Reconstruction

What is a breast reconstruction?

Breast reconstruction is an operation to recreate the shape of the breast after mastectomy (removal of a breast), or partial mastectomy / wide local excision (removal of part of the breast).  Reconstruction can be carried out at the same time as the initial surgery (immediate reconstruction) or months or even years later (delayed reconstruction).

The aim of breast reconstruction is to match the remaining natural breast in size, shape and position as closely as possible.   This can either be done by creating a breast with an implant, which is put underneath the skin and sometimes muscle that covers your chest, or by using skin and fat (and sometimes muscle) from another part of your body. A combination of these techniques may be used for some women.

Your surgeon will advise you on the type of reconstruction that is most appropriate for you. It will depend on:

• the amount of breast tissue that has been removed

• the healthiness of the tissue at the planned operation site

• whether or not you have had radiotherapy to the area of the breast or chest wall

• your general health and body build

• your wishes and lifestyle.

A reconstructed breast will not have the same feelings of sensation and many have no feeling at all.  Your new breast may also be firmer and sit higher than your natural breast and there will be some scarring which will fade with time.  Occasionally surgery on the remaining breast is recommended to achieve symmetry.

It is possible to create a new nipple at the same time as breast reconstruction or more commonly in delayed reconstruction during further surgery at a later date.  Prosthetic stick on nipples are also available. 

Why have a breast reconstruction?

Total or partial removal of the breast for breast cancer is likely to affect how you feel and look to some extent.  Many women wish to address the loss of one or both breasts by undergoing reconstructive surgery or using an external prosthesis.  Each woman is different and therefore making an informed choice which achieves the right outcome for you  is important.  For many women the use of a prosthesis is unacceptable and you may wish to restore your breast to improve your body image and well being.

Types of breast reconstruction:

There are three main types of breast reconstruction:

• Reconstruction using an implant.

• Myocutaneous flap reconstruction, where the muscle and /or fat and skin from your back or abdomen (tummy) is used to create a new breast. In the pedicled flap, the muscle and/or fat and skin stays connected to the area of the body from which it was taken. In the free flap, they are detached and the blood vessels reattached under the microscope.

• Perforator flap reconstruction, in which skin and fat from your lower abdomen, buttock or inner thigh is grafted to the breast area. The skin and fat is completely removed from the original area and a new blood supply is created for the new breast tissue using microsurgery.
   

This kind of reconstruction is a relatively simple procedure and involves placing a silicone or saline filled implant beneath the muscle of the chest immediately after the mastectomy has been performed. The scar from this type of operation is usually side-to-side or at an angle following the line of the original mastectomy scar.

Implants may not give a very good appearance compared to the other remaining breast, as the new breast will not have its normal droop and can look higher. Therefore surgery to the remaining breast may be required. However, this sort of reconstruction gives a better result if both breasts are being removed (bilateral mastectomy and reconstruction).

It is important that you are aware that implants are man-made and therefore will need replacing at some point. 

Using tissue expansion:

Breast reconstruction involving tissue expansion may be required if the skin is too tight post mastectomy and can give very good results and avoids the need for the extensive surgery involved in using tissue flaps.

An expandable implant (like an empty balloon) with a valve for filling it is put under the chest muscle. This is expanded over a few months by injecting sterile salt water (saline) into the implant through a valve just under the skin. This is done weekly or fortnightly at the outpatients clinic. The process continues until the size is slightly larger than your other breast.

After several months the expander is taken out during a second operation and replaced with a permanent implant. The implant, usually made of silicone, matches the size of the other breast and the previous over-expansion allows the breast to droop with a more natural appearance.

Another type of reconstruction using tissue expansion uses a permanent expander implant which again is overinflated and then the excess fluid and valve is removed leaving the expander in the breast.  This is then a mixture of silicone and saline.

Patients with skin damaged by radiotherapy or who have very thin skin are not suited to tissue expansion as the skin will not stretch.

What are implants made of?

Breast implants have an outer silicone shell and may contain silicone gel or saline.

Saline

Saline (salt water) has the advantage of not causing any problems if it leaks out into the body. However, saline-filled implants do not have the natural feel of silicone-filled implants and give a less realistic reconstructed breast. Saline implants are more likely to leak or wrinkle than silicone implants.

Silicone

Silicone implants are very commonly used in the UK. These implants are essentially bags of silicone gel enclosed in a thin silicone rubber case. They are designed to feel soft and flexible like a natural breast and there are many different types. They can be breast-shaped or rounded and filled with solid or liquid gel.

Flap reconstruction:

This type of breast reconstruction uses areas of muscle, skin and fat (known as flaps), which are usually taken from the back or abdomen (tummy). These areas of the body contain very large muscles,which give enough skin, fat and muscle with a good blood supply to create the shape of a breast on the chest wall.

This type of surgery is appropriate for women who have large breasts and who have had a total mastectomy, are unable to undergo tissue expansion due to skin damage from radiotherapy.  Whichever type of procedure is used, women with very large breasts usually need to have surgery to reduce the size of the remaining breast.

Back (Latissimus Dorsi) Flap:

This type of operation involves moving a flap of fat and overlying skin from the back of your body. The flap of skin and underlying fat stays connected to the muscle in the back (latissimus dorsi).

Often, there is not enough tissue to form a whole breast, so an implant may be put behind it to match the size of the other breast.  This type of operation leaves scars both from where the skin and muscle flap is taken and on the reconstructed breast.

Pedicled TRAM (transverse rectus abdominis muscle) Flap:

A flap of fat and some muscle, with its overlying skin, is taken from the abdomen. It is then rotated (with its blood supply from the abdominal muscle), tunnelled upwards from the abdomen and put on the chest wall to create the shape of a breast. This method usually gives enough tissue to match the remaining breast, so an implant is not usually needed.The scar on the abdomen is usually horizontal and just below the bikini line. During the operation the belly button (umbilicus) is repositioned.

Advantages and Disadvantages:

Breast reconstruction using muscle, fat and skin flap rotation, from the back or abdomen, is a major operation and needs a hospital stay of at least one week. Using a flap from the back generally gives less risk of complications than using a flap from the abdomen but an implant is often needed.  You may also experience weakness around the shoulder joint post operatively and may require physiotherapy.

The TRAM flap can only be used for women who are slim, in good health and do not smoke. After the muscle of the abdominal wall has been removed there will be some reduction in abdominal strength and often a mesh is used to reinforce the abdominal muscles to prevent hernias occuring.

The above techniques involve moderately long operations of approximately 3-4 hours and a 5-6 day stay in hospital.

The free tram flap:

This involves taking a flap of skin, fat and some muscle with blood vessels from the abdomen, detaching the flap and reconnecting the vessels to the chest. The advantage over the pedicled TRAM is that it is a safer flap, more tissue can be used and so a larger breast can be created.  It does involve microsurgery and takes longer.

Perforator flap reconstruction:

In Perforator reconstruction, areas of fat and skin from one part of the body are moved to another. The blood supply is cut and then a new blood supply for the flap is created at the area of the breast. These techniques involve microsurgery (rejoining arteries and veins that are only 2-3mm in diameter, using an operating microscope). Blood vessels from the armpit, or near the breastbone, are used to create a new blood supply for the tissue that has been moved to the breast.

Free perforator flaps are flaps of skin and fat with an artery and vein for blood supply. No muscle is taken. These operations are usually done by plastic surgeons, either at the time of the initial breast surgery or some months later. Most plastic surgeons advise delaying a perforator flap reconstruction if radiotherapy is planned, as the radiotherapy can change the appearance of the reconstruction.  These operations take 6-8 hours if only one plastic surgeon is involved and need a hospital stay of about a week.  The success rate for these types of procedures can be very high. 

There are now several types of perforator flaps. They are named after the blood vessel that is used.

DIEP flap (Deep Inferior Epigastric Perforator flap) or the free SIEA (Superficial Inferior Epigastric Artery flap)

Skin and fat is taken from the lower abdomen, but no muscle is taken. Instead the tiny blood vessels are very carefully cut out from the muscle, which is left in the abdomen. The appearance of the new breast is usually very good and it feels natural. As no muscle is taken from the abdomen, the risk of hernias is almost completely removed and no mesh is required to reinforce the abdomen.  The patient also benefits from a "tummy tuck" restoring the contour of the abdomen.

Free SGAP flap (Superior Gluteal Artery Perforator flap) or the IGAP flap (Inferior Gluteal Artery Perforator flap)

This uses fat and skin taken from the upper or lower buttock to create a new breast. It is generally used when abdominal tissue cannot be used due to scarring from previous surgical procedures or because the woman is too slim. The IGAP flap gives a softer feeling to the breast than the SGAP flap. The IGAP flap allows a larger breast size to be created and the scar is hidden in the crease of the buttock.

Flaps taken from other areas of the body

In very rare situations it may be possible to take flaps from other areas of the body where there is enough fat and a suitable blood supply.

All types of perforator flap reconstruction produce a very natural and permanent reconstruction.  They are however unsuitable for obese patients, diabetics or smokers.

Nipple reconstruction:

If the nipple has to be removed during mastectomy or lumpectomy and it is not possible to graft the nipple on to the breast during the immediate reconstruction, it is usually possible to have a nipple made later. This is usually done some time after the breast reconstruction has healed and settled into its final shape and position. This enables the surgeon to position the nipple accurately, in line with the one on your other breast.

Various techniques may be used for nipple reconstruction. Surgery using a local skin flap generally creates a nipple shape on the breast. This can usually be done as day surgery under local anesthetic. Six to eight weeks later the nipple and areola are tattooed to give the right colour.  The nipple may be reconstructed from grafted skin tissue, taken from other suitable areas of your body. Two areas that may be used are the nipple and areola from the remaining natural breast and the top of the inner thigh, where the skin is darker in colour.

It is important to be realistic about what to expect from a reconstructed nipple -it will not behave in the same way or have the same sensation as a natural nipple.

Nipple tattooing:

Following breast reconstruction a new areola (the coloured disc surrounding the nipple) can be created using a technique called "intradermal micro pigmentation" - tattooing! Many women find this procedure enhances the reconstruction making it appear "finished".

A trained practitioner will carry out the procedure approximately 6 weeks after a nipple reconstruction.  Many women will need no anesthetic at all, some require local anesthetic cream and in the most sensitive cases an injection of local anesthetic will be offered.  The procedure will take about 30-40 minutes during which a semi-permanent pigment is injected under sterile conditions to prevent infection.  The exact colour will depend upon your skin tone and the amount injected will vary slightly from person to person.  A dressing will be applied over the tattooed area and can be removed after 2-3 days.  Your practitioner will give you aftercare instructions.  Sometimes the procedure will need to be repeated and a couple of coatings will usually last 18 months to 2 years.  In some cases the opposite nipple will need to be tattooed to obtain a good match.

Some women choose not to have their nipple reconstructed and in these cases tattooing can create the illusion of a nipple.  Some women may opt to have a prosthetic nipple and others nothing at all.

Weight Loss Surgery Support Group

With – Dr. Faisa Al Bashar 

Come Join Us!

Whether you are just exploring the idea of Weight Loss Surgery or you've already had it, come and join the Dubai / Abu Dhabi Support Group. This group is for residents of the U.A.E. but anyone interested in WLS issues are invited to join.

Our mission is to provide pre-op and post-op information as well as support for all types of Weight Loss Surgery - Roux-en-Y Gastric Bypass, BPD, Gastric Banding, Fobi Pouch, etc.  Also to offer a safe place to discuss personal issues regarding obesity, Weight Loss Surgery and related topics. (your support person is welcome too!)

If you are interested in joining us, Call Jenny at 00971504467321 email: contact@dubaisurgery.org for the date, time, and location of our next coffee meeting.  Hope to see you there!

Jenny King MBE MA (UK) and Dr.Al Bashar – FRCS (UK) Bariatric Surgeon