Breast reconstruction is a form of surgery performed on women who undergo a mastectomy to have part or whole of their breast removed, usually to reduce their risk for breast cancer. Breast reconstruction involves restoring the breast's original shape and size as well as sometimes recreating the nipple and surrounding areola. Breast reconstruction is carried out by a cosmetic or plastic surgeon.
Indications for breast reconstruction
Women may opt for a breast reconstruction for several reasons including:
To ensure breasts are evenly balanced, especially when only one breast has been operated on. A patient would usually want their breasts to look similar enough in size and shape to feel comfortable in most clothes.
To avoid the use of a prosthetic breast. Instead, a breast reconstruction means the shape and size are regained permanently and may help to improve self-esteem and body image.
Timing of breast reconstruction
Breast reconstruction may be offered to a patient on an immediate or delayed basis:
Immediate breast reconstruction is performed at the same time as the mastectomy, eliminating the need for a patient to visit hospital for further surgery in the future.
Delayed breast reconstruction is started after the initial surgical wounds have healed and may be the preferred option for women who require radiation therapy, which can delay healing or cause scarring if administered after a reconstruction.
Types of reconstruction
There are several types of breast reconstruction. The breast may be constructed with a breast implant or using a patient's own tissue or a combination of both.
Breast implants are usually saline-filled, silicone shells. Implants may also contain silicone gel but this is less common due to risk of silicone leakage. Implantation may be a one-stage procedure carried out at the same time as the mastectomy or a two-stage surgery carried out at a later date.
With the one-stage process, a breast implant is inserted into the space created where the breast was removed and a graft or mesh often used to hold the implant in place.
The two-stage procedure involves the creation of a pouch using an implanted tissue expander, much like a balloon, which is inserted under the skin and chest muscles. The expander is then gradually filled with small doses of saline solution injected over a period of around 6 months. Once the skin is adequately stretched, a second operation is performed to remove the expander and replace it with the permanent implant. Implants may need to be replaced every five to ten years.
Tissue flap procedures
For these procedures, a flap of tissue is taken from elsewhere in the body and used to recreate the shape of the original breast. Types of tissue flap reconstruction include:
TRAM flap (or transverse rectus abdominis muscle flap)
Skin and fatty tissue as well as muscle and blood vessels are taken from the lower abdominal area and used to create a new breast mound. Microsurgery may be performed to connect the blood vessels.
Latissimus dorsi flap
For this reconstruction, skin, fat, blood vessels and muscle are again used to form the new breast but the tissues are taken form the upper back.
The DIEP or deep inferior epigastric artery perforator flap
This procedure also involves taking tissue from the lower abdomen. However, only skin and fat tissue is removed and not muscle to create a "tummy tuck", with the muscle wall kept in tact and not weakened as it is in the case of a TRAM flap.
The tissues are taken from the buttocks including the gluteal muscle and may be the preferred option for women who do not want tissue removed from their tummy.
Inner thigh flap
The flap is derived from the area of tissue running from the bottom fold of the buttock through to the inner thigh. The procedure is also called the transverse upper gracilis flap or TUG flap. Women with thin thighs have little tissue here so the procedure is usually only an option for women whose thighs touch.
Nipple and areola reconstruction is a separate surgery to breast reconstruction and is usually performed after the breast has had time to heal. Ideally, the nipple will match the original shape, size, position and colour of the natural one and reconstruction may involve the use of tissues form other pars of the body along with tattooing to achieve the correct colour.
Reviewed by Sally Robertson, BSc