Breast Cancer and Breast Reconstruction

Types of Breast Reconstruction

There are several options in breast reconstruction, which can be divided into two main groups:

Autologous using one’s own tissue, creating a flap and implant only reconstruction. The breast is best replaced with tissue like (DIEP/SGAP/TMG) flaps.

‘Flap’ is a term to describe a group of different types of tissue together with a blood supply keeping all of the tissue alive. For breast reconstruction, the ‘flap’ is the living tissue including skin, fat and muscle that can be moved from one site in the body to form the new breast mound. As it is living tissue, it requires a blood supply.

These procedures take longer as they require microsurgical transfer of tissue from one area of the body to another and re-connection of blood vessels. If these approaches are not desired or indicated, a simpler flap can be performed using muscle and skin from the back area, just underneath the shoulder blade.

This procedure is called the latissimus dorsi flap and is usually combined with an implant. For patients wishing to have implant-only reconstruction, depending on the breast size and shape either a single or two stages procedure has to be performed.

Deep Inferior Epigastric Perforator Flap (DIEP Flap)

In the DIEP flap excess abdominal skin and fat from the lower part of the abdomen is used. The blood vessels, which run through the abdominal rectus muscle are meticulously freed prior to transfer to the chest.

Unlike the TRAM flap the muscle is not necessary for reconstruction. As a result of a less invasive procedure, patients are able to resume their pre-operative activities much sooner after surgery.

In these procedures, the abdominal tissue is completely detached from the abdomen and re-attached to the small blood vessels in the breast area, resulting in a microsurgical tissue transfer.

These tiny blood vessels require the surgeon to use a microscope to connect them together. Once this is complete, the blood flow to the tissue is restored. The tissue is then shaped to fit the mastectomy defect to re-create

The skin from the abdomen will be used later to reconstruct the nipple. For patients who underwent a complete mastectomy, the abdominal skin is used to replace the missing breast skin.

In a DIEP flap, the operation leaves a horizontal scar on the lower abdomen, similar to that created in a cosmetic tummy tuck.

This operation is performed under general anesthesia and takes around four to six hours. Resulting in a hospital stay for a period of four to five nights.

Risks and Possible Complications:

There are a number of risks common to any surgical procedure, for breast reconstruction in particular the early days following surgery i.e. bruising, swelling and general discomfort is likely to occur.

At first, your new breast will be larger than your other breast, this is usually due to inflammation and swelling after surgery. It should gradually get smaller over a few weeks or months.

After about a week following your reconstruction it is likely you will have temporary reduced sensation of the abdominal wall as well as reduced or no sensation of the reconstructed breast.

Recovery:

Immediately after your operation you will feel bruised and sore and as mentioned previously swelling will occur.

Pain is usually moderate and can be controlled with standard painkillers. There will be drains in the chest and abdomen, which will be removed between two - five days later. If all goes well you should be out of bed by the next day and the few days following this you will increase the amount of walking you do.

Many Woman want to know when they can get back to doing everyday activities such as socialising with friends, returning to work, driving and going to the gym this will obviously vary depending on the type of surgery you have had how each individual is feeling. Consultant advice for the body to healit may take several weeks to see the final outcome of your surgery.

Superior Gluteal Artery Perforator Flap (SGAP Flap)

The SGAP flap or buttock flap, is ideal for those who do not have an adequate amount of excess tummy tissue.
The breast may be reconstructed with the skin, fat, and the tiny blood vessels taken from the buttock area to achieve a B or C cup breast size.
The SGAP flap procedure uses tissue from the top part of the buttock without injury or sacrifice of the underlying muscles.
A slight buttock lift results in the donor area with a fine line incision easily hidden within the panty line. The tissue is then transplanted to the breast and a microscope is used to connect the blood vessels supplying this tissue to those at the mastectomy site. The tissue is then sculpted into the new breast mound.

The SGAP flap procedure are considerably more demanding and lengthier than earlier methods of breast reconstruction due to the complex anatomy of the tiny blood vessels. However, the surgical effort is rewarded by the excellent aesthetic results that can be achieved. It is a less invasive procedure that results in less pain and faster recovery.

The operation is performed under general anaesthesia and takes on average five to eight hours, following the operation you are likely to stay in hospital for a period of five to seven nights.

The same as DIEP flap, the early days following surgery i.e. one to two days later bruising, swelling and general discomfort is likely to occur and then around one week later it may occur that there is reduced or no sensation of the reconstructed breast the same recovery will occur to that of the DIEP procedure although you will have drains in the chest and the buttock, which will be removed between two to five days late, day-to-day activities will be the same as above but you will need to wear a buttock compression garment for five weeks.

Transverse Myocutaneous Gracilis Flap or Transverse Upper Gracilis Flap (TMG or TUG Flap)

The TMG flap or thigh flap, is ideal for those who do not have an adequate amount of excess tummy tissue. The breast may be reconstructed with the skin, fat, muscle and the tiny blood vessels taken from the inner part of the upper thigh to achieve a B cup breast size. The TMG flap procedure uses tissue under the groin tissue extending to buttock fold, hence the scar will be well concealed.

A slight thigh lift results in the donor area. The tissue is then transplanted to the breast and a microscope is used to connect the blood vessels supplying this tissue to those at the mastectomy site.

The operation is performed under general anesthesia. The operation takes three - five hours, length of stay again is three to five nights following the operation. The same complications and side effects occur as to the previous procedures, drains this time will be in the chest and the thigh, which will be removed two to five days late. A thigh compression garment will need to be worn for five weeks after the operation and the final cosmetic result will be visible at four to six months.

Latissimus Dorsi Flap

The latissimus dorsi myocutaneous flap is an option that may be used for reconstruction, with or without an implant.
This type of flap is not a microsurgical flap; in other words, the tissue is kept attached and rotated from the back area to the breast. This flap uses tissue from the back using a small ellipse of skin, as well as the back muscle.

The latissimus dorsi muscle is a fan-shaped muscle that originates from the shoulder and extends into the back area. This thin tissue does not have any function related to the back, but it does act on the shoulder as an accessory muscle. However, there are other muscles in the rotator cuff area that assume the function of the latissimus dorsi for normal activities. When this muscle is used, there is a slight limitation in such actions as climbing or pushing off with the arm, but that limitation is not noticeable during normal activity.

The latissimus dorsi muscle allows complete coverage of the implant that protects it from infection, scarring, and exposure while the ellipse of skin replaces the area where the nipple has been removed. We use a tissue expander implant that can be implanted using saline, when the tissue has healed after the mastectomy. This adjustable implant can eventually be replaced by a silicone gel implant, which has a more natural feel.

The operation is performed under general anesthesia and takes around three to four hours you will then need to stay at the hospital for two to three nights following the operation. It is likely that seroma (Seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery) will occur in the back wound.
The implants are permanent unless a capsule develops around the implant, the implants will however, may need to be changed at 10 – 15 years later.

Implant Reconstruction

The simplest option for reconstruction is to have implants alone. This option is best for patients who have medical issues that prevent them from having a more complex surgery.

This option is usually completed in two phases. The first surgery consists of placing a tissue expander in the breast area underneath the skin and chest muscle. The tissue expander, which can be expanded like a balloon, will be gradually filled by adding a saline solution approximately once every two weeks. Once your skin has stretched sufficiently, in about three to four months, the next surgery will replace the tissue expander with a may be replaced by a silicone implant. If you do not need the tissue expander, your surgery will only consist of inserting the implant.

Although implant reconstruction is the simplest, it carries the highest incidence of complications

An implant reconstruction is not the same as a cosmetic breast augmentation procedure. In cosmetic breast augmentation, the breast implant is placed underneath normal breast tissue, which cushions the implant and therefore allows the breast to have a natural shape and feel.

After mastectomy, the breast skin is thin and due to the lack of breast tissue, the implant is readily felt. The implant is placed under the pectoralis muscle (The pectoralis major is a thick, fan-shaped muscle, situated on the chest) to improve the feel of the implant as well as to minimise infection and problems with scarring around the implant.

The lower part of the implant will not be covered by muscle. Often, a collagen sheet is used to cover the lower part of the implant to improve the cushioning of tissue over this area. However, implants may become infected or the tissue around the implant may become scarred and firm in the future, and this needs to be taken into account when considering this option.

The operation is performed under general anaesthesia and takes approximately two to three hours, one to two nights stay will be required following this procedure.

Again, unless a capsule hardening develops around the implant the implants will need to be changed at 10 – 15 years.

For further information and appointments please contact us on:
+44 (0) 20 7234 2009, info.lbh@hcahealthcare.co.uk