Breast Reconstruction

Breast Reconstruction Overview

We understand that deciding on whether to have breast reconstruction or not can be a difficult process, especially when you are dealing with your diagnosis and treatment. Whilst we can guide and support you as much as possible, ultimately the decision is yours and should be made on what is best for you and your health.

Although all woman having a mastectomy should have breast reconstruction discussed there is no right or wrong about choosing it for you as an individual. Breast reconstruction can be performed at the time of the mastectomy (known as primary or immediate reconstruction) or at a later date (secondary or delayed reconstruction). If in doubt you can always have reconstruction at a later date.

In general terms a breast can be reconstructed using an implant or tissue from the patient’s own body (back, tummy, bottom or thigh). Sometimes a combination of the two procedures can be used, but the type of procedure used will really depend on what is best for the patient and can be discussed with Amir Tadros during a consultation.

Further information about breast reconstruction is below. Please do not hesitate to Call us if you have any questions or would like to obtain costs.

Why and When

Breast reconstruction is an option and never an essential part of your treatment, however the option of breast reconstruction should be offered to every woman that has a mastectomy.

If you are looking to have reconstruction, it is important to consider the added surgery and potential complications reconstruction will add to your recovery process. Great advances in reconstruction techniques now allow for some excellent outcomes with breast reconstruction following cancer.

The decision on when to have the reconstruction surgery will be driven by the patient’s choice, along with advice from Amir Tadros. When patients require other treatments, especially radiotherapy, it might be considered better to delay reconstruction. Nipple reconstruction can be performed at the time of the reconstruction or usually later.

For further information we would recommend taking a look at bcna.org.au with useful links offering support and information to those affected by breast cancer as well as  mcgrathfoundation.com.au.

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Immediate Reconstruction

This is when the reconstruction is done at the same time as the surgery for your breast cancer. There are advantages and potential disadvantages to planning an immediate reconstruction. It must always be remembered that a reconstruction can still be performed on the majority of patients at a later date after all of the cancer treatment is completed.

Advantages Of Immediate Reconstruction

• As there is no delay between cancer treatment and reconstruction, for some patients this means that the psychological effects of having a mastectomy and therefore losing a breast is reduced.
• A reconstruction using the patient’s own tissue will only involve one operation, and therefore recovery should be quicker.
• An immediate reconstruction can result in a far more natural result for the patient, especially if the mastectomy is carried out through the nipple. This means that all of the breast skin can be saved and used for the reconstruction giving a more natural cosmetic result.
• Amir Tadros can sometimes build a nipple at the same time as a mastectomy. This is true of the reconstructions using the tummy or back but not with implant based reconstruction.

Disadvantages Of Immediate Reconstruction

• Understanding the surgical process of a breast reconstruction and deciding to have immediate treatment, that may lengthen your hospital stay, will inevitably add further pressure at an already difficult time.
• You may have complications from your additional surgery at a time when you are awaiting other treatments for your cancer such as radiotherapy and chemotherapy. This does not mean that your cancer treatment will be affected, but could mean additional surgery to ensure that complications are treated quickly if they occur.
• If you unexpectedly need radiotherapy this can affect the result of your reconstruction. Indeed, if we know you will definitely need radiotherapy after surgery then we may recommend delaying reconstruction.
• The complication rate of immediate reconstruction is slightly higher than delayed reconstruction.

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Delayed Reconstruction

This is when breast reconstruction is performed after all of the cancer treatment has finished, and may be months or years later. There is no time or specific age limit, and should only be carried out when the patient is ready, both physically and mentally, for further surgery.

Some patients choose to have a delayed reconstruction, others are recommended it and some patients who did not initially want to have a reconstruction sometimes decide after a period of time that they are ready to have surgery.

Advantages Of Delayed Reconstruction

• It will avoid the strain of being treated for any possible complications following reconstruction surgery at the same time as undergoing cancer treatment, such as radiotherapy or chemotherapy.
• Avoids the possible effects of radiotherapy (firmness, shrinking and deformity) impacting on the reconstruction. The cosmetic result of immediate reconstruction can be superior to delayed reconstruction. However, if you add radiotherapy to an immediate reconstruction it will have the opposite effect.
• You will not have to deal with the surgery or any decisions relating to the reconstruction at the time of cancer diagnosis and treatment.
• This form of surgery has a slightly lower complication rate than compared to immediate reconstruction.

Disadvantages Of Delayed Reconstruction

• You will need to live with the effects of the mastectomy until the reconstruction is performed. This can be for a number of months or up to a year, depending on the individual case.
• The cosmetic result is potentially not as good. This is because an immediate reconstruction the skin of the breast is often kept and used to cover the reconstruction giving a more natural result. If a delayed reconstruction is performed using your own body tissue then skin needs to be added to the breast from the back or tummy. This skin does have slightly different appearance and the scars on the reconstructed breast will be longer.
• The skin difference is less obvious in delayed implant based reconstruction as the skin is stretched with the inflatable balloon device first (just as with immediate reconstruction).
• If you have had radiotherapy it is unlikely you will be offered implant type reconstruction, as the complications are too high. You will need some tissue from the back or tummy moved to help reconstruct the breast.

Radiotherapy and Breast Reconstruction

Radiotherapy is a very important part of the treatment for certain breast cancer patients, usually those who only have part of the breast removed (breast conserving surgery), as it has been shown to reduce the chances of breast cancer recurring in the remaining breast tissue. There is also evidence to show that the combined efforts of breast conserving surgery and radiotherapy can be as successful as a mastectomy.

However, certain patients that have a mastectomy have also been shown to benefit from radiotherapy. It’s likely use can be predicted in some patients but it will often only be known if radiotherapy is needed after the mastectomy is performed and the cancer analysed.

When carried out, radiotherapy can damage normal tissue as well as cancer cells. It can result in changes to the patient’s skin colour and cause firmness and shrinkage in healthy breast tissue. It can also have the same effects in tissues that have been used to reconstruct a breast. If a silicone implant is present then it can cause an alarming rise in potential complications of capsule formation (firmness from scar tissue) or infection.

The problems associated with having radiotherapy can impact on when to have a breast reconstruction and the particular method to use.

• If radiotherapy is planned or has already been given then implant reconstruction should be avoided in the majority of cases.
• When radiotherapy is almost certainly planned you may be recommended to delay reconstruction until all of your treatment is completed. There is nothing more disappointing for the patient and Amir Tadros to see a good reconstruction be adversely affected by radiotherapy.
• If radiotherapy is a possibility then it is acceptable to take either the cautious route of delayed reconstruction or proceed with an immediate reconstruction and deal with radiotherapy problems if they occur.
• It must be emphasised that not all patients get strong adverse affects from radiotherapy. This can make definitive advice difficult, however Amir Tadros will guide you as much as possible on the best course of treatment for you, based on your individual case.

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Breast reconstruction using implants

Procedure In Brief

This form of reconstruction involves placing an implant under the chest wall muscle and skin. It is usually done as a two stage operation. Firstly an inflatable balloon (tissue expander) is placed under the muscle. This is inflated with a series of injections of saline water to stretch the skin. A permanent implant is then inserted 3-6 months later.

More recently implant reconstruction can be offered as a single stage operation. This has the advantages of maintaining the breast skin and allowing more natural ‘looseness’ to the breast. It requires the use of special materials to be used in addition to the implant to help support the implant internally.

This is either a man-made material or a specially prepared animal skin product. If one-stage implant reconstruction is an option this will be discussed with you.

Advantages Of Using Implants

• When carried out as an immediate reconstruction it only adds a little extra surgery to the original mastectomy operation.
• This technique avoids additional scarring on the rest of the body.
• For a lot of patients the implant will create a very pleasing breast shape.
• The recovery rate for the operation is relatively quick.

Disadvantages Of Using Implants

• The shape of the breast will have little or no natural ‘droop’ and can therefore appear less natural in matching the other breast.
• There are two operations for the patient to undergo, and therefore involves more recovery.
• There are some issues associated with having implants, including the implant causing the breast to harden (usually in 30% of patients) and a small risk of infection resulting in implant loss. See implant problems for further information.
• The implant tends to give less symmetry over the years, as it will not change in shape or size in the same way of the normal breast.

Medicines

A full medical history will be obtained before any surgery. As a precaution, do not take any over the counter medicines or herbal remedies prior to surgery or for 3 days following. Also avoid aspirin, ibuprofen based tablets. It would be useful to bring a list of any prescribed medications to your pre-op assessment.

Smoking

If you are a smoker, try and stop for a six weeks before and five days following surgery as it can reduce the chances of complications.

Surgical Recovery & Final Outcome

• Length of stay in hospital – usually 4 days for both operations (which will be done over 4-6 months).
• Length of surgery – usually between 1-2 hours.
• Time restricted to bed – 1 day, but there will be no need for a bladder catheter
• Time to walking – patients should be able to walk 1-2 days, and walk without any discomfort after a week.
• Time to exercise – patients should be able to exercise after 4 weeks of recovery.
• Time to full recovery – patients should feel fully recovered and be able to return to work by 6-8 weeks.
• Driving – Patients should avoid driving until they are completely free of pain and restriction, and be able to confidently perform an emergency stop. This is to ensure they will be covered by their insurance policy. It may take up to 3 weeks to recover sufficiently.
• Dressings – patients will wear dressings on the breast for 2 weeks.
• Bras & clothing – patients are advised to bring a soft (non underwired) sports bra in the planned new cup size into hospital. The bra should feel comfortable, whilst still providing support. You will need to have two bras at home that can be worn on rotation. The chest measurement does not usually change but can reduce by 1-2 inches. You will be able to wear an underwired bra after 8 weeks; this should be properly fitted to your new shape and size.
• There is around a 3% risk of fluid collecting in the reconstructed breast and an infection occurring. This would need to be treated immediately.
• As with any implant surgery, there is up to a 30% risk of the implant becoming ‘firm’, as well as there being some asymmetry to the opposite breast.
• There are no problems associated with the ‘donor’ areas of the body that skin has been taken from following surgery.

Please do not hesitate to Call us if you have any questions or would like to obtain costs.

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Breast reconstruction using your own tissue

Procedure In Brief

This involves the removal of the skin and fat from the lower tummy (the same tissues as taken during a tummy tuck operation), from the thighs or the flanks which is then used to reconstruct the breast. The tummy skin and fat is the closest like for like replacement of the breast. It is for this reason it can produce very life like reconstructions. However, most importantly this type of ‘own body tissue’ reconstruction will last a life time.

This is done by re-attaching this tummy tissue into the breast with microsurgery. If this is done as an immediate reconstruction at the same time as the mastectomy, then the breast skin is usually kept and the tummy tissue is used to give the breast shape and to form a nipple.

However, if it is done at a later date (delayed reconstruction) then the tummy skin is also used for the new breast skin. Amir Tadros is experienced with this operation, having regularly performed it over a 15-year period, operating weekly in both private and public hospitals.

His success rates are over 98% with flap survival (1.4% failure rate) . With an established team of consultants this operation has now become a reliable 4-5 hour operation (this used to take 8-10 hours) enabling rapid patient recovery and shorter hospital stay.

Microsurgery

The blood vessels are the ones that are re-attached in the breast area with microsurgery to keep the tummy flap alive. These blood vessels pass through the tummy wall muscles to get to the skin and fat. When all the muscle is left behind the flap is called a DIEP (Deep Inferior Gastric Artery flap).

However, in some cases the muscle around these blood vessels needs removing also. This then becomes a TRAM flap (Transverse Rectus Abdominus Muscle flap). These are essentially the same operation except for the small amount of muscle removed. Amir Tadros tends to perform a DIEP flap in 95% of patients as opposed to TRAM flaps.

Advantages Of Using The Tummy

• Using the patient’s own tissue (fat) to reconstruct the breast means it will closely resemble a normal breast in the texture and movement.
• The new breast will naturally ‘droop’ like normal breast tissue and therefore should achieve the same shape as the other breast.
• Generally the results of this type of reconstruction improve over time as the breast changes in size and shape.
• This type of reconstruction is regarded world-wide as one of the most successful and is successful in over 98% of patients.
• Surgery is completed in one operation.
• The patient’s tummy will have a flatter appearance following surgery.

Disadvantages Of Using The Tummy

• Although much faster it is still a big operation taking 3-5 hours to perform, with a 2-3 month recovery period.
• The operation has a 1% failure rate, but this depends on risk factors including, obesity, smoking, past surgical procedures, other illnesses and whether radiotherapy has been used to treat the cancer.
• A scar will be left on the tummy from where the skin and tissue has been removed.
• Although uncommon, patients might experience some pain, weakness or bulging in the tummy. There is also a slightly greater risk of general complications such as pneumonia and blood clots following surgery.
• Patients will experience some numbness on the skin of the lower tummy.

Surgical Recovery & Final Outcome

• Length of stay in hospital – usually 3 days.
• Length of surgery – usually between 3-4 hours.
• Time restricted to bed – 1-2 days, in which the patient will be fitted with a bladder catheter for 24 hours.
• Time to walking – patients should be able to walk after 2 days of recovery, and then walk without discomfort after 10-14 days.
• Time to exercise – patients should be able to exercise after 4 weeks of recovery.
• Time to full recovery – patients should feel fully recovered and able to return to work by 2 months.
• Dressings – patients will have a glue dressings on the breast and tummy for 2 weeks until it peels away.
• Bras & clothing – patients are advised to wear a pressure garment for 4 weeks.
• There is around a 6% risk of experiencing problems with the tummy – pain, bulging in the tummy, skin infection, fluid collection, wound breakdown and the possibility of having a hernia.
• There is a 5% chance of experiencing reconstruction problems – lumps in the tissue, part or total failure of the reconstruction succeeding.
• There are few long term problems associated with this type of surgery, apart from the tummy remaining weaker than before surgery.

Please do not hesitate to Call us if you have any questions or would like to obtain costs for either insured or self pay patients. Please note there are some excesses liable with insured patients. All details can be obtained from Amir Tadros’s secretary.