Reconstruction

Mastectomy is an operation used to treat breast cancer and other breast diseases in which the nipple plus an amount of skin and virtually all the breast tissue is removed. In some cases the underlying pectoralis muscle may also need to be removed.

Breast reconstruction following mastectomy is a complex field involving many choices based on some of the following criteria of risks/benefits as well as integrating with the rest of the treatment plan.

	Type and extent of mastectomy.
	Previous surgery / radiation to breast.
	Size and shape of opposite breast.
	The need for post-operative radio or chemotherapy.
	Potential donor sites for tissue transfer on patient's own body.
	Age, medical conditions and anaesthetic risk of the patient.
	Preferences and /or fears with regards silicone and certain procedures.

Having read the above you will see that certain options may not have been made available to you. This is due to the fact that they have been deemed as technically not viable due to either the nature of your mastectomy, underlying conditions you may have or an inability to integrate those options in a realistic post operative plan.

The other reason may be that either previous surgery or the current mastectomy may damage the blood supply to the tissue needed to be transferred during the reconstruction.

Mastectomy with silicone prosthesis reconstruction
Just after the mastectomy  a silicone prosthesis can be inserted into a pocket created under the pectoralis muscle into which is inserted a bag containing a silicone gel. This is similar to normal cosmetic breast enhancement surgery.

This option is ideal for patients with smallish non-droopy breasts. It is however not a good option in primary breast reconstruction which will need radiation therapy to complete the therapy for the breast cancer. Please see the attached information sheet with regards the history of silicone prostheses and current thinking.

Tissue expansion followed by prosthetic reconstruction
Tissue expansion is a process whereby existing tissue, which is insufficient for breast reconstruction, can be altered by a slow stretching by a balloon type device to create sufficient tissue with which we can create a breast. This is similar to the stretching of the abdominal skin during pregnancy. After mastectomy the device is placed under the pectoral muscle, with an access port on the chest wall, through which fluid can be injected later to fill the device as the skin expands. The expander isn't in the final position, as it requires complete muscle cover to allow expansion. After three months ( if no other treatment is required) or six months (if chemotherapy is administered) the expander is removed and replaced with a permanent silicone prosthesis. At the same time the opposite breast can undergo a matching procedure (i.e.) augmentation, breast lift, breast reduction.

Problems specifically associated with expanders are deflation, extrusion and pain of expansion (rare).

Flap reconstruction of breasts

Latissimus dorsi flap

This flap is ideal for patients who require post operative radiotherapy, for patients who have had the pectoral muscle removed during mastectomy and patients who require more skin than can be reliably achieved with tissue expansion.

For a description of this procedure, see under partial mastectomy.

This flap can be used as a total reconstruction or in some cases  a prosthesis may be added to achieve significant size of the breast mound.

TRAP flap

This total reconstruction is a method by which excess skin and fat of the lower abdomen can be transferred using the blood supply from the rectus abdominus muscle. The paired rectus abdominus muscles form the "six pack" muscles.

One of these is raised with the fat and skin attached and passed through a tunnel between the abdomen and the hole created by a mastectomy.

This operation cannot be performed on people with the following conditions:

Obesity, previous abdominal surgery, diabetes, smokers and major heart/lung problems.

In spite of the above this flap is a very nice forms of reconstruction as it utilizes excess tissue in one region to reconstruct a defect in another, the tissue used is similar, the skin type of breast and lower abdomen are also the same and finally the scar can often be hidden in the panty line (like the scar of a tummy tuck).

Special problems with this procedure are herniation caused by loss of the muscle in the abdomen (5-10% of cases), the length of the procedure and transient loss of sensation to the lower abdominal skin.

Complications of breast reconstruction

Blood loss: With simultaneous reconstruction especially if a flap is used this can be somewhat higher. In this practice all reasonable attempts are made to minimise the usage of blood transfusions including cell saving and post operative  transfusion. Sometimes it is necessary to surgically drain collections of this blood after the operation.

Infection:
All surgical procedures are associated with infection particularly with prosthesis. The average rate worldwide is between 2-5 %. I have had 29 of my patients in the last 10 years; however this means liberal use of antibiotics to prevent this potential problem. This however may necessitate the removal of the prosthesis and replacement after an appropriate time delay.

Wound healing problems
All surgical wounds can experience wound-healing problems such as break down.  This is more common amongst smokers, people who are overweight, people who have had precious chemotherapy and radiotherapy or other forms of immune suppression.

Flap loss
In all cases as with wound healing, the same conditions could affect blood flow throughout  the tissue that has been transported resulting in the flap not getting enough oxygen and failing, fortunately this is a rare but serious problem.

Donor site problems
All the above problems cannot only occur in the reconstructed breast mound but in the donor site should a flap reconstruction be used.

Silicone related problems
Please read the attached article on silicone prosthesis related problems to further your knowledge should we have decided that  a silicone prosthesis is appropriate for your reconstruction.

Anaesthetic related problems
These as you have probably heard can vary from minor (nausea, discomfort) to major (drug interaction etc).

What can I realistically expect?
After all the information and preparation for your surgery it is very normal to expect some insecurity anxiety and emotional swings. Relax, this is completely normal. Most other patients have similar feelings. Talking to either of the surgeons involved will allow to verbalise this and to be re-assured about what are perfectly reasonable concerns.

After preliminary tests and perhaps a visit to the physician in order to make sure any medical conditions you may have are optimally controlled a date will be set for theatre.

Prepare yourself for a stay of 3-5 days if no flap surgery is to be done and 5-7 days with flaps.

What can I expect in hospital?

On the day of admission most of our patients will go to the x-ray department for some form of imaging to ensure optimal surgical outcome. These may include mammogram type hook wire localization of the tumour, sonar, plain x-rays and scans of the armpit to identify potential lymph glands which we may need to sample during the operation. After this you will be returned to the ward and be prepared for theatre.

The Anaesthetist will come and see you and make sure you are ready for the operation and give you a pre-med and the surgeon may need to mark certain anatomical point on your skin depending on the operation to be done.

After the operation all patients who have had flap surgery will go to the high care ward for observation of blood pressure and the flap. The next morning they get transferred back to the ward. You will have drains and drips up and a blood pressure cuff as well as special stocking to aid blood circulation in the legs. This is to prevent the type of problems seen on a long distance airline flights (DVT).

Apart from some pain or discomfort you should feel okay if somewhat tired after the surgery and anaesthetic. This day is one of evaluation and stabilisation after surgery.

On the second day you should be more mobile and the drips will be removed. Between days 3 -7 depending how you have fared and what your circumstances are at home you will be discharged.

At this stage the drainage tubes will still be in position and will remain so until the drainage has diminished between 8 - 12 days. This may be longer in the case of flap surgery. Whilst this is sometimes uncomfortable it serves to prevent build up of fluid in the wounds.

Psychologically  patients tend to have several periods of depression related to surgery and anaesthesia. This is normal and related to pre-operative anxiety, anaeshetic and pain killers, sleep pattern disturbances and sometimes sheer emotional release that the procedure is over. This might also happen to you. If you are depressed or concerned about a specific issue contact one of your team to share these issues. Medication is not routinely prescribed for this as it is transient and does not require treatment.

You will be seen by your Surgeons in the post op period and your progress will be checked. Stitch removal is between days 12 - 14.

During this period the final histology will be reported to us along with the receptor status of your tumour. This will enable us to discuss the non-surgical treatment with you so a decision can be made about the best options with regards to chemotherapy, radiotherapy and/or hormone therapy and also the timing of such interventions.

You will also at this time possibly meet with the Oncologist who will be treating you during this process.

Do not expect a normal breast mound at this stage. Just as when your breast developed during puberty it will change over the next 6-8 months. Wound healing, scar maturing, tissue expansion and gravity all help to mould the new breast mound. This is not an instant process but if you are unsure please check with your doctor.

Challenges you might face during this period may include any number of the combinations, which may vary fromminor irritations like difficulties in finding bras to major relationship crises.

General comments that we hear are that clothing does change during the period of reconstruction until symmetry has improved to allow the wearing of v-necks. Bra wearing is also difficult, but options do exist.

Loss of hair during chemotherapy does occur but fortunately some wigmakers are excellent.

Psychological stresses including, anxiety, depression, social phobias and relationship issues can  surface in this time and should be dealt with as soon as possible so that they don't become major. The surgeons, psychologists and resource groups listed below are  important in helping you and your family.

Genetic counselling is available to determine whether or not those people with a strong family history of breast cancer actually might have a hereditary form of this disease.

Cosmetic colour tattooing of the nipple areola complex and scars to achieve good matching is available as well. This represents the final stage in the breast reconstruction; however it is often useful to highlight eyebrows if there is some hair loss from chemotherapy.

We also have a list of  support services, such as physiotherpists, occupational therapists, and even alternative therapists who all help us to maximise your health.