Reconstruction

Breast reconstruction

What is breast reconstruction?

Breast reconstruction is an operation to recreate the shape of a breast that has been removed by mastectomy (removal of the whole breast) or lumpectomy (removal of part of the breast).

The aim of reconstruction is to restore the shape of the breast and to match the opposite breast as closely as possible. There are different ways of doing this and the type of operation that you have will depend on:

• the type of disease that you have in your breast

• the operation you have had, whether a mastectomy or breast-conserving surgery (lumpectomy)

• whether radiotherapy has been given previously or is planned after this operation

• your health and general fitness

• your choice and preference.

As well as reconstructing the breast, it is also possible to reconstruct the nipple and the surrounding area, which is known as the areola.

It is important to realise that, even if you have a breast reconstruction that matches the other breast, it will never feel the same as the other breast. Also, any nipple that is reconstructed will not have the same sensation as your normal nipple.

Why women choose reconstruction

There are clearly some benefits from having reconstruction and there are also some risks. The following are the benefits:

• You will have increased freedom of dress. If you have a mastectomy and immediate breast reconstruction you may not have to worry about different bras or changing your wardrobe at all.

• You will not have to wear an external prosthesis.

• Women who have had a reconstruction say that generally they feel more confident and better about their bodies compared with women who do not have one.

Problems with reconstruction

Although your shape can be restored, it will not feel like a normal breast and a reconstructed breast often sits a little higher and is firmer than the opposite breast.

Breast reconstruction is not usually one operation. To get a good match between the two breasts, it is usually necessary for patients to have two or three operations. This can involve making the opposite breast smaller, lifting it or making it bigger. It may also be necessary at a second operation to tidy up scars on the reconstructed breast or to make minor adjustments to improve its shape.

There is absolutely no evidence that having a breast reconstruction increases the chance of cancer coming back and it does not make any recurrence of cancer more difficult to detect.

If you are interested in breast reconstruction you need to discuss this with your doctor. If you have been told that you need a mastectomy you should be offered the option of breast reconstruction as long as you are fit enough.

Your surgeon might indicate to you that if you want reconstruction this would be better carried out as a delayed procedure six to twelve months after the mastectomy rather than immediately.

The reasons for this may be because it is planned to give you radiotherapy after mastectomy or some of the skin of the breast that is affected or dimpled by the cancer needs to be removed by the surgeon and this might make reconstruction technically difficult.

Timing of breast reconstruction

Breast reconstruction in the UK is most commonly carried out at the time of initial surgery. If you are having a mastectomy, the whole breast can be reconstructed. If you are having a large part of the breast removed, part of the breast can be replaced using muscle or tissue from elsewhere in the body.

If you have had a mastectomy in the past you may be a candidate for reconstruction. This is called delayed reconstruction. Also, if you have had a lumpectomy. but your treated breast does not match your other breast because it is smaller or an abnormal shape, it is possible to perform a partial breast reconstruction and reshape the treated breast to match it to the opposite side.

If you are having immediate reconstruction at the time of mastectomy it can take longer to organise than a straightforward mastectomy. This should not put you off because delaying surgery by a week or two will not make any difference to your outcome.

If there is going to be a delay, check with your surgeon about whether you should start some drug treatment before the operation. If your cancer is hormone sensitive, taking tamoxifen in premenopausal women or a drug such as letrozole (see page 142) in postmenopausal women before surgery can help control the cancer and even shrink it.

Where can you have a reconstruction?

Most breast units offer immediate reconstruction. This surgery is performed either by a specialist breast surgeon who is trained in both cancer surgery and reconstructive surgery or by two surgeons, the operation to remove the cancer being performed by a breast surgeon and the reconstruction surgery by a plastic surgeon.

If you are having reconstruction it is important to ask your surgeon and breast care nurse to show you photographs of the probable results. You may also be able to get the name and telephone number of a patient who has had this procedure so that you can talk to her. You can get further information on reconstruction from some of the self-help groups such as Breast Cancer Care (see page 221).

What are the types of reconstruction?

There are three main ways in which the breast can be reconstructed:

1 Using an implant alone.

2 Swinging in tissue from your back or your abdomen (tummy). This tissue is left attached to its blood supply and is known as a pedicled flap. The muscle with overlying skin and fat from the back or the abdomen is used either alone or together with an implant to reconstruct the breast.

3 Tissue taken from the abdomen or the buttock region is detached from its blood supply and transferred and attached to a new blood supply in the armpit or under the ribcage to create a new breast. These procedures are known as free flaps and require microsurgery. They are usually performed only by specially trained plastic surgeons.

Breast implants

Breast implants have been used for many years. Most implants are a silicone shell filled with silicone although they can also be filled with saline (salt water).

Although saline implants sound attractive they do not have a natural feel and give a much less realistic reconstruction than silicone implants. Saline implants are also more likely to leak and wrinkle and interfere with the reading of mammograms. For that reason, most surgeons do not use saline implants.

Silicone implants are essentially bags of silicone gel enclosed in a thin silicone rubber outer shell. Silicone is used because it is soft and flexible and feels like natural breast tissue.

Early implants

Implants have changed over the years. Originally the implants that were first used had a thick outer shell and contained thick silicone. These did not feel breast like.

They were quickly replaced by second-generation implants, which contained more fluid silicone and had a very thin smooth-walled shell. The outer shell of these second-generation implants tended to wear out over 10 to 20 years and so with time these implants ruptured or leaked.

Most controversy and problems with breast implants have surrounded the use of these second-generation implants.

Modern implants

The silicone implants that are used now have a rough (textured) outer surface that stops them moving and they have a much thicker shell than the second-generation implants.

The silicone gel that is currently used is often solid silicone gel rather than liquid silicone gel. This means that, if the implant is cut in two, the two pieces remain intact and do not leak.

Silicone injections

The biggest problems reported with silicone are not related to silicone implants but because liquid silicone was injected into the breasts in some women. This was rarely carried out in the UK and silicone injections into the breast are now banned.

Safety of implants

Although there have been lots of reports that silicone implants cause other health problems, all the research that has been performed has shown no link between these implants and the development of any disease.

Silicone implants were banned for several years in the USA but they are now in use again. In the UK the Department of Health has asked medical specialists on three occasions over recent years to look at the safety of silicone implants. The last report in July 1998 concluded that there was no good evidence that silicone implants cause any significant disease including arthritis.

How long do silicone implants last?

The average lifespan of a second-generation implant is about 15 years. By this time about half the implants are either leaking or ruptured.

The new implants that are now in use will almost certainly last much longer and it is currently believed that these implants will last between 20 and 25 years.

What happens if my implant leaks?

It is very rare that, if an implant leaks, any silicone leaks outside the capsule that the body forms around it. If an implant rupture is suspected because of a change in shape of the breast or because a mammogram indicates a possible leak this can be confirmed by ultrasound or magnetic resonance imaging (MRI). The body can react to silicone that has leaked from implants by forming lumps which can be painful.

If the MR scan shows that the implant has ruptured but there is no silicone leaking outside the capsule, it is usual to have the implant removed, the silicone washed out and the implant replaced, but it is not absolutely necessary. The operation to remove the implant usually removes the capsule around the implant to make sure that all the silicone is removed from the body.

Breast reconstruction using implants alone

When reconstruction using implants was first introduced it was common to use implants after a mastectomy to try to produce an immediate breast reconstruction. The implant was placed either under the skin or underneath the chest wall muscle next to the ribs.

Unfortunately reconstruction using implants alone is suitable only for women with small breasts and the final result from this type of reconstruction is not generally as good as that using skin and muscle from the back or abdomen.

The scar from this type of reconstruction usually runs from side to side or, if the nipple is left, it may run under the nipple.

Breast reconstruction using tissue expanders

Once some of the skin of the breast is removed, it is difficult to get the reconstructed breast to match the opposite breast, unless extra skin is produced by stretching the skin and muscle that is already there.

Breast reconstruction using a tissue expander places an expandable implant under the muscle of the chest wall; the expander is attached by a tube to an injection port that sits under the skin placed either below or at the side of the expander or the injection port is integrated into the expander.

This port is used to allow filling and stretching of the skin and chest wall muscle. To allow more rapid expansion of the muscle it is possible to sew in a layer of tissue which is an acellular dermal matrix derived from donated human or pig skin. This results in better expansion of the lower part of the breast where it is needed.

Fluid is injected into the implant over a few months. This results in the tissues stretching and new skin develops in the same way as a woman develops extra skin on her abdomen when she is pregnant. Fluid injection causes some discomfort but this usually settles very quickly.

Reconstruction using tissue expanders

After breast surgery, a patient may choose reconstructive surgery. One option involves inserting an implant under the skin and chest wall muscle. This is expanded over several months by injecting saline into it.

The inflatable silicone bag is left in place for several months until the tissues have stretched to produce a good match to the opposite breast.

Then a second operation is performed to remove the tissue expander and replace it with a permanent implant.

Some tissue expanders have two spaces within the implant. The outer space is filled with silicone gel and the inner balloon is filled with saline. These devices are slightly over-inflated (blown up) to larger than the planned final volume over several weeks and then some of the salt water is removed through the valve to produce a breast reconstruction that matches the opposite natural breast as closely as possible.

An advantage of these devices, which are called Becker expander prostheses, is that they do not need to be removed and can be left in permanently. All the surgeon needs to do is to remove the filler port and the tubing that connects the port to the implant.

Use of implants or tissue expanders is not usually suitable for people who have had radiotherapy. This is because radiotherapy damages the skin and does not allow the skin to stretch as easily. For women who have had radiotherapy, therefore, a reconstruction using skin, muscle and fat from elsewhere is usually required. With the use of tissue matrix (see page 185), it is sometimes possible to get a good quality reconstruction even after radiotherapy.

Breast reconstruction using muscle and skin flaps

This type of reconstruction uses muscle, skin and underlying fat from different parts of the body and transfers them to the breast to create a satisfactory breast shape. This type of surgery is known as flap surgery.

The tissue most commonly used is from either the back or the abdomen – areas of the body that contain large muscles and can provide enough skin, fat and muscle with a good blood supply to help create a reasonable breast shape. The large muscle from the back is called latissimus dorsi and the muscle from the abdomen is rectus abdominis.

Flap reconstructions are now the most commonly used type of reconstruction. These flaps can be used to create larger breasts and are particularly appropriate for women who have had radiotherapy. This type of reconstruction can take many hours to perform and usually requires a stay in hospital of five days or more.

Latissimus dorsi flap with an implant

There is a broad thick muscle that lies directly under the skin on each side of your back called latissimus dorsi. The muscle used to reconstruct a breast is taken from the same side of the body as the breast that has been removed (that is, a right-sided mastectomy would involve removal of the skin and muscle from the right side of the back).

There are other layers of muscle in the back and, although removal of a muscle can result in a slight weakness, in general other muscles compensate for the lost muscle so that you should not notice too much difference during everyday activities.

The skin and underlying fat remain attached to the muscle, which is kept attached to its own blood supply, and the flap is tunnelled through the armpit to create a new breast shape.

Usually the amount of skin that is removed from the back is more than the amount of skin removed at the time of mastectomy and some of the skin can be buried to produce a satisfactory size and shape, so it is generally possible to get a very good match with the opposite breast.

It is not always possible to get enough tissue from the back to fill the whole breast, so a small implant is often placed underneath the muscle to produce a reconstructed breast of the same volume as the opposite normal breast.

This type of operation leaves scars on the back and on the reconstructed breast. The scar on the back is usually positioned so that it will lie under the bra strap. Some surgeons prefer to leave a more diagonal scar. This can make it more difficult to cover up but these types of scars are usually covered by garments such as swimsuits.

The reason for using a diagonal scar is that it can give more skin. The scar on the breast can be very small if the reconstruction is being performed at the same time as the mastectomy because skin can be spared at the mastectomy, but there will be more scarring if you have a delayed reconstruction, because more skin is required to create a satisfactory breast shape after a previous mastectomy.

Lower abdominal tissue

This uses the rectus abdominis muscle and skin and fat from the abdomen. This is known as a transverse rectus abdominis myocutaneous flap reconstruction, sometimes referred to as a TRAM because a transverse piece of skin is used and the rectus abdominis muscle is used.

In this operation fat, usually with underlying muscle and overlying skin from the lower part of the abdomen, is used to reconstruct the breast.

The flap can be rotated and tunnelled upwards leaving it attached to the body; this is called a pedicled flap.

Alternatively, it can be removed completely from the body and reattached to a new blood supply in the breast region – a so-called free flap.

TRAM flaps are usually big enough in volume to match the opposite breast and an implant is rarely needed. The scar on the abdomen is usually horizontal and just below the bikini line. During the operation the umbilicus (belly button) is repositioned.

In a free flap the same skin and fat from the lower abdomen are used but less muscle is taken. The blood vessels supplying the flap are identified and then cleaned and cut and are later rejoined to blood vessels either under the arm or under the breastbone.

Generally the blood supply from a free flap is better than from a pedicled flap. This means that once the wounds have healed there are usually fewer long-term problems and fewer abdominal complications using a free flap.

However, the process of joining together the small blood vessels for a free flap is sometimes not straightforward and the risk of the whole flap dying is greater with this method.

One of the problems with taking muscle from the abdomen is that it weakens the abdominal wall. The surgeon will usually place a mesh to fill the gap where the muscle has been removed to try to stop the development of hernias or bulges. This is not always successful, however, and some people who have had this type of operation complain of some weakness of the muscle of the abdomen.

Other flaps

It is possible to reconstruct the breast using fat and skin from the lower abdomen over the rectus abdominis muscle without taking any muscle. The blood vessels are followed through the muscle but the muscle itself is not damaged. This operation takes much longer and is technically a much more difficult operation. The name of the blood vessels used are the deep inferior epigastric vessels, so it is often called a DIEP flap for short.

It is possible to take skin and fat from the buttock area to reconstruct the breast. These are uncommon procedures in the UK, and are used only in patients who are unsuitable for other types of reconstruction.

Lumpectomy and immediate breast reconstruction

Large cancers are usually treated by mastectomy but it is sometime possible to remove large cancers by lumpectomy and then reconstruct the breast immediately with tissue from elsewhere in the body. The most common tissue used is muscle and skin from the back. Part of the latissimus dorsi muscle with some overlying fat is used. This is known as a latissimus dorsi mini-flap.

Placement of a mini-flap can be performed at the same time as removal of the cancer. Another option is to remove the cancer, check that all the cancer has been removed, and a few days later go back and fill the space in the breast by a mini-flap.

There are other flaps of tissue and muscle that are used in a few centres. The basis of these flaps is having a large enough blood vessel to supply the tissue to be moved, so that the flap survives after it is transferred to the breast. If you are suitable for one of these flaps your doctor will discuss this with you in detail.

Reconstruction of the breast in women who have had a lumpectomy and radiotherapy

Up to one in five women who have breast-conserving treatment finds that the treated breast is smaller than the other side. In this situation, it is possible to make the treated breast bigger or the opposite normal breast smaller. The results of this can be excellent.

Reducing both breasts at the time of lumpectomy

Some women who have cancer and have larger breasts may opt not only to have the cancer removed but at the same time to make both breasts smaller (therapeutic mammoplasty). The same approach that is used in breast reduction allows large volumes of breast tissue to be removed, allowing large areas of cancer or pre-cancer DCIS to be excised, and at the same time producing a satisfactory cosmetic outcome. This surgery is usually possible only in larger units and is ideally carried out by two surgeons working together, a breast surgeon and a plastic surgeon. The results are excellent and most patients are happy that their cancer is gone and their breasts are smaller and sit slightly higher than before surgery.

Surgery to the other breast

If you are having a breast reconstruction the surgeon carrying out your breast reconstruction will try to match the shape of the reconstructed breast with your remaining breast. This is not always possible so it may be suggested that you have an operation on your normal breast to change it so that it matches the reconstructed breast.

This may involve reducing the size of the other breast or lifting it to reduce its natural droop. This type of surgery does leave scars but any scars will fade with time and this may be the only way of getting a satisfactory match to the opposite breast.

Being realistic about breast reconstruction

Every effort is made to achieve the best possible result from reconstruction but not every person will achieve a perfect match to their opposite normal breast. When undressed you may find that your reconstructed breast has less of a droop than the opposite normal breast.

If the shape of your reconstructed breast differs greatly from the opposite breast it is possible to wear an external prosthesis over the reconstructed breast.

If you are unhappy with your reconstructed breast discuss this with your surgeon. If all your questions are not answered or you still feel unhappy, you can request a second opinion.

You can still have radiotherapy or chemotherapy if you have had a flap reconstruction. The only problem with radiotherapy is that, if you have an implant, it is more likely that you will develop some tightening around the implant than women who do not require this treatment.

This tightening is called capsular contracture and it occasionally happens even in women who do not have radiotherapy. When any foreign body, such as an implant, is put into your body, it reacts by forming fibrous tissue or a capsule around it.

Over a few months this fibrous tissue may contract and in some patients the contraction is quite marked, resulting in hardening and change in the shape of the implant that can be uncomfortable and spoil the shape of the reconstructed breast.

About five to ten per cent of women develop marked capsular contracture. This can be treated by removing the implant and taking away the capsule.

The same implant or a new one is then placed. This is usually successful at improving the shape and the capsule does not usually form for a second time.

Lipofilling

This is a new procedure, developed from liposuction techniques. It is used to fill in dents or defects in the breast, or to enlarge a breast. It involves taking fat from one part of the body, for example the inner part of the thigh or the abdomen, and then injecting it carefully into the breast. It may be done in two or three stages and can be done using a local anaesthetic, but usually requires a general anaesthetic.

Nipple reconstruction

It is usually but not always necessary to remove the nipple during mastectomy but it is possible to reconstruct a nipple later. This is generally performed a few months after breast reconstruction so that the nipple that is reconstructed can be matched in its shape and position to the other nipple.

In patients having both breasts removed it is often possible to save one nipple and this can be split into two and grafted on to produce two small nipples during the first reconstruction operation.

A reconstructed nipple is usually created from skin on the reconstructed breast. Having made the nipple it will take six to eight weeks to heal and settle down, and then the area is suitable for tattooing to produce a correct colour match to the other nipple. Tattooing is usually painless and can give a very realistic appearance to the nipple and the surrounding area called the areola.

It is important to be realistic about a reconstructed nipple. It will not behave in the same way as the opposite nipple and will not have any sensation.

It is quite difficult to reconstruct very large nipples so if you do have a large nipple on the other breast, one option is to take part of the normal nipple and transfer it across to reconstruct the new nipple; this is called nipple sharing.

Nipple prostheses

Another option is to wear a stick-on nipple. These are readily available from your breast care nurse.

Nipple reconstruction – nipple flap

Skin on the new breast can be folded into a nipple shape – this is called a nipple flap. There are different techniques and the procedure is usually done under a local anaesthetic and you should be able to go home the same day.

Tattooing after breast reconstruction can give the reconstructed nipple a very good appearance.

It is possible to make a nipple specifically for you. A mould is taken of your other nipple, which allows the stick-on nipple to be a very close match to the shape and colour of your other nipple.

KEY POINTS

• In most women it is possible to reconstruct a breast shape after mastectomy

• This can be done either at the time of mastectomy or later

• Breast reconstruction uses breast implants and/or skin and muscle flaps to bring tissue from elsewhere in the body

• Breast reconstruction can be a major undertaking for you and it is important to be realistic about your expectations

• In women with cancer who have larger breasts, the cancer can be removed and both breasts made smaller – a procedure called therapeutic mammoplasty