When considering breast reconstruction it is important to consider what defines the desirable breast. There are four important parameters which define the beauty of a breast:
- Location on the chest wall
- Proportions of the breast in relation to the torso
- Aesthetically pleasing shape
- Symmetry of both breasts in volume and shape
When is the best time to perform breast reconstruction surgery?
The best timing for this procedure is something we will discuss at length. In some cases, it is possible for your reconstructive surgery to be conducted at the same time as your removal surgery. For some patients, the immediate nature of this is appealing, as they will only require one hospital stay, and won’t need to wake up to the experience of not having a breast or breasts at all. However, this is not suitable for all cases, and breast reconstructive surgery can be performed at any time after following the completion of the cancer treatment.
Breast reconstruction technique
For me, reconstruction a breast or breasts which required removal due to cancer, or other illnesses, is particularly rewarding. It’s also a very complex procedure; be sure to choose a plastic surgeon with extensive experience in this area. The process of deciding on the most appropriate timing and technique for breast reconstruction involves a lot of complex decisions. It’s also essential to consider the preference of the patient, their natural shape, if they have undergone previous breast reconstruction surgery, and their exposure to radiotherapy in treating cancer.
Breast reconstruction is a multi-staged process requiring many physiological variables but consistent amongst all techniques are the interaction of three key anatomical features;
- Breast platform,
- Volume substitution
- Skin envelope
The final shape of the breast is never determined by the platform, the volume, or the envelope independently. It is the combined action of these three elements which will result in a pleasing and natural-appearing breast which maintains a stable shape over years.
This is the footprint the breast makes on the chest wall, analogous to the outline a house makes on a parcel of land. The platform forms the basis or foundation of the overlying three-dimensional structure of the breast. This platform may vary individually in height and width. Also, the position of the platform on the chest wall may vary slightly from one woman to another.
This refers to the three-dimensional shape, projection, and volume of the tissue (or implant) on top of the breast platform. In building terms, this is analogous to the size of a building, taking into account the number of floors, their distribution and external shape. In brief, there are three options available for mimicking breast volume;
- Autologous tissue (patient’s own tissue)
- Alloplastic (breast implants)
- Combination of the two
The decision to choose one technique over the other is highly patient-dependent, and reliant on many factors. However, the primary factors are body habitus, prior radiotherapy and the patient’s wishes to return to regular activity.
The autologous options available to patients include lower abdominal tissue (DIEP, SIEA or TRAM flaps), buttock tissue (superior and inferior gluteal artery perforator flaps), groin tissue (transverse upper myocutaneous gracilis flap) and back tissue (latissimus dorsi myocutaneous flap). Breast reconstructions using natural tissue have a much more natural appearance and feel than implant-based reconstructions, and will last longer. However, this technique is more complex and the required recovery time is usually longer.
The gold standard when all options are available is a DIEP (deep inferior epigastric artery perforator) flap. This is my flap of choice, as unlike the traditional TRAM (transverse rectus abdominus myocutaneous) flap the rectus abdominus muscle and its fascia are not violated in the harvest of this flap. This leads to lower abdominal morbidity in the long term, such as abdominal weakness and hernia rates, plus it has the added bonus of being a tummy tuck.
Should you not have adequate tummy tissue, then my next flap of choice is the TUG flap (Transverse Upper Gracilis). This utilises the upper inner thigh tissue which is the tissue that is excised in an inner thigh lift.
In some cases, an implant-based reconstruction may be able to be performed in a single operation and may or may not require the use of a muscle flap from the back (latissimus dorsi flap). However, usually multiple small operations are required. During the initial procedure, an expander will be placed at the site of the new breast, beneath the muscle and skin. Over a period of weeks, this will then be inflated using saline injections. The act of inflating the balloon acts to recruit soft tissue for future coverage of the implant. About 3 months later a second operation will replace the expander with a permanent silicone implant.
The quantity and quality of the skin envelope has a major influence on breast aesthetics. A skin envelope of appropriate quantity functions like a well-fitted bra, holding the breast mound, or implant, in an appropriate position. This is the case in immediate breast reconstruction following mastectomy where one only needs to replace the breast platform and breast volume.
Both the quantity and quality of the envelope are severely affected by previous radiotherapy or a delayed reconstruction, and in these cases tissue and volume needs to be important from elsewhere.
Surgery to the other breast is often required or requested by the patient to match the reconstructed breast. This can be in the form of an augmentation, breast lift or breast reduction.
Lastly, reconstruction of the nipple and areolar is usually performed some months later using part of the other nipple, or the patient’s tissue from elsewhere.
What are the potential risks and complications of breast reconstruction?
Breast reconstruction surgery using implants has some inherent risks, including:
- Infection around the implant
- Capsular contracture, where firm scar tissue forms around the implant causing it to lose shape and softness. This is particularly pertinent if you have had radiotherapy.
- Implant rupture or failure
- Leakage of the implant’s contents into the surrounding tissues
- Asymmetry of the breasts
- Lumps in local lymph node tissue formed by leaking silicone. These are not serious and don’t cause any health concerns.
- Movement of the implants from their original position
- Further surgery to treat complications
Breast reconstruction surgery using flaps also has some inherent risks these include:
- A clot in the blood vessels to the reconstructed breast. With modern microsurgical techniques this is rare, but should it occur, it can result in the flap tissue dying
- Small areas of hardness may develop in the new breast. These are a result of poor blood supply to the fat cells. This is called fat necrosis
- Fluid collection, which is called a seroma, under the new breast or where the flap was taken
- Should you not be a candidate for a DIEP and have a TRAM flap, there is a risk of weakened abdominal muscles, which can result in a hernia.
- Difference in size and shape between the natural and reconstructed breasts
How much does a breast reconstruction cost?
Breast reconstruction surgery is a reconstructive procedure and may be covered by private health insurance. You will need to review your policy carefully to determine what is covered.
Should you not have private insurance, I provide a public breast reconstructive service at POW, Royal Hospital for Women’s and Westmead Hospitals at no cost to you.
My policy with all reconstructive cases is as follows:
- Private patient in a private hospital: This does incur a “gap fee” which is dependent on the type of operation involved. This offers you the luxury of choosing your hospital and the date of the procedure. After our consultation my staff will give you an itemised account of the total cost.
- Private patient in a public hospital: I charge “no gap” in these circumstances and I perform the operation. However, the waiting time is dependent on the availability of operating time at one of the public hospitals I work at.
- Public patient in a public hospital: In these circumstances you go on one of my public waiting lists . As you will operated on in a large teaching hospital there is a likelihood that an advanced plastic surgical trainee may perform the procedure. Should this be the case, I will directly supervise the operation and I am responsible for your care and your outcomes.