CONSIDERING BREAST RECONSTRUCTION

Breast reconstruction - What does it mean?
This is a planned surgical procedure to re-create the breast shape when the breast tissue has been removed. It is also possible to have a nipple and areola reconstruction. However, this is done at a later date when the desired shape has been achieved and the tissues have had time to settle.

It is important to realise that breast reconstruction may sometimes require additional surgery over time.

How is the new breast formed?
The breast can be formed either using an implant under the skin or by taking tissue from another part of the body. A combination of these techniques is used for some women. Your Surgeon will advise you which technique is likely to be most suitable for you according to your individual circumstances and physique.

What is an implant?
An implant is a specially manufactured device that can be used to give the shape and substance of the missing breast tissue. Implants are usually made of silicone or a combination of silicone and salt solution.

Breast reconstruction using implants.
A filled implant offers the simplest reconstructive technique, but is not suitable in all cases. It works best when the breast is small and pert.

Through the mastectomy scar, the surgeon places the implant under the skin and muscle covering the chest and the skin is then closed together.

When it is felt that there may be insufficient skin to cover an implant, or in larger breasted women, an implant known as a tissue expander may be used.

Breast reconstruction with permanent prosthesis after previous tissue expansion.
(Nipple complex has also been reconstructed)

What is a tissue expander?
The tissue expander is a deflated silicone bag with a valve mechanism. The implant can be slowly expanded over 2 - 3 months by injecting sterile saline (salt solution) into the valve. Sometimes, this cause discomfort, but this usually settles in 24 - 48 hours.

The gradual enlargement of the implant allows the tissues to stretch. Inflations will continue at regular intervals until the reconstructed breast is slightly bigger than the natural breast. By leaving the tissues slightly over expanded for about three months, a more natural 'droop' can usually be achieved when the excess saline is then withdrawn. Once the desired effect has been achieved the valve is removed under local anaesthetic.

Breast reconstruction using body tissue.
This technique involves taking a flap of muscle, fat and skin from one of the large muscles such as the back (latissimus dorsi muscle) or the abdomen (rectus abdominus muscle) to create a breast mound.

Using the muscle and skin from the back. A flap of muscle complete with the overlying skin and blood supply is taken from the back behind the affected breast and tunnelled just below the armpit so it can be positioned on the chest. Additionally an implant may need be used to give sufficient fullness to match the opposite breast.

The skin is then sewn together leaving an oval scar over the breast and a horizontal or diagonal scar on the back.

Using the muscle and skin from the abdomen. A flap of muscle with the overlying skin and blood supply is taken from the abdomen and tunnelled upwards so it can be positioned on the chest. This usually gives sufficient fullness without the need to use an implant. The skin is then sewn together leaving an oval scar over the breast and either a vertical or horizontal scar on the abdomen.

This method may not be suitable when patients have had previous abdominal surgery.

Nipple Reconstruction.
This procedure is carried out when all other reconstructive surgery is completed and the tissues are fully healed. This is because it is difficult to determine the optimum position for the reconstructed nipple until the new breast has had time to settle into shape.

Prosthetic Nipples

There are a number of different ways of creating a nipple and areolar. A small flap of tissue from the breast mound maybe used to create a nipple. For the areolar (the pigmented skin surrounding the nipple) a skin graft from the groin or lower abdomen may be used. It is also possible to obtain the effect of a nipple and areolar by using a tattooing technique. Alternatively, various artificial nipples are available, or can be custom made and then applied to the skin.

Nipple reconstruction six months after immediate
breast reconstruction by latissimus dorsi flap

What does a breast reconstruction look and feel like?
Results can vary according to individual factors such as; existing tissue, tissue healing, the type of reconstruction chosen and the opposite breast.

The surgeon will aim to create a breast that has good shape and is reasonably symmetrical with the opposite breast. This is easier to achieve for some patients than others. Sometimes surgery to the natural breast may be suggested in order to obtain an improved match.

It is important to have a realistic expectation of what surgery can achieve. The reconstructed breast will not look exactly like the natural breast and will not have the same sensitivity. Looking at yourself undressed the contour of the reconstructed breast maybe rounder or flatter than your natural breast, probably with less droop but when dressed or in a swimsuit these differences should be apparent only to you.

The reconstructed breast should feel soft to touch, although firmer than the natural breast.

You may find it helpful to see photographs of the results of breast reconstruction or to talk to someone who has had reconstructive surgery. Breast Cancer Care have a network of volunteers willing to share their experiences and offer information and support. They can be contacted by phoning the Nationwide Freeline on 0500 245 345.

Discuss your thoughts and expectations of what surgery can achieve for you with your surgeon so that he can consider which method of reconstruction will be the most appropriate for you.

When is breast reconstruction usually done?
Breast reconstruction is possible at the time of the mastectomy (immediate reconstruction), or otherwise at a later date (delayed reconstruction). Some patients may be advised by their surgeon to delay reconstruction until 9 - 12 months after their initial surgery, other patients may feel unsure initially, and so opt to consider at a later date.

Surgery to the opposite breast.
Surgery to the opposite breast may be suggested to improve the overall result of the reconstruction by more closely matching the the natural breast with reconstructed breast. Surgery to the opposite breast is usually done at a later date and may involve enlarging or reducing its size, or lifting it to reduce the natural droop. In some cases, the nipple may need to be repositioned, and possibly may become less sensitive.

What are the benefits?
Breast reconstruction alleviates the need to wear an external prosthesis and so can simplify practical matters such as bra and clothing selection and dressing. This may be particularly important for women with an active lifestyle. It can help to restore a feeling of wholeness, and psychologically can improve body image, optimism, self esteem and confidence.

Reconstruction does not generally interfere with any additional treatments such as chemotherapy or radiotherapy.

There is no known effect on the recurrence of cancer in the breast and check ups can still be carried out quite easily. However, it is important when attending for mammograms that the radiographer is informed if you do have an implant.

What are the drawbacks?
Reconstructive techniques which use body tissues entail a longer operating time, additional scarring and usually a longer period of recuperation than implant techniques. This is particularly so when the abdomen is used. However, reconstruction with just your own tissue will usually achieve a more natural look.

Skin taken from another part of the body may differ slightly in colour.

Reconstruction using a tissue expander requires regular visits to the hospital whilst the implant is being filled, and takes some months for the final result to be achieved. However, when reconstruction is delayed, it is usually possible to inject a larger volume of fluid which may mean the implant can be filled in just one or two sessions.

The natural breast can change in size and shape due to fluctuation in body weight or with aging which may mean that the breasts become more unequal.

What about complications?
We would stress that over recent years both implants and surgical techniques have improved, lessening the risk of complications. However, occasionally, as with any operation, problems may arise. Possible risks are outlined below.

Sometimes fluid collects under the skin. This is usually recognised by some swelling and can be easily drained.

Poor wound healing may occasionally occur, particularly in smokers or if radiotherapy has been given previously.

Wound infection occurs rarely. In this situation an implant may need to be removed to allow the infection to resolve. Antibiotics are given routinely when implants are used to minimise the risk of infection.

Sometimes scar tissue around an implant may tighten causing the implant to feel hard and round. This is known as capsular contracture. Massaging the skin over the implant may help prevent this. Sometimes further surgery maybe necessary.

Implants may occasionally fail (i.e. leak or rupture) or become displaced in which case further surgery will be necessary to remove and replace the implant. In terms of the safety of silicone implants, there is no convincing evidence to show that implants cause disease or adversely affect patients.

When muscles are taken from other parts of the body this can result in weakness may result in the donor area. In the back this may affect the shoulder and in the abdomen a hernia may develop. A special mesh may be positioned in the abdomen at the time of surgery to compensate for the loss of muscle.

What are the alternatives to reconstructive surgery?
The other way of outwardly restoring the bust contour is to wear a silicone breast form which is usually worn inside the bra which will hold it in place. There are many shapes and sizes and you will be individually fitted. There are also some breast forms which can be fixed to the skin with special adhesive strips and in some cases can be worn without a bra.

Suggested further reading: Understanding breast reconstruction
This booklet can be obtained from CancerBacup by telephoning 020 7613 2121

If you require further advice or information please contact the
Macmillan Breast Care Nurses, Hazel Ricard and Hilary Rickwood on 020 8565 5885