LMSSA(Lond), LRCP(Lond), LRCS(Eng), MS,FRCS
Consultant Oncoplastic Breast Surgeon
Breast reconstruction
I strongly believe in breast conservation wherever possible. In the case where breast conservation is not possible and a mastectomy is recommended as the best option for treating breast cancer, you will have the opportunity to consider having breast reconstruction. A simple mastectomy will leave a flat chest wall and breast prosthesis will enable you to have the appearance of natural breast in clothing and reduce the imbalance produced by surgery. Many patients, however, feel that simple mastectomy has a profound effect on them both physically and psychologically, and that flat chest is a constant reminder of their cancer experience.
In the majority of cases you will be able to have immediate breast reconstruction where a mastectomy is followed immediately by breast reconstruction during the same operation. Patients are often overwhelmed with the advice and the implications of breast reconstruction and find it very difficult to focus attention and understand the details of reconstructive surgery. I understand that dilemma, and always offer several sessions of clinical consultations and counselling before undertaking this surgery so every patient has the opportunity to have all their questions answered and is entirely happy with the decisions that they are making.
In some cases it is not possible to have immediate breast reconstruction for various reasons particularly where cancer treatment dictates this. In those patients the option of delayed breast reconstruction is offered where I perform breast reconstruction at a later stage following the completion of all your cancer treatment.
Types of breast reconstruction
There are two main types of breast reconstruction, Reconstruction using an implant or using your own tissue which is called “autologous reconstruction. In some occasions we may use a combination of the two.
1. Implant based reconstruction
Breast implants are used widely for both cosmetic and breast reconstruction purposes. They are Silicone gel filled implants and the safety of the implants we use has been verified and tested over many years and has the approval of MHRA and FDA.
The concept of implant based reconstruction is to create a pocket for an implant to be placed in after performing a mastectomy where some the skin (and sometimes the nipple is also preserved) of the breast is preserved. The implant is placed behind the chest wall muscle (Pectoralis major) which covers the upper pole of the implant. The lower pole of the implant is covered either by a portion of your own skin and fat with the top layer of the skin removed. This is called a dermal sling and is normally suitable for patients with large breasts where they have some redundant skin and the reconstructed breast has the appearance of breast uplift. In patients with moderate size breast the lower pole of the implant is covered by what is called “Acellular dermal matrix (ADM)” which is a biological mesh derived from animal skin or heart lining. It has been processed to make it completely safe to use in humans because it has been washed out from all its cells so it contains no cells but provides scaffolding for your body to build a layer of tissue on it.
The idea behind all this is that generally it is not possible to remove the breast and put an implant in under the skin. The implant will act as a foreign body, much like a splinter, and work its way out. The above mentioned techniques also provide an extra layer of tissue on top of the implant to give it more natural feel and appearance.
Patient who had double mastectomies and breast reconstruction using implants and a dermal sling
Before
After
Patient who had double mastectomies and reconstruction using and implant and ADM
Before
After
Implant based reconstruction tends to be a quicker operation (2-3 hours) compared to Autologous reconstruction (Tissue from own body 5-8 hours) and requires less time for recovery and less risk of needing subsequent surgery. However the reconstructed breast can feel cold sometime and have less natural feel. The implants I use have a very robust safety profile but all implants in general carry the risk of rupture (1% risk) and occasionally can lead to what is called capsular contracture where a tight fibrous capsule is formed by the body around the breast implant causing it to become less natural looking. This can be corrected by replacing the implant and removing part of this capsule surgically through the same scar.
2. Autologus breast reconstruction
This type of reconstruction involves moving some tissue (muscle or fat or both) from one part of your body and shaping it to resemble your breast. This often takes place following a mastectomy where a part of your skin is preserved. Reconstruction often takes place immediately at the same operation. I use a muscle form your back called latissmus dorsi which a large flat muscle on your back and swing it to the front and shape it to replace the breast. This leaves a small scar on you back where the muscle a taken from. This procedure is sometimes complemented by taking some fat from you abdomen or thighs (in a way similar to liposuction) and purified then injected into the reconstructed breast to enhance the volume and achieve better shame and cleavage. This procedure called lipofilling/Lipomodelling or fat transfer.
Patient had right mastectomy and reconstruction using LD muscle and lipomodelling (fat transfer)
Before
After
Another way would be to take a large amount of tissue including fat, skin and blood vessels from you abdomen and reconnecting the blood vessels into the chest wall. This is called a free flap or DIEP flap. This leaves a scar on the abdomen similar to the scar from a tummy tuck. This tends to give a more natural feel to the breast with no need to use breast implants.
Each type of reconstruction has its advantages and disadvantages and what suits one person may not suit another. Therefore I firmly believe that breast reconstruction should be tailored to each individual according to their shape, body habitus, and personal views.