Before undertaking breast reconstruction surgery, we must first consider the patient’s overall health which can be affected by many factors including: age, medical conditions, level of fitness, smoking and medications:
Age:
Some 70 year olds are far fitter than people 20 years younger who may be much less active.
Medical Conditions:
Poorly controlled diabetes, high blood pressure, heart or lung conditions may mean that a complex reconstruction, requiring a long anaesthetic, may not be safe.
Smoking:
Giving up is hard to do, but the vast majority of patients with a new cancer diagnosis have an extra inventive to stop. This will help with the risk of deep vein thrombosis (DVT) and clots on the lung (pulmonary embolus) but also reduces the risk of wound breakdown and problems with the microsurgery required for complex breast reconstruction .
Medications:
Steroids affect the skin and slow down wound healing while some of the immunosuppressants used for rheumatoid arthritis/transplants increase the risk of infection. Aspirin, clopidogrel and warfarin make you bleed more in surgery. Chemotherapy agents such as Herceptin can have major side effects on the heart and its ability to function normally.
Immediate:
For some the concept of being without a breast is too much to consider on top of the cancer diagnosis, in which case an immediate reconstruction may be best and more of the natural breast skin can usually be preserved. However, the patient goes to sleep with a breast but wakes up with a reconstruction which may be quite different to what was there before.
However, sometimes patients are not fit enough to have cancer surgery and reconstruction in one go. Moreover with more advanced cancers, it may be sensible to move on with the cancer removal and additional (adjuvant) medical treatment such as radiotherapy and chemotherapy, before addressing reconstruction when the dust has settled.
Delayed:
Equally for other patients, the reconstructive options are secondary to the initial cancer treatment and they may wish to proceed with mastectomy as soon as possible. This does mean that more of the native breast skin is removed (go flat) in order to get the wound healed and minimise the risk of collections occurring below the breast skin.
Advantages include that it may be easier to get on with subsequent chemo-radiotherapy as there is less down time and the reconstruction can be performed at a subsequent and more convenient time. Also people can optimise their fitness, lose weight and recover from the side effects of chemotherapy.
DIEP, MS-TRAM and TRAM FLAP
Advantages:
The ‘Gold Standard’ in breast reconstruction. Uses the patients’ own tummy tissue and transplants it to the breast to restore breast volume and shape with some of the benefits of a tummy tuck. Will move, feel and age in a more natural way than an implant reconstruction and withstand radiotherapy better.
Disadvantages:
Longer surgery, admission and downtime. Long abdominal donor site scar similar to a ‘tummy tuck’.
Recovery:
4 – 6 hours of surgery
4 – 6 days in hospital
At least 6 week recovery to normal functioning
What do DIEP, MS-TRAM and TRAM mean?
When first developed in the 1970s the abdominal tissue would be taken with one of the underlying tummy muscles and was known as a Transverse Rectus Abdominus Myocutaneous (TRAM) Flap. Later a smaller amount of muscle was taken, Muscle Sparing (MS-TRAM) Flap. Further refinements allowed the muscle to be completely spared as the just the skin and fatty tissue were taken on the underlying blood vessel, the Deep Inferior Epigastric Artery Perforator (DIEP) Flap.
Advantages:
Lumbar flap or Latissimus Dorsi (LD) flap is another more recent secondary option after the DIEP flap. May be used in those who do not have enough tummy tissue available.
Disadvantages:
Donor site tends to produce drain a lot of fluid post-operatively, similar to the LD flap. Only a short blood vessel can be taken from the back to vessels from the tummy area may be taken as well and joined to the flap.
Recovery:
4 – 6 hours of surgery
4 – 6 days in hospital
At least 6 week recovery to normal functioning, back may need to be drained in outpatients
Advantages:
For those of slimmer build with no tummy but smaller breasts then this may be a good secondary surgery option, producing quite a ‘perky’ breast reconstruction.
Disadvantages:
Wound healing of the inner thigh donor site can be an issue. Limited volume achievable. More complex microsurgery as vessels smaller.
Recovery:
4 – 6 hours of surgery
4 – 6 days in hospital
At least 6 week recovery to normal functioning, the thigh can take a while to settle.
Advantages:
Can recruit some of the upper (S-GAP) or lower (I-GAP) buttock tissue and were initially popular as an alternative to the DIEP flap.
Disadvantages:
‘In the crease’ scar of the I-GAP flaps means that the patient sits on the scar which can delay wound healing and be painful in the long term. Buttock tissue tends to be much more firm than abdominal or thigh tissue.
Recovery:
4 – 6 hours of surgery
4 – 6 days in hospital
At least 6 week recovery to normal functioning
Advantages
No donor site. Good for smaller non-droopy breasts. Better for bilateral cases as symmetry improved. Quick recovery.
Disadvantages
Radiotherapy will tend to cause a very high rate of complications. Tends to be firmer and colder. Implants do not last for ever. Hard to match fuller, more droopy breast. Will need to be placed under the chest (pectoralis) muscle.
Recovery
2 hours in surgery
1 or 2 days in hospital
Should be well-healed in 1-2 weeks.
If a saline expander is used then this will need to be enlarged over a period of weeks via injections into the port every fortnight or so until the desired volume is achieved. 6 weeks for initial result to settle.
For all surgery, scars take 18 months to fully mature.
For the younger patient who has not had children, perhaps having bilateral, ‘risk-reducing’ surgery, implants may be a very good option as no donor site is required and radiotherapy should not be an issue.
Advantages:
In order to improve the soft tissues a more recent innovation is to cover the lower part of the implant with a piece of organic mesh derived from pig or cow skin. Removes the need for a donor site such as in the back flap operation.
Disadvantages:
Notorious for producing an inflammatory response and seroma.
May not be able to reduce the longterm effects of radiotherapy.
Recovery:
2 hours of surgery
1 to 2 days in hospital
Drains may be required for 2 weeks, but wounds should heal well by 2 weeks
6 weeks for initial result to settle
Advantages
A very reliable, classic option since the 70s. No microsurgery service required.
Disadvantages
Combines the disadvantages of an implant with the downside of a donor site on the back. Collection of tissue fluid (seroma) is a common complication. In plastic surgery units, the LD flap is only used in salvage situations.
Recovery
3 – 4 hours of surgery
5 – 7 days in hospital
Can take 10 days for drains in the back to finish
Wounds should be well healed in 2 weeks
6 weeks for initial result to settle
Symmetrisation:
Despite the best efforts of the surgeon, if a patient has very large or droopy breasts then it may just not be possible to match the other side and an uplift (mastopexy) or reduction may be required to achieve optimum symmetry. Best left until 3-6 months after the initial reconstruction. This tends to be a day-case procedure, taking 90 minutes or so.
Lipofilling:
After the mastectomy, any implant or tissue based reconstruction can have small areas of scarring that result in small defects which may be troublesome, especially in the cleavage area. If so fat may be harvested from the flanks or thighs, using gentle liposuction, and injected into the depressions. Again day-case procedure, taking 90 minutes. Donor site scars are 3-4 mm.
Nipple Reconstruction:
The ‘cherry on the cake’ is a nipple reconstruction where 3 small flaps of skin around 15mm long are raised up and gathered around to make a nipple. Once healed a tattoo can be applied to colour in the areola and complete the reconstruction. Alone a day-case procedure under local anaesthetic taking around 45 minutes.
It helps to know the details of any operation you’re going to have. Watch this short video to find out what happens before, during and after breast surgery…
FAYE WYMER