Reconstruction after Mastectomy

Mastectomy is usually performed for breast cancer. Reconstruction of the breast after a mastectomy operation is often desirable. There are three primary ways of reconstructing the breast after mastectomy. Two of these methods require the use of implants. The third method of reconstruction, using the patient’s own natural fat and skin tissue has become the ‘gold standard’.

The ‘TRAM Flap’ Method

A large piece of skin and fat from the abdomen could be transferred to the chest to reconstruct the breast(s). The tissue which is removed is similar to that removed in the Abdominoplasty (‘tummy tuck’). This tummy tissue is then turned up onto the chest (pedicled TRAM flap) or transferred freely (free TRAM flap) and then joined to blood vessels using an operating microscope to re-establish circulation.
The TRAM flap operation is a one-stage technique, but it does require a longer operating time than some of the more traditional methods – three to five hours. Breasts reconstructed by the TRAM flap technique have virtually normal breast softness, and tend to sit more naturally than occurs with techniques requiring implants. The donor area of the abdomen is closed similar to the ‘tummy tuck’. The aesthetic result of the surgery depends on many factors, and not every patient will be able to achieve the same quality of reconstruction. Also, some patients with serious medical conditions may be unsuited to such a long operation, while others may be unsuitable because of previous abdominal surgery.

Other Flaps

Sometimes your surgeon will suggest using a Latissimus Dorsi muscle and skin from the back. These flaps usually (but not always) need an implant to add sufficient bulk. They produce a scar on the back, which can be very visible.
Other options for breast reconstruction include using tissue from the buttock (gluteal flap) or upper hip (Rubens flap). The gluteal flap is suitable for younger women who have had no children, and thus have tighter and flatter tummies. The disadvantages are a much higher failure rate, up to 20%, and asymmetry in the buttock.
The Rubens flap utilizes tissue from the ‘love handle’ area. This flap is least preferred for many reasons.

Tissue Expansion

If using implants is preferred, an empty silicone bag (expander) is inserted under the skin of the mastectomy area. This expander has a small valve attached, concealed under the skin, is then gradually filled with sterile saline solution, over the course of several weeks or months. After adequately stretching the skin, a second operation is performed to replace the expander with a ‘permanent’ implant, either saline-filled or silicone gel-filled. Each operation usually takes less than one hour.
A breast reconstruction using implant usually looks different. It is less “mobile” and feels firmer than the natural breast.  

The ‘Best’ Option

Choice of reconstruction method will depend on many factors, including age, state of health, size and shape of opposite breast and availability of abdominal skin. Your surgeon will discuss this with you and recommend the best option in your own case. As a general rule, reconstruction involving implants is simpler and easier for both patient and surgeon, but they tend toward more long-term complications such as hardness, discomfort or pain, need for later implant removal or exchange, and do not feel as natural as a normal breast.

Risks and complications

Failure and complications can occur.
• In free flap reconstruction, the main concern is the lack of blood flow in the rejoined blood vessels. If flow is not restored, the reconstructed breast would die. Major failures of this nature occur in less than 5% of patients.
• Less serious complications include bleeding, infection, severe scarring, partial loss of circulation in the flap, abdominal hernia (about 2%), and drug and anaesthetic reactions varying in severity to the point of death (very rare).  Thrombosis (clots) in the leg veins (about 5%) can be fatal. Small areas of hardness in the new breast, caused by ‘fat necrosis’, may need to be removed. Asymmetry with the other breast is common and may need more surgery to achieve better symmetry.

 

• If a TRAM flap is used, there will be a long scar in the lower abdomen. Although designed to hide within the bikini line, it can be visible.  The reconstructed breast usually has no sensation, but about two thirds of patients notice return of some feeling. Most patients have a mild weakness in the abdominal muscles, which sometimes is permanent.
• Reconstruction using implants may result in hardening and pain in the reconstructed breast, caused by ‘capsular contracture’ and this often requires further surgery. Other complications include infection of the implant, ruptures of implants. Implants do gradually deteriorate over time. As a general rule, they should not be considered as lifetime devices, as many need to be replaced at least once during the lifetime of the patient.
• Smokers should give up completely, and must be totally off all cigarettes and nicotine substitutes such as patches, gum, etc. at least 3 weeks before flap surgery, as smoking greatly increases the risk of failure.  If you are taking Warfarin, Aspirin (or similar drugs) or any of the non-steroidal anti-inflammatory agents such as Naprosyn, Indocid, Feldene, Brufen, Orudis and Voltaren, you must inform your surgeon.

Nipple Reconstruction

If the nipple has been removed during the mastectomy, a nipple reconstruction is possible. This small operation is usually performed at least three months after the main breast reconstruction to achieve better symmetry.  The nipple is usually fashioned from a small tongue of skin lifted up from the breast mound and a small skin graft. The ‘finishing touches’ to the nipple occur with the colouring of the nipple and areola to match the other breast, using a medical tattoo technique.

Post Operative Restrictions – TRAM Flap

Because this operation removes a segment of the rectus muscle from the abdominal wall, activities of the abdominal wall are to be limited for three months.  This includes – ‘sit-ups’, and ‘tummy-tightening’ exercises used in aerobics programmes.  Also restricted for 3 months is heavy lifting, i.e. weights more than about 10 kilograms and lifting small children.  Light exercise after the surgery in encouraged, especially walking and swimming, although you shouldn’t swim for about three weeks after the operation, and then, start slowly. 

Breast Cancer

A common question is whether breast reconstruction increases a risk of recurrence of breast cancer.  Studies indicate that breast reconstruction has no adverse effect on the course of breast cancer. Also, a reconstruction does not disguise a possible local recurrence of breast cancer. 

Pregnancy

After a breast reconstruction, patients may have successful pregnancy with little risk to the baby.  However, you should discuss this with your Oncologist first.  It is also not advisable to fall pregnant for at least one year after TRAM flap reconstruction to reduce the risk of hernia formation.

The Other Breast

As a general rule, plastic surgeons try to match the reconstructed breast to the other breast – if the patient is happy with this breast. However, if this breast is too small, very large or ‘floppy’, it may be best to improve it and match the reconstructed breast to this new breast. This is usually done at a second stage, at the same time as the nipple reconstruction.
Additional costs will be incurred for these extra procedures, but Medicare rebates and Health Fund cover usually apply.

Medicare and Health Fund Coverage

Post mastectomy surgery qualifies for a Medicare rebate and Hospital fund cover. Health Fund cover applies when you have been in a health fund for longer than twelve months, according to ‘Pre-existent Condition’ rules.  Note however that not all the costs of the surgery will necessarily be met by Medicare and your fund, depending on the level of fees charged by your surgeon, anaesthetist, assistant surgeon etc. Discuss this with your surgeon or the practice manager before your operation. Implants are usually covered by your health fund, but you should check this in advance. Some Health Funds have exclusion provisions, or ‘up front ‘payment rules for these types of operations, although most will agree to cover hospital costs according to your policy rules. That said, forewarned is forearmed, so check with your fund first.

Empathetic Advice

Most surgeons will be happy to introduce you to patients who have had breast reconstruction.

If you need more information, please call 03 8769 8555 or email us at info@corymbiahouse.com.au and we will get back to you next business day.

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