Breasts are symbolic of a woman’s femininity and sexuality. Losing a breast due to cancer may have a devastating effect on a woman. Change in body image resulting from mastectomy is one of the most difficult psychological aspects of dealing with breast cancer. Breast reconstruction after a mastectomy has evolved over the last century. There is not only an increase in patient acceptance but also in popularity. Advances in well-established surgical methods and techniques have improved aesthetic outcomes and achieved a high level of satisfaction among woman opting for breast reconstruction. Woman with breast reconstruction have been reported to have an increase in self-confidence and emotional well-being.


What is Breast Reconstruction?

Breast reconstruction is performed through one or more plastic surgery techniques to restore a breast to near normal shape, appearance and size following a mastectomy (removal of the entire breast). The nipple and the darker area surrounding the nipple (the areola) can also be surgically reconstructed at a later stage.

The goals of breast reconstruction are:
• Restore absent breast tissue and provide permanent breast contour by the alternative use of breast implant and/or own body tissues (skin, muscle, fat) from another part of the body (flap reconstruction).
• Achieve good symmetry or balance with the contralateral breast


When can breast reconstruction be performed?

The timing of reconstruction depends on several factors including type and stage of breast cancer, the need for further treatment after surgery, age and general health status.

• Immediate breast reconstruction is done at the same time as the mastectomy. Both the breast surgeon and plastic surgeon will coordinate and plan before the surgery. A Skin Sparing Mastectomy is usually performed by the breast surgeon to accommodate the reconstruction. The advantage to this is that the patient wake up from surgery with a breast mound newly in place so that she will never experience a completely flat chest. The chest tissues are not damaged by radiation therapy or scarring. By having both mastectomy and reconstruction being perform together, it saves the patient from going through another anaesthesia and recovery a second time.

• Delayed breast reconstruction is performed as a separate operation after mastectomy. This is indicated for those patients who require radiotherapy and will have to wait for few months to let the skin in the treated area to recover completely before having breast reconstruction. Waiting a while before the reconstruction may also give patient time to come to terms with the emotional effects of the cancer and its treatment.


Breast reconstruction can be accomplished in three ways

1. Breast reconstruction with breast implant
2. Breast reconstruction with tissue flap
3. A combination of breast implant and body tissue reconstruction


Breast Reconstruction with Breast Implants

Silicone cohesive gel-filled implant usually is the choice of implant used as it has a natural feel and texture. This implant will be placed behind the skin and/or pectoral muscle to create a new breast mound. This method is suitable for patient who has a breast cancer that allows for a skin sparing mastectomy. Women with tight chest skin and muscles however, may need an expandable implant or a tissue expander, which is then followed by a permanent implant in a two-stage operation. An implanted tissue expander, which is like a balloon, is put under the skin and chest muscle. Through a tiny valve under the skin, the plastic surgeon injects saline at regular intervals to fill the expander over time (about 4 to 6 weeks). After the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant.

There are some important factors to keep in mind if the patient is considering of having breast implants reconstruction:
• Implants does not last a lifetime. There is a need to replace them every 10-12 years.
• Scar tissue may form around the implant and the breast may feel hard (known as capsular contracture).
• Not suitable if the patient requires radiotherapy after mastectomy.


Breast Reconstruction with Tissue Flap

In a flap reconstruction, the surgeon may be able to use patient’s own body tissue to make a new breast. Skin, fat and muscle are taken from another part of your body and made into a breast shape. The flap needs a good blood supply to survive. The surgeon will either leave the body tissue connected to its original blood vessels or will cut the vessels and reconnect them to blood vessels under your arm or in the chest wall.
If the flap stays connected to its original blood supply it is called a 'pedicled flap'. If the flap is connected to new blood vessels, this involves microsurgery and is called a 'free flap'.

Tissue flap procedures use tissue from the abdomen, back, thighs or buttocks to reconstruct the breast. The two most common types of tissue flap surgeries are the TRAM flap (Transverse Rectus Abdominis Muscle flap), which uses tissue from the abdomen, and the LD flap (latissimus dorsi flap), which uses tissue from the upper back. Pedicled flap from the back (LD flap) generally has less risk of complications than using a pedicled flap from the abdomen (TRAM flap).

TRAM flap (Transverse Rectus Abdominis Muscle flap) procedure uses tissue and muscle from the lower abdomen. The tissue from this area alone is often sufficient to shape the breast, and therefore an implant will not be necessary. The TRAM flap procedure can be done either as a pedicle door a free flap. An additional benefit is that the patient receives a tummy tuck at the same time!

LD flap (latissimus dorsi muscle flap) procedure involves the use of latissimus dorsi - a muscle in the back, under the shoulder blade. This muscle can be used without significant loss of function together with its overlying skin and still attached to its own blood supply – also called pedicled flap. The surgeon will then tunnelled it under the armpit (axilla) and move into the breast defect to form a new breast. Occasionally, when reconstructing a small breast, the volume from a LD flap alone will be sufficient without the need of an implant.


A Combination of Breast Implant and Body Tissue Reconstruction

In order to give the surgeon additional options and more control over the aesthetic appearance of the reconstructed breast, a LD flap (latissimus dorsi flap) is most commonly used in combination with breast implant. This flap provides the muscle and tissue necessary to cover and support the breast implant, thus helping to create a more natural looking breast shape. This method is often used when the patient has a larger breast and there isn't enough flap tissue to form a whole breast. Therefore an implant may be put behind the flapt to match the size of the other breast.


Nipple and Areola Reconstructions

Nipple and areola reconstructions are the final phase of breast reconstruction. Nipple can be created by using the tissue on the breast skin or by taking a small graft from the opposite nipple. The darker area surrounding the nipple – the areola can be created by a skin graft taken from the groin or labia region. Tattooing may be done to match the colour of the nipple and areola of the other breast. Nipple and areola reconstruction is usually done at the same time as the breast reconstruction.

 
Discussion during Consultation

During an initial consultation, Dr Fok will assess and explain which reconstructive options are best for individual patient based on their age, medical health status, the size of the breast, the amount of tissue available for a flap procedure, lifestyle, and goals. The options of breast reconstruction will be discuss in details so that the patient could learn more about the procedures. It is important that the patient understands and know about their treatment plan so that they can decide if the benefits will achieve their goals and if the risks and potential complications are acceptable.


What happens on the day of surgery?

Breast reconstruction surgery is done under general anaesthesia in hospital. Surgery duration depends on the timing of reconstruction – immediate or delayed reconstruction. Reconstructive procedures using tissues from another part of the body takes 4 to 6 hours and reconstruction with an implant takes about 2 hours. A small, thin tube may be temporarily placed under the skin to drain any excess blood or fluid. It will be removed before discharge from the hospital. The patient will need to stay in hospital for 3 to 4 days. Sutures will be removed between 10-14 days after surgery. Patient may require to wear a support garment for about 3 weeks.


What to expect during the recovery phase?

Generally, we encourage patient to sit out of bed and walk around in the ward on her first to and second post surgery day. The sooner she is up and slowly moving around, the sooner she can go home and resume normal daily activities. Some stretching exercises and getting back mobility in the arms will aid in relieving the tightness in the chest and speed up the healing process. They should avoid lifting heavy objects and strenuous sports for 4 to 6 weeks after reconstruction. The scars are initially reddish in colour but will improve and lighten over time. There are usually some numbness on the chest and the area which the flap was taken. This will gradually decrease in the next 3 to 6 months. Healing will continue for several weeks as swelling decreases and breast shape and position will improve.


What are the risks and complications involved?

Risks and complications of breast reconstruction can include:
• Bleeding
• Infection - This is a possible complication following any type of surgery. If it happens, additional course of antibiotics will be prescribed to get rid of the infection.
• Collection of fluid under the wound - Sometimes fluid continues to collect near the wound after your wound drains have been taken out. This is called a seroma. The fluid usually goes away on its own. Sometimes it has to be drained off with a needle and syringe.
• Pain and discomfort - After any type of operation, you are likely to have some pain and discomfort. It varies from patient to patient. Some will need painkillers for a couple of weeks or so after surgery. Patient may also feel uncomfortable to move their arm on the side where surgery has been done. This is particularly likely if they have breast reconstruction at the same time as surgery for breast cancer and have some lymph nodes removed from your armpit. It is important that they continue using your arm and do stretching exercises everyday after the surgery.
• Delayed or incomplete healing due to previous surgery, chemotherapy, radiation, smoking, alcohol, diabetes, various medicines and other factors
• Scars - excessive scar tissue and keloid formation
• Complications at the donor sites for flap procedures, including abdominal hernias and muscle damage or weakness
• Differences in the size and shape of the two breasts. Additional surgery may be recommended for the contralateral breast to improve symmetry to match the reconstructed breast. This could include reducing or enlarging the size of the breast, or even surgically lifting the breast.
• Lack of normal breast sensation. Breast reconstruction restores the shape, but not feeling in the breast. With time, the sensation on the reconstructed breast may return but it will not feel the same as it did before your mastectomy.
• Swelling in the arm (lymphedema). This is normal but it should start to go away once the patient starts to do some exercises to get back the movement of the shoulder and arm.
• Tissue death (necrosis) of all or part of the flap
• Problems with anesthesia