Dr. Dirk Lazarus, Plastic Surgeon, Cape Town, South Africa

The diagnosis of breast cancer or the loss of a breast is a difficult time for a woman. Not only does she have to deal with the cancer and its consequences, but she might have to cope with feelings of loss of her femininity, lowering of her self esteem and self confidence, depression, anger and so on. Fortunately, plastic surgery can offer women who are due to undergo mastectomy or who have undergone mastectomy the option of a breast reconstruction procedure. A breast reconstruction procedure can in many cases restore a breast and often result in an overall enhancement of body shape, as well as an improvement in self esteem and general well being. With current breast reconstruction techniques, a breast of similar size and shape to normal can now be created. When a woman opts for a breast reconstruction it is often a sign of positivity and acceptance on her part. Breast reconstruction is not a single procedure - many options are available depending on the individual woman's figure and desires.

This information will give you a basic understanding of the procedure - when it is appropriate, how it is done, and what results you can expect. It cannot answer all of your questions, since a lot depends on your individual circumstances. Please be sure to ask if there is anything you do not understand about the procedure.

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Who is a candidate for breast reconstruction?

Any woman who has lost or who is about to lose a breast or part of a breast may be a candidate for breast reconstruction. Although breast reconstruction is usually performed for women who have had breast cancer, breast reconstruction may be performed for other causes of breast loss or inadequacy (e.g.: Poland's syndrome, trauma, etc.). Breast reconstruction may be performed at the same time as mastectomy (immediate reconstruction) or at any time thereafter (delayed reconstruction). Not all women desire a breast reconstruction and for some women other alternatives, such as a padded bra, or nothing at all may be more suitable.

The healthier and fitter you are, the less risky surgery is. Factors which make surgery more risky include smoking, obesity, heart or lung disease, diabetes and extremes of age.

The reconstruction has no effect on any subsequent treatment, whether it is radiotherapy, chemotherapy or hormone treatment. Also, a reconstruction will not interfere with the further check-ups for breast cancer that will be needed.

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What are the risks?

All surgery caries some risk. General problems that may occur with surgery include bleeding, infection, collection of fluid, excessive scarring, or difficulties with anaesthesia. Although they are uncommon, any of these complications or others can occur. Complications are more frequent in women who smoke. Depending on the type of reconstruction opted for, there are additional specific complications which may occur.

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When should the reconstruction be done?

Ideally, if you are considering reconstruction, you should consult with a plastic surgeon as soon after the diagnosis of breast cancer is made so that you can be advised of your reconstructive options before you start treatment. Clearly this is a difficult time for a woman, the diagnosis of cancer having just been made, much of what might be said will not be remembered. A second consultation can (should) always be scheduled to discuss matters further. Do not be afraid or shy to ask questions at any time.

Reconstruction done at the time of mastectomy usually achieves a better cosmetic result than if it is done some time after mastectomy. Some women opt for a reconstructive procedure many years after their initial mastectomy, while other women do not desire a reconstructive procedure and are content to pursue other alternatives such as a padded bra or nothing at all. You should do what you feel comfortable with and should not rush into any procedure without due thought.

Once the diagnosis of breast cancer is made, the oncologist, surgeon and other members of the breast team will decide, in consultation with you, the best treatment of the cancer. The options are variable and may include mastectomy (the removal of the whole of the breast), wide local excision (removal of the cancer/lump and surrounding tissue), radiotherapy (which requires several visits back to hospital for treatment sessions), chemotherapy and hormone therapy.

Whether you opt for a breast reconstruction procedure or merely a mastectomy is entirely your choice. If you do change your mind at any stage, whether before or after the mastectomy, your wishes can still be accommodated - a breast reconstruction procedure can be done at any time.

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What kinds of breast reconstruction techniques are available?

For some types of breast cancer there may be no difference in relative cure if the breast is treated by mastectomy or by wide local excision and radiotherapy. Although with wide local excision you will keep your breast, it may result in a considerable loss of breast tissue. In addition, the scarring caused by the subsequent radiotherapy that is required, may cause the breast to contract further. Most plastic surgeons feel that the cosmetic result of mastectomy and reconstruction is better than that of wide local excision and radiotherapy, although this depends on the individual case and this opinion may not be shared by your oncologist or general surgeon. Some woman feel relief at having the entire breast removed since the breast has malignant change in it anyway. Ultimately you will have to make your own decision guided by the professionals.

If you are to undergo a mastectomy and you are relatively fit, you will be given the option of having an immediate breast reconstruction. Whether you want just the lesser procedure of the mastectomy alone or whether you wish to have the additional surgery required for the reconstruction is a decision that only you can make. Some reconstructive procedures such as the insertion of a prosthesis or implant are relatively small procedures that add little to the time and complexity of the operation. Most flap reconstructions, on the other hand, allow for the creation of a more natural breast, but the surgery takes longer and is more complex. The Plastic Surgeon can advise you of the options available to you. Factors which influence the type of reconstruction that you may be suitable for include your general health, age, weight, previous operations, size and shape of your breasts and whether or not you smoke.

It is important to remember that your primary operation is for cancer and that the aim of treatment is to get rid of the cancer. The reconstruction is done with the aim of making a breast to the size and shape that you want. If you have always had breasts that are too large or too small you can discuss the option of having them reduced or augmented at the same time as the mastectomy or reconstruction. It is important, however, that your expectations and goals are realistic and that you understand the limitations of what can be achieved. Although post-mastectomy reconstruction can improve your appearance and renew your self-confidence, it is important to bear in mind that any reconstruction will not achieve an entirely normal breast: scars will be present and the shape and size may be different from previously.

Breast reconstructions are usually covered by medical aids. The operations are performed in a hospital theatre and you will be asleep under general anaesthesia for the duration of the procedure. Mastectomy takes between one and two hours. Depending on the type of reconstruction, the surgery can take from one hour to eight hours or longer.

A number of breast reconstruction techniques exist. For the best results, it is important to choose the method that is right for you. As this can be a difficult time for you, you will have to rely to a large extent on the guidance of the plastic surgeon and other doctors who are treating you. The factors that influence the choice are:

Your desires
What you are suitable for: the size and shape of your breasts, your body fat distribution
What you are fit for: your age, general health, are you a smoker?

Breast reconstruction techniques fall into two main categories:

Breast reconstruction using some form of implant
Breast reconstruction using your own tissue (flap technique)

In general, women with small to moderate size breasts and not much breast droop are suitable for reconstruction with an implant. Women with a bit of a tummy and slightly larger breasts may be better suited for a flap reconstruction. Occasionally both an implant and a flap are needed.

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Types of reconstruction

Implant
Some women, especially those who have small breasts without much droop, can have a quick and simple reconstruction performed by having an implant placed beneath the chest wall muscles on the side of the mastectomy. A breast implant is a silicone shell filled with either silicone gel or a saltwater solution (saline). The commonest complication of implants is capsular contracture. Capsular contracture is the formation of a hard scar around the implant. This can become painful with time and may require removal of the capsular contracture and replacement of the implant. Implants rarely become infected or move.

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Tissue Expander
Some women may require the formation of a slightly larger breast and/or one with more droop than can be created by the insertion of an implant alone. These women may be suitable for reconstruction with a tissue expander.

A tissue expander is similar to a balloon in that it can be inflated (but with saline, not air). The tissue expander is implanted under the muscle, and once the initial incisions have healed (usually after a three weeks) inflation is started. Inflation is done simply in the outpatient department or rooms as a weekly injection of saline into the tissue expander. Once the expander has reached the appropriate size, it is removed and replaced with a permanent breast prosthesis. This requires a second, small operation. A special type of tissue expander (called a Becker), is designed to be left in place after expansion. The Becker expander-implant is considerably more costly than normal expanders and implants.

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Flaps
The use of flaps (the woman's own body tissue, also called autologous reconstruction) has several advantages over the use of an implants. It provides soft, warm tissue that forms a natural looking breast, often with the added advantage of a free tummy tuck. The commonest flap used today is the TRAM flap which comes from the lower tummy (below the belly button and between the hip bones). The TRAM flap does however leave a long scar across the bottom of the tummy (usually hidden in the panty line). The operation is relatively long (4-5 hours). Although the TRAM flap will make the best breast, sensation in that breast may be poor. Better results are obtained if the reconstruction is performed at the same time as mastectomy rather than at some stage later, especially if a skin sparing mastectomy is done and the TRAM flap buried like a breast implant.

Occasionally other flaps may be used. The latissimus dorsi flap is taken from the big muscle of the back and can be used in such a way that the scar lies underneath the bra strap. This flap usually requires the use of an implant as well as it does not have the bulk of the TRAM flap. Other flaps that have been used but which are not routinely done may come from the buttocks or hips.

The creation of the breast mound is merely the first stage in breast reconstruction. Six months to a year after the breast mound has been created, the next stage can be done if desired. Many women are happy with the breast mound alone and do not opt for further surgery.

Subsequent stages consist of: creation of a nipple and areolar, minor touch ups to the reconstructed breast and attention to the other breast. The areolar can be created in one of two ways: either as a skin graft taken from the upper thigh, buttock, opposite breast, or some other site, or by means of tattooing if this facility is available. The nipple is usually created from the skin of the breast mound. This operation (creation of a nipple-areolar) is a small procedure and can be done as an outpatient or day case, under local anaesthesia if preferred.

Concurrently with the first or second stage of breast reconstruction, the other breast can be reduced, lifted or augmented to achieve greater symmetry with the reconstructed side. In addition minor touch ups may be performed to the reconstructed breast to improve its shape.

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How should one prepare for the operation?

In general you should be fit to have the procedure. Ideally the operation is done when you are at your normal weight and no specific diet or exercise program is required prior to surgery. It is advisable to stop smoking at least one week prior to surgery and not to smoke till the wounds have healed - about two weeks after the operation. It is well known that there is a higher frequency of complications in women who continue to smoke. Best of all stop smoking altogether.

On the day of surgery you should be feeling fine and not have flu, a cold or any other illness. It is wise to shower or bath and wash well the morning of surgery.

The first stage of reconstruction, creation of the breast mound, is almost always performed under general anaesthesia, so you will sleep through the entire operation. Follow-up procedures may require only a local anaesthesia, combined with a sedative to make you drowsy or may be done under general anaesthesia.

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What can be expected after the surgery?

Strong pain killers will be given to you following the operation so that you should only experience some discomfort. After most operations for breast reconstruction, you will be left with surgical drains in place - these allow the removal of excess fluid which may accumulate at the operation site. They are generally removed a few days after the operation. Most of the time stitches that are used are dissolving, but sometimes some sutures will require removal about 10 days following the surgery.

You will initially feel tired and sore after the operation. Nevertheless, it is a good idea to get up out of bed on the day following the surgery so as to prevent the formation of blood clots in your legs. Depending on the type of operation you had, you will remain in hospital from one to ten days. You are likely to feel tired and sore for a week or two after reconstruction. You should refrain from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following reconstruction.

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How long does it take to get back to normal?

It may take you up to six weeks to recover from a combined mastectomy and reconstruction or from a flap reconstruction alone. If implants are used without flaps and reconstruction is done apart from the mastectomy, your recovery time may be less.

Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. Most scars will fade substantially over time, though it may take as long as one to two years. They will never disappear entirely. The better the quality of your overall reconstruction, the less distracting you will find those scars.

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What will I look like after the procedure?

You will look better after a reconstruction. Chances are your reconstructed breast may feel firmer and look rounder or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. But these differences will be apparent only to you. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.

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