A comprehensive guide to breast construction

Breast reconstruction is something many patients may wish to explore after a mastectomy. In this article, Mr Venkat Ramakrishnan, a leading breast surgeon, explains the differences between the types of breast reconstructions.

 

 

A mastectomy is often employed for patients with breast cancer in order to remove all the breast tissue which contains cancerous cells, or for patients who are at high risk of developing breast cancer.

The procedure will render the chest flat where the breast or both breasts were before. In some cases, the nipples may be removed as well if the cancer has reached them, but sometimes they may be spared.

There are many ways to approach a breast reconstruction and many options that patients can explore regarding what kind of reconstruction, and when the reconstruction is performed.

The best kind of reconstruction for a patient will depend on: their overall health; the size and location of their breast cancer; their breast size before the mastectomy; if the patient is still to undergo further treatment; if there is a possibility for tissue from other places of the patient’s body to be used for reconstruction; if one or both breasts are receiving a reconstruction; the projected recovery time from the surgery; the patient’s willingness to undergo perhaps more than one procedure; and the desired aesthetic and tactile result of the reconstruction.

 

What can be used to reconstruct the breasts?

Breasts can be reconstructed using biological tissue or synthetic implants.

 

Flap procedures

Biological options are referred to as ‘flap’ procedures. This is because these procedures involve a technique where tissue is sourced from the patient’s own body in order to shape a new breast. The surgeon will mimic the remaining breast as much possible, or if both breasts have been removed in the mastectomy, then they will recreate the breasts based on patient specifications. The types of flap reconstructions are:

• Deep inferior epigastric perforator (DIEP), sourced from the abdomen.
• Transverse upper gracilis (TUG), sourced from the upper thigh.
• Lumbar artery perforator (LAP), sourced from the lower back.

Flap reconstruction can be preferable because it uses the patient’s own tissues so there is an organic element to it, and they will look and feel the most natural compared to an implant. The tissue will age and shift with weight, just like natural breasts, and there is no risk of puncture as with an implant.

However, flap procedures are more taxing on the body because of the expanded surgical site, so the recovery can take longer, around three months. There will also be more visible scarring, not just on the chest where the new breast is, but also from where the flap was taken. There may be some distortion, dimpling, and muscle damage at the flap site.

A flap reconstruction may not be possible if the patient is very skinny.

 

Implant reconstruction

Synthetic prosthetic implants are a good option for patients who have enough skin to cover the implant and want minimal scarring and a shorter recovery time. Breast implants vary in size, shape, profile, and texture, meaning that the implant does not need to match the patient’s breasts from before mastectomy – if they would like to go bigger or smaller, that is possible. Breast implants are typically made of silicone gel, so the feeling is not as natural as a flap reconstruction, but it is quite close. There is some risk of the body rejecting the implant because it is a foreign object, but this is very rare. Breast implants are not likely to last an entire lifetime, and so there may be need for a revision surgery in the future.

 

Sometimes, flap techniques and implants can be combined.

 

When is breast reconstruction performed?

 

Immediate reconstruction

Breast reconstruction surgery can be performed during the mastectomy itself, in what is called a one-stop operation or immediate reconstruction. Instead of sealing the chest cavity after the tissue has been removed, the cavity is immediately filled with the implant or the flap tissue. Some patients may need a mesh to be placed on the muscle wall to support the weight of the new breast.

An immediate reconstruction is beneficial for some patients because it prevents them from having to undergo more than one procedure and needing to go under anaesthesia and through the recovery process again (as it is combined into one). It also helps to avoid any mental duress that the patient may experience after a mastectomy.

However, an immediate reconstruction is not recommended for patients who are still undergoing breast cancer therapies like radiotherapy as the reconstructed breast may interfere with the treatment, or may become distorted during the course of it. The surgery itself is much longer, and recovery time, although one period, is still longer overall, at around eight weeks.

 

Delayed reconstruction

The alternative is a two-stop operation, or also known as a delayed reconstruction. When performing the mastectomy, the surgeon places a tissue expander in the chest cavity – this helps to preserve space for the implant or flap tissue at a later date. After their initial mastectomy, the patient will return to the surgeon every few weeks so that the cavity can be gradually expanded with air or saline until the desired size is reached, at which point the tissue expander is extracted and the implant is place or the flap procedure is performed. The recovery time is projected to be around a month.

The risk with a delayed reconstruction is the skin healing too much that there is not enough to stretch over the implant. Additionally, it can be quite traumatic for the skin and muscles to undergo multiple procedures, and scarring can be more extensive.