Why having a breast reconstruction?

In our society female breasts are still perceived as an important feature and symbol of femininity. Consequently, various different emotional reactions in response to breast surgery are observed. In many cases a breast amputation has a profound effect on a woman's well-being. It may result in serious feelings of insecurity, discomfort or infemininity. Daily matters such as for example the selection of clothing and personal care may become a mental burden. The mental and psychosocial effects of breast amputation are difficult to cope with.

When considering the viability of a breast reconstruction after amputation, one needs first to be or become aware of the underlying personal motives. Realistic expectations concerning the surgical possibilities and obtainable results need to be assessed in consultation with the plastic surgeon. It is an established fact that the result of a breast reconstruction is strongly influenced by the existing pre-operative proportions of your body, as well as by the tissue quality in the amputated area. Ultimately, the personal qualification of the degree of success of the breast reconstruction compared to your expectations determines the final success of this reconstruction.

Who does qualify for a breast reconstruction?

The management of breast cancer is a multidisciplinary challenge with the involvement of a (general) surgeon or a gynaecologist, a radiologist, an internist and a plastic surgeon. Nowadays breast sparing surgery is an important alterative by which optimal cancer treatment is combined with acceptable aesthetic results. Regrettably, in many cases a breast amputation cannot be prevented, especially in case of large or multifocal tumours or in case of a very small breast.

A breast reconstruction operation can be carried out either immediately, i.e., at the time of the amputation, or at a later point in time. The surgeon will advise you with respect to the most appropriate time of treatment in your case. Delayed reconstruction is generally done one year or more after the amputation, mainly to allow the scar to mature.

The reconstruction technique to be used in a particular case is dependent on the patient's desires, personal appearance, and what is surgically achievable. Basically, during the operation tissue is transferred to the side of the amputation, which means per definition that the reconstructed breast will remain insensitive. Oncological follow-up will not be impeded by any reconstruction. Most of the costs of a breast reconstruction operation are reimbursed by your health insurance plan.

Reconstruction by means of a breast prosthesis or tissue expander

The presence of a normal breast muscle and healthy soft tissue at the amputated side is a necessary prerequisite for the application of this technique. Irradiation in the past or future irradiation is a contra-indication, since having undergone irradiation therapy increases the risks of post-operative complications. A normal breast prosthesis can be placed beneath the breast muscle, if the skin is sufficiently elastic, or in case of subcutaneous mastectomy. Both circumstances are rarely present. Otherwise, a tissue expander has to be placed beneath the breast muscle to allow for slow expansion of present soft tissues. The tissue expansion will start approximately three weeks after the insertion of the expander. Expansion will be continued for a time period of two months or until the desired volume is reached. The expander itself can be compared with a water-filled breast prosthesis. However, as there is a significant chance of expander leakage it is generally advised to replace the expander by a permanent breast prosthesis during an additional secondary intervention. The kind of complications and the duration of the hospital stay are generally the same as for cases of augmentation mammoplasty (see folder). Unfortunately, due to the lack of breast tissue overlying the prosthesis, capsule formation will be sooner regarded as disturbing, compared to what is the case in augmentation mammoplasty.

Latissimus dorsi muscle breast reconstruction

When this technique is applied the latissimus dorsi muscle of the back is transferred with its overlying skin to the amputation side. The donor area at the back will be closed primarily, resulting in a horizontal scar that later can be covered by the bra. Functional deficits due to the usage of this muscle are negligible. However, the volume of this tissue is unfortunately seldom sufficient to allow for symmetry with the normal breast, consequently in most cases an additional breast prosthesis needs to be placed beneath the transferred tissue. Complications are rare and are principally of the same nature as observed in augmentation mammoplasty (see folder). Sometimes fluid accumulation can occur at the donorside on the back. If so, needle aspiration and compression bandages are adequate treatments. Pain at the donorside will usually disappear after three weeks. Although the back scar is usually placed in the bra line, the scar is sometimes widened due to the large mobility of the back area. The duration of the hospital stay is generally 4-5 days. In order to increase symmetry, it can be advised to have an additional small prosthesis placed at the healthy side as well.

Breast reconstruction using abdominal tissue

(TRAM, DIEP of SIEA flap) Lower abdominal wall tissue, as resected during a tummy tuck operation, will be transferred to reconstruct the amputated breast. This tissue can be transferred either pedicled on the central abdominal muscle, or free (with microsurgical repair of the inferior epigastric vessel to i.e. the axillary vessels). Using the free technique, dependent on the individual anatomy, the central abdominal muscle can be spared either, partly or completely. The reconstructed breasts will feel soft and natural due to the use of abdominal tissue. The abdominal scar is identical to that which remains after a tummy tuck intervention. If a large part or the complete abdominal muscle is sacrificed, a mesh will be used to close defect in the abdominal wall. Nonetheless, sometimes bulging of the abdominal wall is observed, mainly after a pedicled technique. Herniation of the abdominal wall is rather exceptional. If herniation occurs, another operation using a large synthetic mesh to reinforce the abdominal wall will be necessary. Every tissue transposition or transplantation bears the risk of tissue loss due to vascular compromise. In approximately 10 percent of the pedicled transfers, delayed wound healing can be observed at the margins of the transfer. Free transfer bears the risk of thrombus formation at the anastomosis side. Surgical re-exploration with removal of the thrombus is only possible within the first hours of thrombus formation. Irreversible thrombus formation with complete flap loss is observed in 3-5%. Other reconstructive techniques have to be considerated in these cases. Other complications at the donor side are similar to those after a classical tummy tuck intervention. Hospital stay is generally 6 days, heavy lifting is forbidden during the first postoperative month. Once healed, the reconstruction can be regarded as stable throughout the remaining life span.

Nipple- and areolareconstruction

Nipple-areola reconstruction is generally delayed for four up to five months after the surgery to allow the reconstructed breast to descend slightly in a natural way. If symmetry is insufficient at that time, nipple areola reconstruction can be combined with a secondary correction. Normally nipple-areola reconstruction is carried out under local anaesthesia. The nipple is reconstructed using local tissue, followed by a tattoo of the areola complex.