the buttock (S GAP flap).
The simplest form of breast reconstruction uses a solid silicone implant to replace the volume of the breast tissue that has been removed. This is only applicable to patients who have an immediate reconstruction where all of the inside of the breast is removed but the breast skin has been saved. A teardrop shaped solid silicone implant then replaces the volume of the inside of the breast. The results can look very good and the advantage of this type of surgery is that it is simple and quick and that you do not have a scar in another part of your body. The problems are that it involves using an implant that can get infected or can harden (capsule formation) over a period of years. It is now known that there is no danger from silicone leaks which anyway cannot happen with a solid silicone implant.
For some patients with small breasts who have previously had a mastectomy and are undergoing a delayed reconstruction an expanding silicone implant can be used. This type of reconstruction is done because there is clearly not enough skin remaining on the chest wall to form a new breast.
A collapsed and flat implant is therefore inserted at surgery. This is attached to a small valve which lies just under the skin at the side of the chest. In the weeks following surgery it is possible to inject saline through the skin and into the valve so that the implant slowly expands and stretches up the skin in the shape of the new breast.
This is again a very simple procedure but is only suitable for reconstructing small breasts and cannot usually be carried out on patients who have previously had radiotherapy. Overall the reconstructed breast is naturally quite firm and practically never has any significant natural droop. As a result this type of reconstructed breast always sits higher than the normal breast although it should look good in a bra.
Particularly in patients who are undergoing delayed reconstruction, extra skin and tissue from another part of the body can be used to make up for the skin that has been previously lost. One place to take the skin and tissue from is the upper part of the back on the same side as the mastectomy. This is called a latissimus dorsi flap, the name referring to the muscle that is moved together with its overlying skin and fat. In the majority of cases the tissue from the back is not enough to recreate a large enough breast, and this type of reconstruction is therefore usually combined with a small solid silicone implant placed underneath the natural tissue from the back. The end result is a softer breast with some degree of droop. Of course, this type of reconstruction does leave a scar on the back although this is usually placed at a level where it will be too low to be easily seen or will lie underneath a bra strap . The operation is longer (3 - 4 hours) and is more complicated than the simpler techniques using implants only. The main problems with latissimus dorsi flaps are that often the reconstructed breast does not have quite as much droop as the normal breast, and there are still the same problems with the use of silicone implants, namely infection or hardening (capsule formation).
A lot more tissue can be harvested from the lower abdomen (or occasionally the buttock). Because this is a large amount of tissue and it has to be moved from further away it is a very complicated operation which takes a lot longer (6 - 7 hours). The great advantage of this type of surgery is that there is often enough tissue on the lower abdomen (or buttock) to build the new breast to the correct size without the use of an additional implant. The net result is a soft breast made out of your own tissue with a similar shape (degree of droopiness) to the normal side. The disadvantage is that this operation leaves you with a very long scar, low on the abdomen (although the resulting flat tummy is a big bonus). The most critical part of the procedure is where the blood vessels from the lower abdomen are joined to blood vessels in the chest. This is a very delicate manoeuvre and is carried out under a microscope. If the process fails the tissue loses its blood supply and dies resulting in complete failure of the surgery. In this case it is usually necessary to take tissue from the back to make up for this. This serious complication occurs in approximately 5% of operations. The overall cosmetic result, however, is the best of all the types of breast reconstruction.
Breast reconstructive surgery is available to all patients undergoing mastectomy at The London Bridge Hospital no matter what age they are. We have a consultant breast plastic surgeon (Mr David Ross) who is readily available for consultations. In most cases it is sensible to discuss the issue of plastic reconstructive surgery with your consultant breast surgeon first. Some of the simpler reconstructive procedures are carried out without the need for plastic surgery but in many cases we would wish you to have a consultation with Mr Ross prior to any definite decision being made. In this way we are able to discuss all the various methods of reconstruction with you in a way that will hopefully ensure that you have the best type of operation for you. We have an extensive album of photographs showing the end result of all these types of operations which you may find helpful in making your choice.
Second Opinion
The diagnosis of any breast problem, but especially breast cancer, is something that causes a lot of anxiety and worry. There are often a number of treatment options available that may be appropriate. Deciding on which type of treatment is the best for you can be very difficult. We advise that you take time to think over any decisions that you may have to make. Your consultant surgeon will make every effort to explain all the options to you together with the advantages and disadvantages. The best option in terms of curing the cancer will be recommended to you, but all the other possibilities will be also outlined so as to provide a complete picture.
The London Bridge Hospital are always happy to provide second opinions on your proposed or planned treatment. This may be with regard to the diagnosis and treatment of breast cancer but may also be of help for other breast problems such as the treatment of nipple discharge.
Click here for more information on Breast Care Surgery consultants at London Bridge Hospital
