Category: breast

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

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

Breast 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 envelope. 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

TRAM flap placed inset into the remnant breast skin envelop – Best breast reconstruction method

Breast 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

• 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 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 wishes for a simpler and shorter surgery and lower initial cost. 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 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 performed simultaneously 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.

• A permanent way of augmenting the breast shape and volume by transferring fat from another part of the body e.g. the abdomen or thighs.
• The fat is processed and injected under the skin (in the subcutaneous plane) of the breasts, and not into the actual breast tissue.
• The technique of injection is very crucial to the survival of fat. The fat is gently injected using multiple small 1 ml syringes depositing the fat in small aliquots (parcels). This ensures the largest surface area for maximal diffusion of nutrients from surrounding tissue and thus enhance survival of the fat cells.
• At least about 60-70% of the fat injected survive. These cells will permanently live in the injected site.
• The fat injected contain a small amount of patient’s own stem cells which helps to rejuvenate the skin.
• The amount of fat injected in each session should not be excessive. Otherwise the resultant swelling would reduce blood flow to the fat cells and thus lower their survival rate. Therefore multiple sessions of fat transfer may be needed to achieve the desired volume.
• Realistically each session of fat transfer can increase the breast volume by half to one cup size (75 – 150 ml)
• The survival of fat injected into the breast can be further enhanced by wearing the Brava Device.
  • A device that uses a negative pressure to stretch the breast tissue
  • It is worn for more than 10 hours day for at least 2-4 weeks after the fat transfer procedure
  • This promotes better blood circulation within the breast tissue that helps fat survival
• Fat transfer to the breast generally does not affect breast feeding.

CONCURRENT PROCEDURES

• Patients undergoing liposuction of the abdomen and thighs may transfer the unwanted fat to the breasts
• Mummy makeover which consists of tummy tuck and breast augmentation. Fat transfer to the breast can be considered instead of breast implants.
• Fat transfers to face and breast concurrently.

SUITABLE CANDIDATES

• Patients who do not want augmentation using a foreign body.
• Sufficient fatty deposits in the abdomen or thighs.
• Willing to undergo more than one session of this procedure.
• Willing to accept less dramatic and instantaneous results.
• Suitable for :
  • Tuberous breast..
  • Mild breast deflation after breast feeding
  • Widened cleavage post breast implant insertion.
  • Breast contour deformity post breast cancer surgery reconstruction.

DESCRIPTION OF PROCEDURE

• Injection of tumescent fluid (to control bleeding) into fat donor site (abdomen and/or thighs)
• Fat is gently syringed out from the abdomen and/or thighs via well-hidden small cuts (less than 1 cm)
• Fat is processed using Coleman’s technique : Harvested fat is then centrifuged and separated into 3 layers : upper layer of free oil, middle layer of usable fat, and lower layer of water, blood and tumescent fluid.

Fat Transfer Technique

• The usable fat is gently injected into the breast under the skin, using multiple small 1 ml syringes depositing the fat in small aliquots (parcels).
• The injection sites in the breast are well hidden in the areola.
• Duration of procedure (depending on complexity) : 1.5 – 3 hrs

ANAESTHESIA

• General anaesthesia
• Combination of local anaesthesia with intravenous sedation

POST OPERATIVE COURSE

• Home on the same day.
• Support bra for 1-3 months.
• Medication to reduce swelling and pain.
• Swelling, bruising and tightness over the breast for about 2 weeks.
• Sutures over the small injected sites are removed after 1 week.
• Light exercise from 3-4 weeks after procedure.
• Final results usually seen in approximately 3 months.

FINANCIAL COUNSELLING

• Fat transfer for the management of tuberous breasts or post breast cancer reconstruction may be considered as non-cosmetic.

RISK AND CAUTION

• The transferred fat that did not survive can result in a small amount of calcium deposits (macrocalcification) appearing in a mammography. This is different from microcalcification (which is indicative of breast cancer). Meticulous injection technique is important in preventing this.
• Fat injection does not increase the chance of breast cancer. Patients are often confused about this point.

After consultation, Dr Ng would guide you to decide on the best surgery for breast enhancement i.e. fat grafting (transfer) to breast or breast augmentation using implant. Structural fat grafting to the breast remains a top choice of some of the best plastic surgeons in Singapore and around the world.

What are the various methods of breast enhancement ?

There are surgical and non-surgical methods and combination of both. Breast augmentation using implant is still the most common option. Patients who are not keen on foreign material may consider the Brava (negative suction device) or a combination of Brava with fat grafting to the breast. Artificial filler injection has been controversial and associated with undesirable complications.

Is fat grafting to the breast effective ?

Each session of fat grafting to the breast can increase the breast volume by half to one cup size. This can result in soft and natural breast consistency. Fat is harvested from the abdomen and thighs in a non-traumatic fashion. It is then processed after centrifugation. Injection is done very carefully in the subcutaneous layer of the skin to ensure optimal survival of the fat cells. Non-surviving fat cells does not turn cancerous but leave behind calcification that may cause confusion during mammography. Several sessions may be necessary to achieve the desired outcome.

What are the various types of breast implants and are they safe ?

Breast implants can be filled with saline or silicone. They are either circular or tear drop (natural profile) in shape. The most common implant used nowadays contains cohesive silicone gel in tear drop shape. This type of implant simulate the natural appearance of the breast and its content resists extensive leakage even when the implant is ruptured. Silicone breast implant has good safety record.

What are the considerations when choosing breast implants ?

The main points of discussion with your surgeon would include size, type of implant, location of the cut (incision), and placement of the implant. During the consultation, your plastic surgeon would let you try a variety of implant sizes to simulate the outcome.
The commonest incision is at the breast fold which is well-hidden. This incision affords easy access and allows more accurate orientation of tear drop shape implant. Incision in the arm pit used to be popular with round implant. Incision around the areolar can affect nipple sensation and limit the size of implant if the areolar is small.
In most Asian patient with smaller breast volume, the implant is usually placed behind the chest muscle (subpectoral). This placement provides more soft tissue coverage and reduces the incidence of capsular contracture (scarring) around the implant.

What is the recovery process after breast implant surgery?

Breast enhancement can be done as a day surgery procedure. Most patients return to work within a few days and the post- operative swelling and bruising would resolve in about two weeks. Self-massage would be taught to hasten the recovery.