Breast reconstruction can involve reconstruction of part or all of the breast and can be necessary for one or both breasts. It is usually undertaken after breast cancer surgery but can also be done when breast tissue is lost for other reasons. For all types of breast reconstruction, it is important to have a full discussion beforehand and to be aware of all the options you are suitable for.
In my clinical practice, I frequently meet women who have been through or are going through breast cancer treatment. One of the great advances in treatment of breast cancer is the recognition that breast reconstruction is a really important part of the treatment. It allows women the chance to rebuild their bodies after the trauma of cancer surgery and for some to regain a sense of their femininity. Breast reconstruction can be immediate – done at the time of cancer surgery or delayed – done at a later stage when cancer treatment is complete. For some women, delayed reconstruction is a better option. For others, they may have the choice between immediate or delayed reconstruction. Breast reconstruction is also done for women who have undergone risk-reducing mastectomies either after having a cancer on the other side or when they are at high risk of developing breast cancer in the future due to genetics.
The breast can be reconstructed in a number of different ways. The option chosen depends on the size and shape of the breast to be reconstructed, if it is one breast or both, if radiotherapy is or was needed, the availability of tissue in other parts of the body eg abdomen, inner thigh, buttock or back and of course, what option the woman would prefer. The first basic choice is between autologous reconstruction (using the patients own tissue to reconstruct the breast) or implant-based reconstruction or a combination of both.
A tear-drop shaped (usually) implant is placed under the pectoralis chest muscle and matched in size to the opposite breast. This can give a good reconstruction in women with a small opposite breast that does not have any sagging of the tissue. No additional scars are needed. It is not so suitable for a large breast reconstruction or when a patient needs radiotherapy. Radiotherapy affects the overlying skin and can cause it to be very tight and inelastic. If the breast is being reconstructed immediately, an implant can be directly placed at the time of surgery. If it is some time since the mastectomy was done, the skin will need to be gradually stretched out or expanded first. This is done by placing a tissue expander where the implant will eventually go. A tissue expander is like an empty breast implant that can be gradually inflated with saline injections until it has stretched the skin sufficiently. It can then be replaced by the permanent implant. The reconstructed breast will feel firmer than a natural breast and will sit higher out of clothing. In the long term, implants may need to be replaced or adjusted.
The large latissimus muscle from the back on the same side as the affected breast can be lifted up including an area of the back skin and swung around to reconstruct the breast. For a small breast, this may be enough on its’ own but for most breast reconstructions, an implant is needed as well to match the volume needed for the breast. The additional coverage of muscle and back skin over the implant protects it more and gives a more natural appearance the breast. It is best for small to medium sized breast reconstructions. Although it can be used when radiotherapy has been given, as there is usually an implant used as well, it too will give a better result when radiotherapy has not been given.
This technique transfers skin and fatty tissue from the tummy area (between the bellybutton and the pubic hairline) with or without some underlying muscle to reconstruct the breast. Normally we try to leave the muscle entirely behind but sometimes due to the variations in blood supply to the skin, it is necessary to use some muscle as well. Usually this tissue is completely detached from the abdomen and then reattached via its blood vessels to the blood vessels of the chest wall. (Free flap surgery and microsurgery) On some occasions, the tissue is left attached and swung up to the breast but usually it is detached and then reattached. The great advantages of this technique are that it does not require any implants to supplement volume, it can give a very natural and longlasting result and closing the tummy incision gives a “tummy-tuck” effect on the abdomen. It is a long procedure but is increasing in popularity due to reasons just explained. It is possible to reconstruct a large breast or both breasts at the same time using this method.
Using this method, the skin and fatty tissue (usually but not always with a small underlying muscle) is transferred up to the breast to make the new breast. The blood vessels are reattached to the chest wall vessels to keep the tissue alive in a similar way to that of the abdominal flap reconstruction. This technique is useful in women who have small breasts and/or not enough abdominal tissue to transfer and who would rather not have a breast implant. There is a limit to the size of breast that can be reconstructed with thigh tissue but it too can give a longlasting, natural appearance to the reconstructed breast.
Similar to the techniques used to transfer tissue from the abdomen and inner thigh, tissue can also be transferred from the buttocks to the chest to reconstruct breasts. Buttock flaps have fallen behind abdominal and thigh flaps in popularity in recent years due to some of the technical aspects of the surgery and because buttock fat has a slightly firmer consistency compared to the other sites. It is still a good option in selected patients who may not have all the other options.
Other techniques of breast reconstruction are also in use but these are the most commonly used methods.
Once the breast is reconstructed, the next step is nipple reconstruction. In some instances, nipple-sparing mastectomies are done so that the nipple and areola (pigmented area around the nipple) are preserved, but most mastectomy patients lose their nipples during the mastectomy surgery. Nipples can be reconstructed by rearranging the tissue on the surface of the new breast to form a new nipple. Occasionally a skin graft is used as well. Mostly this is done as a separate procedure under local anaesthetic but sometimes can be done at the same time as the mastectomy. Once healed, tattooing can be used to recreate the pigmented colour of the nipple and areola. A new technique of 3D nipple tattooing is able to recreate the appearance of a nipple as well and some women opt for this instead of a surgical nipple reconstruction.
It can be difficult to match a reconstructed breast exactly to the natural breast on the other side or in bilateral cases to get both breasts symmetrical. Therefore, it is common to have further procedures to try and match both breasts better. This may involve fat transfer or liposuction to do small adjustments. Or it may involve a breast lift or size reduction or implant placement on the opposite breast. Of course, it is an individual woman’s choice whether to undergo further symmetrising surgery or not.
I hope that this has given a clear summary of the options available for women wishing to have breast reconstruction. It is an essential part of the treatment for breast cancer. While some may choose not to undergo breast reconstruction, it is vital that it is offered and discussed with all and that those who wish to do so, can avail of it.