Breast Reconstruction

About 1:13 Australian women develop breast cancer at some time in their lives.

Although early diagnosis and less radical treatment methods have reduced the need for mastectomy, surgical removal of all or part of the breast is still the corner stone of treatment.

Why do only 10% of women who undergo mastectomy in Australia have a reconstruction?

• A fully informed personal choice.
• A lack of information on what is available.
• Misinformation regarding the dangers or poor aesthetic results.

There is no evidence that breast reconstruction increases the risk of recurrence of the original tumour, or that it impairs the ability to detect any recurrence.

The Advantages of Community Awareness
It is beneficial for all women to have a basic knowledge of what is available regarding reconstruction so that if they, unfortunately, ever do require some form of mastectomy, thought has already been given to this. This is particularly advantageous in the case of reconstructions performed at the time of the mastectomy. Many cases of breast cancer requiring mastectomy are well suited to a variety of what is called "skin sparing mastectomy". This involves preservation of most of the skin envelope and/or significant modifications of the standard mastectomy incisions, which provides an ideal opportunity for very natural reconstructions.

Speak to a Breast Reconstructive Surgeon
With a diagnosis of breast cancer a decision must be made regarding treatment options. The life threatening implications of cancer, possible body image change and the general disruption of the family routine has to be dealt with. Although beneficial, consultation with a reconstructive surgeon at this time and a decision on one of the many reconstructive alternatives, although in the long term beneficial, may be perceived as unnecessary additional stress and thus not requested. In many cases, however, such a discussion can alleviate some of the anxiety and fears associated with mastectomy. Some basic prior knowledge and thought may make this option more desirable and helpful.

It is important to realise that there is no rush. Decisions do not have to be made straight away. There is no reason to believe that waiting a week or two to decide on treatment options, including reconstruction, will make any difference to prognosis.

All these options must first be discussed with the breast surgeon.

The primary aim is to control the cancer in the breast.

Why have a Reconstruction?
The most common reasons stated for requesting, and the advantages of having undergone reconstruction:

• Feel whole.
• Maintain or regain a sense of "femininity".
• Avoid the inconvenience, potential embarrassment and discomfort of an external prosthesis.
• Feel physically balanced.
• Minimal restriction with choice of clothing.
• An impression there is less worry regarding health because the reconstruction has taken away a constant reminder of the life threatening nature of the disease.

When is the most Suitable Time for a Reconstruction?
Breast reconstruction may be performed at the time of the mastectomy (Immediate) or, alternatively at a second operation months or years later (Delayed). In suitable cases immediate reconstruction offers the potential to provide the most natural results. There are many other factors for or against either immediate or delayed reconstructions. This should be discussed fully with the breast surgeon and, in many cases, a Plastic and Reconstructive surgeon.

What Reconstruction Methods are Available?
There are many factors which determine the most suitable procedure for each individual, such as personal preference, physical features and the surgeon's recommendation.

Factors Favouring an Implant Reconstruction

• A relatively small opposite breast with minimal sag.
• Good quality remaining chest wall soft tissue which has not been treated with X- ray therapy.
• A desire for a relatively simple method of reconstruction involving a short hospital stay and minimal, if any, additional scarring.

Most implant reconstructions involve the use of "tissue expanders". These are inflatable prostheses, which are inserted under the chest wall soft tissue. Over 2-3 months they are gradually inflated by injecting saline solution into them. This recreates much of the skin excised at the time of the mastectomy by a combination of stretch and further skin growth in the same way the abdomen accommodates a pregnancy. At a second operation the expander is removed and a permanent implant inserted.

In some circumstances a permanent adjustable implant is inserted primarily. This is often possible with immediate reconstruction.

Silicone gel or saline filled implants are used. I favour the gel implants as, in my experience, they produce a better shape and more natural feel.

The present state of scientific knowledge does not implicate silicon gel with any disease process.

Factors Favouring the use of Natural Tissue

• A desire to match an opposite moderate sized breast with natural sag.
• Tight thin chest wall soft tissue.
• Post operative X- ray therapy as part of the initial treatment regime.
• An individuals wish to avoid an implant.
• Physical suitability and desire for an abdominoplasty ("tummy tuck").

The "trade off" for this type of reconstruction is the increased magnitude of the operative procedure, the associated longer hospital stay, convalescence and some added risks.

The most common donor areas for natural tissue are the lower abdomen (the TRAM flap) and the back (the Latissimus Dorsi flap). The TRAM flap tissue is that which is discarded at the time of a routine "tummy tuck". This is either left attached to one rectus abdominus muscle (pedicle) or is cut completely free and revascularised on the chest wall using micro surgery (free tissue transfer).

When a Latissimus Dorsi flap is used an implant is usually also required to achieve the desired volume.

Figure 2 illustrates the techniques for reconstruction using the TRAM flap

A. Free microvascular transfer

B. Pedicle technique

C. Following transfer

The Opposite Breast

To provide optimal symmetry, surgery on the opposite breast is often advised. This may take the form of augmentation, reduction or uplift.

The risk of developing cancer in the opposite breast should be discussed with the breast surgeon. Very occasionally some form of prophylactic mastectomy and immediate reconstruction is advisable.

Nipple and Areola Reconstruction

A nipple is usually reconstructed at a second stage, about three months later. The nipple and surrounding areola area can be coloured using intradermal tattooing as a simple office procedure.

Figure 4 illustrates reconstruction of a breast at the time of a skin sparing mastectomy using a Latissimus Dorsi muscularcutaneous flap and an implant

A.	B.	C.

A. Skin sparing mastectomy
B. Flap elevation and transfer
C. Flap in position over permanent implant

Although breast reconstruction techniques have evolved to become very sophisticated, often with excellent results it has to be recognized that there are limitations in what can be achieved and every individual case is different. It is impossible to recreate the “perfect” breast.

The realistic expectations, risks, convalescent time, and costs should be discussed fully with the reconstructive surgeon.

It is often advantageous to view representative photographs and speak to other patients who have undergone reconstructive procedures.