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What type of breast reconstruction is best?

If you have been recommended to have a mastectomy (removal of the entire breast) as part of breast cancer surgery treatment, then you should be offered the choice of having breast reconstruction. Some women may not choose to have any form of breast reconstruction and opt out to have a simple mastectomy i.e. go flat. However, for others, reconstruction may be something they would like to consider undertaking.

What type of breast reconstruction is best does depend on many factors. The surgeon should have a thorough discussion with you, outlining the various options available. The type of breast reconstruction that is best suited to you, however, does depend upon various factors including: the biology of the cancer, the need for adjuvant treatment such as chemotherapy and / or radiotherapy, your body shape and size, whether you have had any previous surgery, and your lifestyle and personal choice. Smoking and having a high body mass index (BMI) may also play a factor. Several clinic consultation discussions are usually needed in order to go through all the options.

Deciding upon which breast reconstruction to have can sometimes be difficult and confusing, and your surgeon, as well as your breast care nurse, will help and guide you in the decision-making process.

What is immediate breast reconstruction and delayed breast reconstruction?

Breast reconstruction can take place either at the same time as the cancer operation (immediate reconstruction) or at a later stage (delayed reconstruction). There are pros and cons to both.

Some women choose to have an immediate breast reconstruction for various reasons. Usually the main driver for an immediate reconstruction is that for some women, going ‘flat’ i.e. having no breast mound, is not an option. Having an immediate reconstruction means that this situation can be avoided.

An immediate breast reconstruction may also minimise the number of general anaesthetics although this does depend on the type of reconstruction that is planned.

However, if there are any surgical complications, wound infections or delayed wound healing, then this may delay any subsequent planned adjuvant treatment, such as chemotherapy or radiotherapy.

Some patients prefer to have a delayed reconstruction as it gives them time to deal with the cancer diagnosis. Deciding whether to have breast reconstruction when dealing with a cancer diagnosis can be overwhelming, and some choose not to consider this until much later on.
Mastectomy wounds generally heal reasonably quickly which should not delay starting adjuvant treatment if needed. If radiotherapy is given, then generally reconstruction will be delayed for at least 6 months afterwards. A prosthesis that is placed in the bra can be used to give a breast shape in the meantime.

Having a delayed operation, however, means that additional general anaesthesia will be needed for the reconstruction surgery. In addition, the patient will have to live without a breast until such time that the reconstruction surgery happens.

What are the different types of breast reconstructions?

Breast reconstruction can be divided into implant based reconstruction and autologous based (using your own body tissue) reconstruction.

Implant based reconstruction

This is the quickest surgery to perform and to recover from. Some hospitals perform this as a day case which means you do not need to stay overnight in the hospital and can go home the same day as your surgery. Most women are back to their normal selves within 4 weeks.
Implant-based reconstruction will use only one scar on the breast. The implant itself is normally placed under the pectoralis major muscle (chest wall muscle) that is lifted off the rib cage (sub-pectoral reconstruction). Sometimes surgeons may also use either a mesh or a special synthetic material called an acellular dermal matrix (ADM) or mesh to cover the bottom part of the implant.
More recently some surgeons are now placing the implant underneath the skin only having wrapped the implant with an ADM (pre-pectoral reconstruction).

Implant surgery does require ‘maintenance’ surgery’. As breast implants do not last forever, at some point in the future the implant will need to be replaced. This could be for a number of reasons including; implant leak, rupture, migration and capsular contracture. When that time will come is impossible to predict.

If you are slim built, then it is not unusual to be able to feel the rippling of the underlying implants. This can be bothersome for some women.

In addition, there is no way around the fact that you will feel the presence of an implant. This is especially true when you lie on your front or side.

If there is a chance that you may need radiotherapy treatment, then there is a risk that an implant-based reconstruction may not give the best aesthetic outcome. Some surgeons may either advise against having an implant-based reconstruction or will make you aware of the possible risks involved. These include capsular contracture, wound healing issues, infection and possible implant loss.

Autologous (tissue) reconstruction

The following reconstructive options fall into the category of ‘autologous’ reconstruction (using your own body tissue).

Latissimus dorsi (LD) reconstruction

The LD muscle is a large muscle on your back, situated over your scapula. This muscle works together with other muscles around your shoulder to enable you to perform actions such as pushing you up from the bed or chair and pulling movements. The absence of this muscle, however, does not stop you from doing these activities in the future, as other muscles around the shoulder will compensate.
In this type of reconstruction, the LD muscle is lifted off the ribcage at the back, tunnelled through an opening in your armpit and used to fashion a breast mound.
You will have two scars, one on the breast, the other on your back.

This operation can take around 4 hours and occasionally an implant may be needed to boost the volume if the muscle bulk is not sufficient. Recovery time may take about 6-8 weeks.

DIEP flap based reconstruction

DIEP stands for Deep Inferior Epigastric Perforator, which is the blood supply that keeps this particular flap alive and healthy. This is a reconstruction that uses the fat and skin around the abdomen (tummy). Some refer to this reconstruction as similar to having a ‘tummy tuck’ at the same time, which on one hand is true, however, that should not be the only reason why this is chosen over the other reconstruction options.
This surgery is the longest to do, taking anything between 5-6 hours, and takes the longest to recover fully, about 2-3 months. The skin, fat and the DIEP vessels are detached from your body and reattached to vessels within your chest wall or armpit, using microsurgical techniques. Sometimes, an opening in one of your chest wall ribs may be made in order to find the vessels for attachment.
You will have two scars, one on the breast, the other along the bottom part of your abdomen (similar to a C-section scar but extends across the entire width of your lower abdomen).
This type of operation is performed jointly between breast and plastic surgeons.

The reconstructed breast does feel the most natural and if it is successful (and only about 2-3% fail), then you won’t need any further maintenance surgery.
However, as the stakes for this surgery are high, many surgeons won’t operate on women who are smokers or are overweight with a high BMI (body mass index) as these two factors increase the risk of complications.

Some surgeons may also choose not to do this surgery if there is a chance that radiotherapy is needed post-surgery. This is because they would prefer for the flap not be subjected to radiotherapy and instead would perform this surgery in the delayed setting.

TUG based reconstruction

TUG stands for transverse upper gracilis and it is most superficial muscle found in the upper inner part of the thighs. This muscle’s function is to bring the thighs inwards, but its absence does not affect this movement.

However, there is not a great deal of tissue bulk here and this reconstruction is suitable if you want to achieve a small breast volume and do not wish or unable to have a DIEP based reconstruction due to previous abdominal surgery for example. You will have two scars, one on the breast, the other along the upper inner part of your thigh, which is usually well hidden.
The operation may take 5-6 hours and recovery may take 6-8 weeks.

Conclusion

The ultimate decision about which type of breast reconstruction most suitable for you involves extensive discussions between you and your surgeon. Factors such as your lifestyle, the need for adjuvant treatment such as radiotherapy, your general health and choice will determine which is the right choice for you.

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