Delayed Breast Reconstruction

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Delayed reconstruction may be better for you if:

  • you feel more comfortable waiting until you recover from your first surgery to remove breast tissue.
  • the timing doesn’t allow it
  • you are having other treatments
  • you feel rushed and uncertain

If you are uncertain about whether to have reconstruction, your surgeon might be able to have an expander placed at the time of your mastectomy to preserve your skin in preparation for a future procedure.

Whether to have an immediate or delayed reconstruction is a very individual decision with many different factors to consider when making the choice that is best for you. Talking to other women who have been through reconstruction can be beneficial in understanding the options available and how each of those options might impact on your particular circumstances.

Implant or Flap Reconstruction:

There are two main techniques for reconstructing your breast:

  • Implant Reconstruction: the most common form of reconstruction, which involves inserting a silicone gel or saline implant under the chest muscle to create a breast mound. There are two methods for implant reconstruction; One Stage or Two Stage reconstruction [Implant Options]
  • Autologous or “Flap” Reconstruction: this type of reconstruction uses your own body tissue to create a new breast. Fat, skin and blood vessels, and often times muscle, are taken from another part of your body (usually the abdomen, back, buttocks or inner thighs) and moved to the chest to form a new breast. Some Flap reconstructions, such as the Latissimus Dorsi Flap method, use both tissue and an implant to create a new breast [Flap Options].

Considerations:

The main advantages of implant reconstruction include:

  • a shorter, less complex operation
  • recovery time is quicker than any other types of reconstruction
  • no extra scars as the surgeon uses the existing mastectomy
    incision
  • allows the volume (size) of the new breast to be adjusted
  • can give a good appearance, particularly for women with small
    breasts, or women having both breasts reconstructed
  • is more accessible, as more surgeons and hospitals offer this
    procedure.

The main advantages of Flap Reconstruction include:

  • a softer, more natural feel and appearance
  • the breast will age with you, maintaining better symmetry
    overtime
  • as your body gains or loses weight, your new breast will also gain
    or lose weight
  • a larger range of breast sizes can be created
  • radiation therapy is better tolerated
  • reduced fat and skin on the abdomen, looks like a “tummy tuck”.

The main disadvantages of implant reconstruction include:

While the initial surgery and recovery may be quicker than other types
of reconstruction, the overall reconstruction process can take longer
(with multiple steps, including multiple doctor’s office visits to receive
tissue expander injections and replacing the expander with a permanent
implant). In addition;

  • implants don’t feel as soft or as warm as a breast formed using
    your own tissue
  • if you are having a unilateral reconstruction (one breast only), the
    new breast may not have the same droop as the natural breast
    and can sit higher than your natural breast
  • the implant can change shape slightly when the muscle over the
    implant tightens (contracts) during some movements
  • the cosmetic outcome may be compromised by radiation therapy
  • you may need surgery in the future to keep your breasts looking
    balanced (symmetrical) as, over time, the natural breast may
    droop more than the new breast
  • if you lose or gain a lot of weight, the implant may no longer
    match the other breast as it will not change size
  • you may need surgery to replace implants if they dislodge,
    wrinkle, deflate, leak (rupture) or cause tightening of the scar
    around the implant
  • implants usually need to be replaced in 10-20 years.

The main disadvantages of Flap Reconstruction include:

  • more complex, longer operation with a risk of more complications
  • longer recovery period
  • extra scars on the body where the tissue has been taken
  • the donor sites (e.g. abdomen) may be compromised in strength
    and/or appearance after surgery

Nipple Reconstruction:

If the nipple and areola are removed during your mastectomy, it is possible to create a new nipple using either a small flap of skin and tissue from your reconstructed breast or by taking a small skin graft from the end of a reconstruction scar (e.g. from the abdomen or back).

Nipple reconstruction can be done at least 3 or 4 months after breast reconstruction surgery has been completed – in order to allow the reconstructed breast time to heal and settle into place.

Tattooing can be done from 3 months after your nipple has been reconstructed.

The reconstructed nipple will not feel or respond as it did before your mastectomy. The aim of nipple reconstruction is simply to mimic the look of a natural nipple and give the newly reconstructed breast a more regular appearance.

All nipple reconstruction loses some projection as part of the normal healing process. However, if the nipple flattens more than expected, your surgeon may have to redo the reconstruction and reinforce the nipple with a graft of scar tissue, fat, or dermal matrix material.

For some women, having a nipple reconstruction is important as it marks the completion of their reconstruction journey, but others are happy with the look of their new breast without a nipple. For those women who do not want further surgery but would like to have the appearance of a nipple, there are several options including; getting a 3D tattoo, using nipple prostheses or temporary nipple tattoos.

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Flap Options

Flap Reconstruction involves either:

  • The tissue being completely cut from its original blood
    vessels, picked up and moved to its new place in your chest.
    This is referred to as a free flap.
  • Or, the tissue can remain attached to its original blood
    vessels and moved under your skin to your chest. This is
    referred to as a pedicled flap.

In both types, the tissue is formed into the shape of a breast and stitched into place.

Because pedicled flaps have been around longer and are easier to do, they tend to be more widely available. Free flaps require your plastic surgeon to have skill in microsurgery, which involves attaching the blood vessels from the tissue flap to the vessels in the chest area so that the new breast gets sufficient blood supply. Not all surgeons are trained in this type of surgery.

The most common tissue flap techniques are:

DIEP Flap: DIEP stands for deep inferior epigastric perforators, which are the blood vessels within the abdomen. In this technique fat, skin and blood vessels, but not muscle, are cut from the wall of the lower belly and moved up to the chest to recreate a breast shape (a Free Flap).

Because no muscle is used in a DIEP reconstruction, most women recover more quickly and have a lower risk of losing abdominal muscle strength. The operation is, however, long and very complex, and so recovery time is usually also longer than a reconstruction using an implant. Because this procedure requires special surgical training as well as expertise in microsurgery, not all surgeons can offer DIEP and it is not available at all hospitals.

TRAM Flap: TRAM stands for transverse rectus abdominis muscle, a muscle in your lower abdomen between your waist and your pubic bone. A flap of this skin, fat, and all or part of the underlying rectus abdominus (“6-pack”) muscle are used to reconstruct the breast and may use either a Free Flap or a Pedicled Flap technique.

TRAM Flaps are the most commonly performed type of flap reconstruction as the tissue is very similar to breast tissue and makes a good substitute. The technique has also been around for some time, and many surgeons know how to do them. The main disadvantage is that this technique does cut through muscle, with a higher risk of compromising abdominal muscle strength.

Latissimus Dorsi Flap: In this technique, the surgeon uses a large muscle in your back (the Latissimus Dorsi) to reconstruct your breast. It involves moving an oval flap of skin, fat, muscle and blood vessels from your back to your chest to form a new breast “mound”. The flap is moved under your skin and put into position on your chest.

An implant is almost always required under the flap to make your breast large enough to match your remaining breast and achieve the desired shape, size and projection.

Latissimus Dorsi reconstructions can be performed at most major public and private hospitals in Australia and is a technique that most plastic surgeons can perform.

The new Scarless Latissimus Dorsi procedure currently being pioneered in Western Australia allows the patient’s muscle flap to effectively be used without the additional scarring on the patient’s back.

Other types of tissue flap reconstructions include:

SIEA Flap: SIEA stands for the superficial inferior epigastric artery blood vessel that runs just under your skin in your lower abdomen. This technique is very similar to a DIEP flap, except that a different section of blood vessels in the belly are moved with the fat and skin.

TUG and PAP Flaps: Flap reconstruction using tissue from your thighs.

I-GAP and S-GAP Flaps: Flap reconstruction using tissue from your buttocks.

The physical effects of each type of flap reconstruction are highly individual to your body, your range of motion, your physical strength and your normal activities. It is important to discuss how the reconstruction procedure you are considering may impact on your lifestyle and what can be done to improve any loss of strength or motion.

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Risks:

As with any surgery there are risks that need to be weighed up against the proposed benefits. Your surgeon should discuss these risks, as well as the general surgery risks with you well before you book in for your procedure.

Some of the main risks associated with flap reconstruction are:

  • Tissue breakdown: The flap needs a good blood supply to survive, but in rare instances, the tissue moved from the donor site to your breast area won't get enough circulation and some of the tissue might die. If this happens, the entire flap would need to be removed and replaced. Sometimes the flap can be replaced within a short timeframe, but in most cases the surgical team will remove all the dead tissue and allow the area to heal before identifying a new donor site to create a new flap.
  • Lumps in the reconstructed breast: If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. They may go away on their own but if they don't, they may have to be removed surgically.
  • Seroma or build up of fluid: Fluid may collect at the flap site, or in areas such as under the back wound (with a Latissimus Dorsi reconstruction). Depending on the amount of fluid, it may naturally drain away, or it may need to be syringed by the surgeon or another skilled health professional.
  • Hernia or muscle weakness at the donor site: A hernia happens when part of an internal organ (often a small piece of the intestine) bulges through a weak spot in a muscle. Hernias usually happen when someone who has a weak spot in an abdominal muscle strains the muscle, perhaps by lifting something heavy. Your risk of hernia is much lower with a DIEP flap or muscle-sparing free TRAM Flap than with any other type of TRAM flap. Still, as with any abdominal surgery, there is some risk of hernia with all reconstructions using abdominal tissue.

    If you have had a Latissumus Dorsi reconstruction, you may have some weakness in your back, shoulder, or arm because some of your back muscle used to build your new breast. You may have partial loss of strength or function that makes it hard to lift things and twist. This can affect your ability to perform certain swimming, golf, or tennis stokes, or to turn and manipulate objects.

  • Abdominal wound infection and dehiscence: Any infection may be treated with antibiotics. In rare cases, the skin of the lower abdomen completely breaks down and requires repeated visits to the theatres for debridement of the non viable tissue.
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Preparing for Surgery:

  • Smoking increases the potential for serious risks. It is advised that you plan to give up smoking and any nicotine therapy at least 2 months before surgery
  • You may be advised to stop taking certain medications such as nonsteroidal anti-inflammatory drugs (NSAIDS), aspirin, or other aspirin-like medications that may interfere with blood clotting for a brief period before your surgery
  • You may also be asked to stop taking naturopathic substances such as garlic, ginko, ginseng and St John’s Wort, as they may affect clotting and anaesthesia. Be sure to tell your surgeon and anaesthetist everything you are taking and take their advice before stopping any medication
  • Avoid excessive alcohol prior to surgery
  • Eat a well-balanced diet, including plenty of foods rich in vitamin C, which may help promote tissue healing
  • Exercise regularly to build energy, improve fitness and maintain strength
  • Ready your home, including preparing food and rearranging furniture if necessary
  • If necessary, arrange for someone to take care of your children while you are in the hospital
  • Make sure a relative or friend will drive you to and from the hospital. You will not be able to drive for a few weeks and should only consider doing so when you have healed sufficiently
  • You should not be alone for at least 24 hours after you arrive home
  • Arrange for help with shopping, housework and caring for any small children as you will be unable to do any heavy lifting or strenuous activity for several weeks
  • Some women have found it helpful to do something special before their surgery to remember their pre-surgery bodies. Sensitively taken photos or breast memory casting might help you to prepare to lose your breasts.

Recovery:

  • Your surgeon will provide you with advice on caring for your new breast, when you can shower or bathe, as well as how to look after any drains that may be still in place when you are sent home. Drainage tubes remove -fluids that collect in the surgical site. The drainage tubes remain in place until the amount of -fluid draining substantially decreases.
  • A surgical support bra may be worn to help reduce swelling and support the reconstructed breast. An abdominal binder or compression clothing may be recommended to help support the donor site (e.g. abdomen). You may need to wear these for several weeks.
  • You may be prescribed painkillers, antibiotics and anti-inflammatory drugs when you are first discharged from hospital. It is vital to use these as prescribed to successfully manage any pain and to reduce the risk of infection.
  • Post-operative recovery can take longer if complications occur, so it is important to get adequate rest, make sure you follow your surgeon’s directions and exercise within the limits of comfort – if you feel any pain or pulling, especially around the wound sites, stop.
  • It is normal to feel tired and sore after your surgery. Generally it is advised not to swim, play sports, exercise or do any heavy lifting for a few weeks (depending on your reconstruction choice). Your Specialist Plastic Surgeon will prepare detailed instructions on post-operative care - make sure you follow these carefully. If you are having difficulty regaining strength or motion, some physiotherapy sessions may assist.
  • It can take up to twelve months to completely heal and for scars to fade and for you to get a good indication of how your new breast will settle into your body. You might feel further surgery to refine the shape of your new breast mound is necessary, but this is a personal choice. Revision surgery can take place anytime from 3 months post-reconstruction. At this time, you may wish to consider having a nipple reconstruction, or nipple tattoos, to create a more realistic looking breast.

Implant Reconstruction

Implant reconstruction is the most common form of reconstruction and is available at many public and private hospitals throughout Australia. Implant reconstruction involves inserting an implant under your chest muscle to recreate a breast shape and may be done either at the same time as your mastectomy (immediate reconstruction) or some weeks, months, or even years after your mastectomy (delayed reconstruction).

Although implant reconstruction has been around for many years, there have been many advances in the products and techniques available in recent years to improve both the aesthetic outcome and the process of breast reconstruction.

There are two methods for implant breast reconstruction:

One Stage: This method is suitable for selected women who have had skin and nipple-sparing mastectomies and are seeking immediate reconstruction. This option may be especially beneficial for women who are having bilateral prophylactic mastectomies.

The aim of this technique is to achieve reconstruction in one-step through the use of a specialised surgical mesh (Acellular Dermal Matrix) to create a secure pocket within the chest that supports and cradles the implant. After your mastectomy, when the breast tissue has been removed by your breast surgeon, the reconstruction surgeon will place both the mesh and the implant into your chest. As your surgeon can manipulate the implant position within the sling, the result is a more natural looking breast.

Many one-stage immediate breast reconstruction surgeries involve the placement of an adjustable implant which can be expanded post-operatively over a period of several months, until the desired size is achieved.

Two Stage: This more traditional method can be used for both immediate and delayed reconstructions. In the first stage of this procedure, your reconstructive surgeon places a tissue expander between the skin and chest muscle after all the breast tissue has been removed. A tissue expander is a silicone balloon which is used to expand and grow your skin to make room for the final implant. The expander has a valve that allows the surgeon to add increasing amounts of saline (a salt water solution) over time (between 2 to 6 months) until the skin gradually is stretched enough to accommodate the implant.

The second stage of the procedure is the exchange of the tissue expander for the permanent implant. Once the skin has been stretched to achieve the desired breast size, an operation is required to place the permanent implant.