Breast Reconstruction Surgery – Post Breast Cancer

INTRODUCTION

  • Breast reconstruction restores breast morphology and volume after mastectomy (complete removal of breast tissue) usually due to breast cancer.
  • The breast surgeon performs the mastectomy and the reconstruction usually is done by the plastic surgeon.

Breast Cancer Surgery

The general schematic of breast cancer surgery is outlined below :

  • Excision of tumour :
    • Wide local excision and breast conservation surgery
    • Mastectomy (removal of the entire breast) :
      • Simple mastectomy (removal of breast tissue and overlying skin)
      • Skin sparing mastectomy (removal of breast tissue while preserving the overlying breast skin for immediate breast reconstruction)
  • Lymph node management
    • Sentinel lymph node biopsy (sampling of lymph nodes in the armpit to determine cancer involvement)
    • Axillary clearance (clearance of armpit lymph nodes)
  • Breast Reconstruction
  • Adjuvant therapy
    • Chemotherapy
    • Radiotherapy

TWO MAIN CONSIDERATIONS FOR BREAST RECONSTRUCTION

Timing Of Reconstruction

  • Immediate breast reconstruction :
    • Reconstruction is done on same day as the mastectomy.
  • Delayed reconstruction :
    • Reconstruction done months to years after the mastectomy.

Immediate Vs Delayed Breast Reconstruction

Immediate ReconstructionDelayed Reconstruction
1Psychological benefitPositiveNegative
2Socio-economic costSingle stage : lower cost overallMultiple stages : higher overall cost
3Breast envelopBreast enveloped preserved. Natural-looking reconstruction.Skin envelop resected. Usually less natural result.
4Stage of breast cancerFor early stage breast cancer.All stages
5Adjuvant therapy (chemotherapy or radiotherapy)May delay adjuvant therapy if there is wound healing problems.No delay.
6Breast cancer surveillanceNATheoretically allows monitoring of advanced stage CA (Stage III and IV) before reconstruction.

 

Method of reconstruction.

  • Autologous reconstruction :
    • Reconstruction using the patient’s own tissue from another part of the body
  • Alloplastic reconstruction :
    • Reconstruction using breast implant and/or tissue expander.

 

Autologous Vs Alloplastic Breast Reconstruction

Autologous ReconstructionAlloplastic Reconstruction
1Initial cost of procedureMore – but offset laterLess initially – but may need revision surgery for implant exchange thus increasing long term cost
2Complexity of surgeryMore complexSimple
3Time to recoveryLongerShorter
4Breast contour and shapeMore natural, better match for the original breast shapeDifficult to match the original breast shape
5Donor site morbidityScar arising from another part of the body which donated the tissue for reconstructionNo new scar
6Adjuvant therapyMay delay adjuvant therapy if there is wound healing problemHardly any delay
7Capsular contractureNilThick scar can develop in the capsule surrounding the implant (capsular implant) causing the implant to change shape or feel harder .
8InfectionDonor siteImplant infection wound require removal
9Implant ruptureNilImplant rupture would require removal and/or replacement.
Breast Reconstruction Protocol - best options after breast cancer surgeryBreast Reconstruction

 

IMMEDIATE VERSUS DELAYED BREAST RECONSTRUCTION

  • Immediate breast reconstruction:
    • This is becoming the norm.
    • Before the 1990’s there were fears that immediate breast reconstruction was unsafe. The concern was early reconstruction could risk cancer recurrence. However, several studies have shown that immediate reconstruction offers many advantages and is just as safe as delayed reconstruction for early stage breast cancer.
    • Skin-sparing mastectomy is performed to remove the interior breast tissue and nipple areolar complex while keeping the external skin. The plastic reconstructive surgeon then restores the breast volume within this breast skin envelop. The ability to preserve the native breast skin envelop is extremely important in producing natural looking result.
    • Immediate breast reconstruction has a huge positive psychological benefit for the patient who wakes up from the surgery without feeling the loss of body form.
    • It is also more cost effective as a single stage procedure versus delayed reconstruction.
  • Delayed breast reconstruction ;
    • This is losing popularity.
    • Simple mastectomy is performed to remove the breast tissue and overlying breast skin envelop.
    • When reconstruction is done much later, there is more residual scar and the appearance is less natural compared to immediate reconstruction.
    • Delayed breast reconstruction is preferred in advance breast cancer (which carries higher risk of recurrence).

 

METHODS OF BREAST RECONSTRUCTION

AUTOLOGOUS RECONSTRUCTION

  • It is ideal to perform reconstruction using the principle of “replacing like with like”. Therefore, autologous breast reconstruction using patient’s own tissue is preferred whenever possible.
  • The result is long-lasting and the reconstructed breast tend to appear more natural in appearance and consistency.

 

Transverse Rectus Abdominis Myocutaneous (TRAM) Flap

  • The transverse rectus abdominis myocutaneous (TRAM) flap is the most common autologous breast reconstruction procedure.
  • It is similar to a tummy tuck which removes excessive lower abdominal skin and fat together with a portion of the abdominal muscle, transferring it to the breast for reconstruction. The nett result is a flatter tummy and reconstructed breast.
  • Patients who had previous Caesarean delivery may also undergo this procedure.
Pedicled TRAM flap harvest after mastectomy for immediate breast reconstruction - breast cancer surgeryPedicled TRAM flap harvest after mastectomy for immediate breast reconstruction
TRAM flap placed inset into the remnant breast skin envelop - breast cancer surgeryTRAM flap placed inset into the remnant breast skin envelop – Best breast reconstruction method
Breast Reconstruction - TRAM Flap - Post operative appearance with drains - breast cancer surgeryBreast Reconstruction – TRAM Flap – Post operative appearance with drains – Best breast reconstruction method

 

Latissimus Dorsi (LD) Flap

Latissimus Dorsi (LD) Flap for Breast Reconstruction - alternative top option breast cancer surgery Latissimus Dorsi (LD) Flap for Breast Reconstruction – alternative top option
  • The latissimus dorsi (LD) flap is the alternative if the patient wishes to be pregnant after cancer treatment (in which case the TRAM flap is not suitable).
  • The LD muscle is a fan-shaped muscle from the back. It is a thin muscle and does not provide much volume. Breast implant may be needed to supplement the LD flap if more volume replacement is needed.

 

ALLOPLASTIC RECONSTRUCTION

Breast Implant and Tissue Expander for Breast Reconstruction - Single stage or two stage reconstruction breast cancer surgery Breast Implant and Tissue Expander for Breast Reconstruction – Single stage or two stage reconstruction
  • Breast reconstruction using implant is a simpler and faster procedure. The recovery process is usually more straight forward because there are fewer wounds involved.
  • In some instances, the residual skin envelop after mastectomy appear thin. A tissue expander is used to gradually stretch the skin before final placement of definitive breast implant.
  • The disadvantage of implant reconstruction is the difficulty to match the shape of the contralateral unoperated breast.
  • Other considerations include implant rupture or capsular contracture (scarring around the implant).
  • The initial cost of implant reconstruction may be lower, but the long term cost may even out.

 

HOW SHOULD PATIENT DECIDE ON THE METHOD OF BREAST RECONSTRUCTION ?

 

  • Autologous breast reconstruction is recommended if the patient’s priority is a natural appearance and softness with long-lasting result which matches the contralateral breast well. She must be willing to accept a higher initial cost, longer surgery and additional scar from the tissue donor site.

 

  • Breast reconstruction using implant is suitable for patient who wish for simpler and shorter surgery and lower initial cost. Those patient in poorer health may elect this method of reconstruction. She must bear in mind the possibility of further revision surgery for change of implant. She would also accept less than ideal match of breast shape with the contralateral side.

 

ANCILLARY PROCEDURES AFTER THE INITIAL RECONSTRUCTION

  • Nipple reconstruction :
    • 4-6 months after the first stage of breast reconstruction.
    • Local breast skin tissue is used to reconstruct a new nipple.
  • Nipple areolar tattooing
    • 1-2 months after nipple reconstruction to provide colour to the reconstructed nipple and areolar.
  • Fat transfer :
    • Optional procedure to correct contour imperfections of the reconstructed breast if necessary.

 

TIMELINE OF BREAST RECONSTRUCTION

Breast Reconstruction Timeline - recommended schedule for breast cancer surgeryBreast Reconstruction Timeline – recommended schedule for best possible result

 

RISK AND COMPLICATION

  • Bleeding
  • Wound infection
  • Implant-related complication :
    • Infection
    • Capsular contracture
    • Rupture
  • Abdominal herniation or bulge
  • Scarring

 

FINANCIAL COUNSELLING

  • Immediate breast reconstruction done together with mastectomy is insurance and Medisave claimable.

 

During the consultation, Dr Ng would guide you to choose the best breast reconstruction surgery methods most commonly used by some of the top plastic surgeons in Singapore and other parts of the world.