Breast Reconstruction after Mastectomy can be performed using a variety of techniques, using a woman’s own tissue or using prosthetic breast implants.
The type of technique available to each patient is dependent on multiple factors, these include patient preference, previous surgery, radiotherapy, body habitus and other health issues.
If you are considering breast reconstruction Dr O’Mahony can discuss with you which options are available, taking into account your specific circumstances.
Dr O’Mahony understands that you have breast cancer or have been advised to consider a mastectomy to reduce your risk of breast cancer, it is a very difficult and confronting time. The amount of information to digest and the decisions to be made regarding cancer surgery, reconstruction and any future treatments can seem overwhelming. The information below may be a helpful guide.
Timing of Breast Reconstruction
The timing of Breast Reconstruction is dependent on a number of factors such as the type of reconstruction planned, the need for further cancer treatment such as radiotherapy, smoking, body habitus and a woman’s general health status.
Many women who are considering mastectomy will be understandably anxious to have their breasts reconstructed as soon as possible. In many cases an immediate reconstruction will be possible and successful, however Dr O’Mahony will advise some women to delay reconstruction for a number of months, for the reasons such as those mentioned above. Whilst this may seem disappointing at first, in all cases it is important to look for the end result to be as successful as it can be, with the risks of surgeries minimised as much as possible.
Prophylactic Breast Reconstruction
Some healthy women who have a high risk of breast cancer due to the BRCA1, 2 or other genes may elect to undergo mastectomy to manage this risk. The recent media attention given to high profile figures, such as Angelina Jolie, who have chosen this path has increased community awareness of prophylactic breast reconstruction.
Women who are considering prophylactic treatment should first visit a Breast Cancer Surgeon to discuss their individual risks and the relative benefits of mastectomy, and secondly a Plastic & Reconstructive Surgeon such as Dr O’Mahony to discuss what options are available to them for breast reconstruction.
Breast Reconstruction using your own tissue
Using your own tissue to reconstruct a breast has many benefits, and avoids the need for prosthetic material. However, the procedures are very complex, with more lengthy surgical and recovery time.
The most common procedures are the TRAM Flap (Transverse Rectus Abdominis Muscle) or DIEP (Deep Inferior Epigastric Perforator) Flap. These procedures are quite similar and both use skin and fat from the abdomen to reconstruct the breast. The TRAM flap also takes some abdominal muscle, whereas the DIEP flap spares all muscle but is only suitable for patients with a specific pattern of blood vessels supplying the skin of the abdomen. In both flaps the tissue is transplanted from the abdomen to the chest, and rejoined to the body by microsurgically joining it to blood vessels in the chest behind the ribs.
In general this procedure is suitable for patients who have sufficient lower abdominal fat to make a breast, have had no major abdominal surgery in the past, are non-smokers and are in good overall health.
On average the hospital stay is 1 week, with up to six weeks recovery at home and up to 3 months before you would feel back to your normal self.
Breast Reconstruction using implants
Implant based reconstruction has the benefit of being a shorter and less physically invasive surgery, although it is usually undertaken in 2 stages, taking the final result longer to achieve.
The first stage of surgery involves placing a deflated, or empty silicon prosthesis called an ‘Expander’ behind the pectoral muscle in the chest. Two weeks following surgery Dr O’Mahony starts to inflate this expander by injecting fluid through the skin directly into the expander. Expansions are simple to undertake in the office, and performed weekly until there is sufficient volume of skin and muscle created to fit a formal prosthesis and make a breast of the desired size. A new form of expander that uses air rather than fluid to expand the prosthesis may be available to suitable patients and Dr O’Mahony can explain the relative benefits of both styles to you. Once the skin has settled from the expansions a second operation is undertaken to replace the expander with a formal breast shaped silicon prosthesis.
In general this procedure is suitable for slim patients with insufficient tissue of their own to make a breast. It is also suitable for those who do not wish to undergo such a lengthy and involved reconstruction as a TRAM/DIEP flap or do not wish to have scars elsewhere on their body. It is not suitable for smokers or those who have undergone radiotherapy to the breast.
Both procedures require a hospital stay of up to 1 week, but you could return to work 2-3 weeks after the first and 2 weeks after the second procedure. The overall time taken to complete the reconstruction with the 2 procedures and the expansions is at least 3-4 months.
Breast Reconstruction using a combination of tissue and implants
In patients who have had radiotherapy to the breast, implant reconstruction alone can carry a risk of postoperative complications of up to 50%. This is due to changes in the skin, chest and breast tissue caused by radiotherapy, including a reduced blood supply and fibrosis, or stiffness of the tissue.
In patients who are unsuitable for or wish to avoid a TRAM/DIEP flap and would otherwise choose implant based reconstruction, a healthy muscle must first be moved into the chest in order to protect the implant. In these ladies the Latissimus Dorsi (LD) muscle flap is transferred from the back, through the armpit and into the chest to line the space for the expander and implant with healthy tissue. In most cases Dr O’Mahony will still use the 2-stage expander and implant approach in ladies who have an LD flap.
This procedure is usually reserved for those who have had radiotherapy, and do not need their LD muscle to be preserved (rock climbers or wheelchair users cannot usually spare their LD muscle). In some rarer cases women have sufficient fat over the LD muscle to make a breast without the need for an implant, and in those women this procedure can also be used as an alternative to the abdominal flaps.
The LD plus expander surgery requires two hospital stays of up to 1 week for both the first and the second stages. The overall recovery and time off work is approximately 4-6 weeks for the first procedure and 2 weeks for the second.
Nipple and Areola Reconstruction
In some circumstances the breast cancer surgeons spare the nipple and areola, but this is a decision taken between the patient and the Breast Cancer Surgeon who can best advise on the relative risks of this approach.
If removed, the nipple and areola are not reconstructed at the same time as the breast. If a woman wishes to proceed with nipple reconstruction it can be undertaken using the local breast skin 6 or more weeks after the breast reconstruction, usually as day surgery under local anaesthetic. Recovery from nipple reconstruction is very straightforward, although a bulky dressing protecting the new nipple for a few weeks can be tricky to camouflage in some clothing.
The pigmented areola can be tattooed around the new nipple anytime from 6 weeks after its creation. This is only requires anaesthetic cream and the tattoo is performed in Dr O’Mahony’s office.
If you would like more information or arrange a consultation with Dr. O’Mahony, please contact us for an appointment.