Breast reconstruction: making the right choice

When it comes to breast reconstruction, there are several considerations patients need to take into account.

Breast reconstruction is the surgical restoration of breast shape and volume after mastectomy (complete removal of breast tissue), usually due to breast cancer. The breast surgeon performs the mastectomy and the reconstruction is typically done by the plastic surgeon.

The main considerations for breast reconstruction are timing and method. Immediate reconstruction is done on the same day as the mastectomy while delayed reconstruction is done months or years later. The reconstruction can be achieved using the patient’s own tissue from another part of the body (autologous reconstruction) or with a breast implant (alloplastic reconstruction).

When should it be done?

Before the 1990s there were fears that immediate breast reconstruction was unsafe
and that early reconstruction could risk cancer recurrence. However, studies have shown that immediate reconstruction is as safe as delayed reconstruction for early-stage breast cancer.

Pros and cons

In immediate breast reconstruction, skin-sparing mastectomy is performed. This removes the breast tissue and nipple-areolar complex while keeping the skin. The plastic reconstructive surgeon then restores the breast volume within this breast skin envelope. The ability to preserve the native breast skin envelope is important to produce a natural-looking result.

In delayed breast reconstruction, the breast tissue and overlying skin are removed. This leaves more scars and the breast looks less natural compared to immediate reconstruction.

Immediate reconstruction has a positive benefit for the patient, who awakes from surgery without feeling the loss of body form, and is more cost-effective. However in advanced breast cancer, delayed breast reconstruction is preferred since the risk of recurrence is higher.

Reconstruction methods

Reconstruction should ideally be performed using the principle of “replacing like with like”. Therefore, autologous breast reconstruction using the patient’s own tissue is preferred. The result is long-lasting and the reconstructed breast appears more natural in appearance and consistency.

The transverse rectus abdominis myocutaneous (TRAM) flap is the most common autologous breast reconstruction procedure. Like a tummy tuck, this removes excessive lower abdominal skin and fat with a portion of the abdominal muscle, transferring it to the breast for reconstruction. The result is a flatter tummy and reconstructed breast. Patients who have had caesareans may also undergo this procedure.

TRAM flap reconstruction is unsuitable for women who wish be pregnant after the treatment. The latissimus dorsi (LD) flap is more suitable for them. The LD is a fan-shaped muscle on the back. It does not provide much volume and a breast implant may be added.

Breast reconstruction using implants is a simpler and faster procedure. The recovery process is less complicated. Sometimes, a tissue expander is used to serially stretch the skin before placing the definitive breast implant. It may be also more difficult for the implant to match the shape of the contralateral unoperated breast. In the long run, implant replacement may be required in the event of rupture or capsular contracture (scarring around the implant). The initial cost of implant reconstruction may be lower than autologous breast reconstruction, but the long-term cost may even out.

Additional procedures

Nipple reconstruction is planned four to six months after the first stage of breast reconstruction. Local tissue is used to reconstruct a new nipple. This is followed by nipple areolar tattooing one to two months later.

Fat transfer can subsequently be introduced to correct contour imperfections, if any, of the reconstructed breast.