Breast Reconstruction

Last updated date: 14-Jun-2023

Originally Written in English

Breast Reconstruction

Overview

Breast cancer is the most frequent malignancy in women and the second greatest cause of cancer mortality. The extra anxiety of a deforming operation following a cancer diagnosis plays a big role in the patient's therapy and overall psychological recovery for patients having mastectomy. Once the oncologic therapy is complete, the plastic surgeon, in collaboration with the patient and their breast surgeon, will devise a strategy to restore the patient's body image.

Breast reconstruction surgery may be chosen by women who have had surgery as part of their breast cancer treatment to restore the shape and appearance of the breast. Breast reconstruction aims to return one or both breasts to near-normal shape, appearance, symmetry, and size after a mastectomy, lumpectomy, or congenital deformity. 

 

What is Breast Reconstruction?

mastectomy

Many women who have a mastectomy (surgical to remove an entire breast to cure or prevent breast cancer) can have the shape of the removed breast reconstructed.

Women who want to have their breasts restored can do it in a variety of ways. Breast implants can be used to rebuild a woman's breasts (saline or silicone). They can also be repaired with autologous tissue (tissue from elsewhere in the body). To restore the breast, both implants and autologous tissue are sometimes employed.

Breast reconstruction surgery can be done (or begun) at the time of the mastectomy (called immediate reconstruction) or after the mastectomy incisions have healed and breast cancer therapy has been completed. Reconstruction might be delayed for months or even years following a mastectomy.

If the nipple and areola were not saved after the mastectomy, they may be recreated on the rebuilt breast in the final stage of reconstruction. Breast reconstruction surgery may include surgery on the other, or contralateral, breast to ensure that the two breasts are the same size and form.

Breast reconstruction generally falls into two categories: 

  • Implant-based reconstruction or 
  • Flap reconstruction. 

Breast implants are used in implant reconstruction to help build a new breast mound. Flap (or autologous) reconstruction is a type of breast reconstruction that uses the patient's own tissue from another place of the body to produce a new breast. When deciding which alternative is preferable, a variety of variables should be considered:

  • Type of mastectomy
  • Cancer treatments
  • Patient's body type

 

Anatomy and Physiology

Breast Reconstruction

The degree of the ablative operation will, to some part, determine the reconstructive options accessible. Breast skin loss, with or without nipple loss, can be explained by autologous tissue repair or tissue expansion. Because implants are most consistently placed in a sub-muscular pocket, loss of underlying muscle (pectoralis major, pectoralis minor, or both) offers complications for implant-based restoration.

 

Indications of Breast Reconstruction

Indications of Breast Reconstruction

The timing of reconstructive operations is an important factor throughout the planning phase. There are choices for both immediate and delayed repair, and the decision must be personalized to each patient and their individual oncologic situation to provide optimum safety, oncologic soundness, and final functional and cosmetic outcome. Immediate repair refers to reconstruction performed concurrently with cancer removal. This increases the time spent under anesthesia but has the significant advantage of allowing for a more natural skin envelope for reconstructive choices. The skin envelope following a skin/nipple-saving mastectomy can result in a more natural-looking breast postoperatively.

Oncologic factors including as stage and BRCA mutation status are important in deciding if this is a viable choice. The requirement for adjuvant therapy, notably radiation therapy, has an impact on immediate reconstruction. The presence of a foreign body in the radiated area enhances wound disintegration and associated problems. Patients who require adjuvant radiotherapy are frequently best served by autologous tissue repair, whether pedicled or free flap.

Delayed reconstruction happens when a patient undergoes a scheduled mastectomy and then returns to the operating room to complete the reconstructive component of the treatment at a later date. This option is accessible for people who haven't chosen whether they want breast reconstruction or who need adjuvant radiation therapy to improve their results. Breast reconstruction using alloplastic implants is covered in a later article and is still a possibility for many patients.

 

What factors can affect the choice of Breast Reconstruction method?

breast reconstruction method

A woman's choice of reconstructive surgery might be influenced by a number of variables. These criteria include the size and form of the breast being reconstructed, the woman's age and health, her history of previous operations, surgical risk factors (such as smoking history and obesity), the availability of autologous tissue, and the tumor's placement in the breast. Women who have already had abdominal surgery may be ineligible for an abdominally based flap repair.

Before deciding on a form of reconstruction, a lady should consider many variables.

 

What factors can affect the timing of Breast Reconstruction?

timing of breast reconstruction

The requirement for radiation therapy is one aspect that might influence the timing of breast reconstruction. Because radiation therapy can occasionally create wound healing issues or infections in rebuilt breasts, some women may want to postpone reconstruction until after radiation therapy is finished. However, due to advancements in surgical and radiation methods, rapid reconstruction with an implant is often still a possibility for women who will require radiation therapy. Autologous tissue breast reconstruction is often reserved for following radiation therapy, so that the radiation-damaged breast and chest wall tissue may be replaced with healthy tissue from elsewhere in the body.

Another consideration is the kind of breast cancer. In most cases, women with inflammatory breast cancer require more extensive skin excision. This can make immediate reconstruction more difficult, thus reconstruction may be considered when adjuvant therapy is completed.

Even if a woman qualifies for rapid reconstruction, she might opt for delayed reconstruction. For example, some women choose to wait until they have healed from their mastectomy and following adjuvant treatment before deciding on a kind of reconstruction. Women who postpone reconstruction (or choose not to have it at all) might utilize external breast prosthesis, also known as breast forms, to provide the appearance of breasts.

 

How do surgeons use implants to reconstruct a woman's breast?

mastectomy surgery

Following the mastectomy, implants are placed beneath the skin or in the chest muscle. The majority of mastectomies are performed using a method known as skin-sparing mastectomy, in which much of the breast skin is spared for use in breast reconstruction.

Implants are usually placed as part of a two-stage procedure.

  • In the first stage, the surgeon places a device, called a tissue expander, under the skin that is left after the mastectomy or under the chest muscle. The expander is slowly filled with saline during periodic visits to the doctor after surgery.
  • In the second stage, after the chest tissue has relaxed and healed enough, the expander is removed and replaced with an implant. The chest tissue is usually ready for the implant 2 to 6 months after mastectomy.

In certain situations, the implant can be inserted in the breast during the same operation as the mastectomy, which eliminates the need for a tissue expander. Acellular dermal matrix is increasingly being used by surgeons as a scaffold or "sling" to support tissue expanders and implants. Acellular dermal matrix is a type of mesh manufactured from donated human or pig skin that has been cleaned and processed to remove all cells in order to reduce the risk of rejection and infection.

 

Surgery and recovery

  • After mastectomy, enough skin and muscle must remain to cover the implant.
  • Shorter surgical procedure than autologous tissue reconstruction; less blood loss
  • Recovery time may be reduced compared to autologous repair.
  • Many follow-up appointments may be required to inflate the expander and place the implant.

 

Possible complications

  • Infection
  • Accumulation of clear fluid causing a mass or lump (seroma) within the reconstructed breast
  • Pooling of blood (hematoma) within the reconstructed breast
  • Blood clots
  • Extrusion of the implant (the implant breaks through the skin)
  • Implant rupture (the implant breaks open and saline or silicone leaks into the surrounding tissue)
  • Formation of hard scar tissue around the implant (known as a contracture)
  • Obesity, diabetes, and smoking may increase the rate of complications
  • Possible increased risk of developing a very rare form of immune system cancer called anaplastic large cell lymphoma 

 

How do surgeons use tissue from a woman's own body to reconstruct the breast?

Breast reconstruction flaps

A chunk of tissue including skin, fat, blood vessels, and occasionally muscle is extracted from elsewhere in a woman's body and utilized to rebuild the breast in autologous tissue reconstruction. This portion of tissue is referred to as a flap.

Flaps for breast reconstruction can come from a variety of places in the body. Breast reconstruction flaps are frequently derived from the belly or back. They can, however, be extracted from the thigh or buttocks.

Depending on their source, flaps can be pedicled or free.

  • The tissue and blood vessels are transferred together across the body to the breast region using a pedicled flap. Blood vessels do not need to be rejoined after the tissue is relocated since the blood supply to the tissue utilized for reconstruction is left intact.
  • The tissue is cut away from its blood supply using free flaps. It must be connected to new blood arteries in the breast using a process known as microsurgery. This provides blood circulation to the rebuilt breast.

 

Surgery and recovery

  • Longer surgical procedure than for implants
  • The initial recovery period may be longer than for implants
  • Pedicled flap repair is often a shorter procedure than free flap reconstruction and needs less hospitalization.
  • When compared to pedicled flap repair, which needs a surgeon with microsurgery skill to re-attach blood vessels, free flap reconstruction is a lengthier, more difficult procedure.

 

Possible complications

  • Necrosis (death) of the transferred tissue
  • Blood clots may be more frequent with some flap sources
  • Pain and weakness at the site from which the donor tissue was taken
  • Obesity, diabetes, and smoking may increase the rate of complications

 

How do surgeons reconstruct the nipple and areola?

nipple and areola

A surgeon can restore the nipple and areola when the chest has healed following reconstruction surgery and the location of the breast mound on the chest wall has stabilized. Typically, the new nipple is formed by cutting and transporting tiny pieces of skin from the reconstructed breast to the nipple site, where they are shaped into a new nipple. The surgeon can re-create the areola a few months following nipple repair. Tattoo ink is typically used for this. However, in rare situations, skin grafts from the groin or belly may be removed and connected to the breast to produce an areola during nipple reconstruction.

A nipple-sparing mastectomy, which maintains a woman's own nipple and areola, may be a possibility for certain women, depending on the size and location of the breast cancer, as well as the shape and size of the breasts. 

 

What type of follow-up care and rehabilitation is needed after breast reconstruction?

after breast reconstruction

When compared to a mastectomy alone, any sort of reconstruction increases the amount of negative effects a woman may encounter. A woman's medical team will regularly monitor her for issues, which might develop months or even years after surgery.

Women who have had autologous tissue or implant-based reconstruction may benefit from physical therapy to enhance or maintain shoulder range of motion or to recuperate from weakness encountered at the donor location, such as abdominal weakness. A physical therapist can assist a woman in regaining strength, adjusting to new physical limits, and determining the safest methods to conduct daily activities. 

 

Does breast reconstruction affect the ability to check for breast cancer recurrence?

mammogram

Breast reconstruction does not enhance the odds of breast cancer recurring or make it more difficult to detect recurrence using a mammogram, according to research.

Mammograms of the other breast will be performed on women who have had one breast removed via mastectomy. Women who have had a skin-sparing mastectomy or are at high risk of recurrence of breast cancer may have mammograms of the rebuilt breast if it was reconstructed using autologous tissue. Mammograms are not often done on breasts that have been rebuilt with an implant following a mastectomy.

Before having a mammography, a woman with a breast implant should inform the radiology technician about her implant. Special treatments may be required to increase mammography accuracy and minimize implant damage.

 

Immediate vs Delayed breast reconstruction

Delayed breast reconstruction

Immediate breast reconstruction

A rapid reconstruction provides you with a new breast immediately. Surgeons will attempt to match the reconstructed breast to your other breast, but it will not be identical.

The replacement breast will feel and appear different than the one that was removed. However, some women find that rapid reconstruction helps them cope more readily with their thoughts about breast loss.

Advantages

  • When you wake up from your mastectomy or breast conserving surgery, you will have your new rebuilt breast.
  • Because there are fewer procedures, there are fewer anesthetics.
  • Because the surgeon can generally use the existing breast skin, your completed breast may appear better.
  • You will have minimal scarring on the reconstructed breast itself; you may have a little piece of skin where your nipple used to be, with a scar surrounding it. However, the surgeon may not always need to remove the nipple.

 

Disadvantages

  • You may not have as much time to plan the sort of restoration you desire.
  • If you get radiation following surgery, it may affect the appearance of the reconstruction.
  • If you are getting radiation, your doctor may urge you not to have implant reconstruction. However, you can have a temporary implant while undergoing radiation and a second reconstructive procedure thereafter.
  • When compared to a mastectomy alone, the recovery period following surgery is lengthier with a reconstruction.
  • The sort of reconstruction you have may result in additional scars on your body.
  • More surgery is expected; this is generally minor surgery to get the greatest aesthetic impact, and might entail the creation of a new nipple.
  • If you suffer difficulties following surgery, your chemotherapy or radiation may be delayed.

 

Chemotherapy and radiation can occasionally impair the body's ability to mend itself. So, if you have wound concerns following surgery, you won't be able to begin these therapies until the wounds have healed. Radiotherapy or chemotherapy at this time would halt wound healing and increase your risk of infection.

Chemotherapy must be administered at the right time. Chemotherapy performs best when started within 6 weeks following cancer surgery, according to study. That might not be viable if the rebuilding does not go as planned.

 

Delayed breast reconstruction

Some women choose to wait until they have recovered from their mastectomy and breast cancer treatment before considering reconstruction.

Advantages

  • You now have more time to consider your alternatives and consult with a qualified surgeon.
  • Your breast cancer treatment will be completed, and your reconstructive surgery will have no effect on it.
  • Because you have time to prepare for your operation, your recovery will be faster.

 

Disadvantages

  • If you have no breast tissue following the mastectomy, you might opt to wear an artificial breast (prosthesis).
  • You may have a greater scar on the rebuilt breast than you did before.
  • You may require more surgery to achieve a satisfactory aesthetic result. This is generally minimal surgery that may be done as an outpatient procedure.

 

Reconstruction after breast conserving surgery

Reconstruction after breast conserving surgery

Breast conserving surgery involves removing only a portion of the breast. The breast normally looks great following this sort of surgery, which is followed by radiation.

When only a portion of a woman's breast is removed, few women require reconstructive surgery. Some women, however, may require reconstruction of the leftover breast tissue. A partial reconstruction or breast reshaping may be achieved.

  • Having a partial reconstruction

Some women will require a bigger quantity of breast tissue to be removed, such as a quadrantectomy. This means that around a fourth of the breast tissue is removed by the surgeon. This form of surgery causes a dimple in the breast, making the treated breast smaller than the other. However, it is occasionally feasible to restore the contour of the breast with a partial restoration by filling the dent with a tiny region of live tissue.

To fill up the dent, the surgeon may utilize tissue from your back. This is known as a latissimus dorsi flap (LD flap). There are alternative approaches. These will be explained to you by your surgeon. To lessen the danger of the cancer returning, you will require radiation to the remaining breast tissue.

 

  • Reshaping the breast

If you need a portion of your breast removed and have huge breasts, reshaping may be a possibility. It is known as therapeutic mammoplasty. The tumor and a region of healthy tissue surrounding it are removed by the surgeon. The leftover breast tissue is then reshaped to create a smaller breast.

To lessen the danger of the cancer returning, you will require radiation to this residual breast tissue. You can undergo surgery to make your second breast smaller (breast reduction) at the same time as your reconstructive surgery, so they match in size. You can also opt to have this later.

 

Conclusion 

Breast reconstruction surgery is used to repair breasts after a mastectomy. Breast reconstruction can be done in a variety of ways. Implants are used in some procedures. Others utilize tissue from your body (such as your stomach) to create a breast. Breast reconstruction can take place immediately following a mastectomy or years later.