A breast reconstruction is an operation to rebuild a breast. This can be a result of cancer surgery (lumpectomy or mastectomy), injury or in an undeveloped breast. The aim is to recreate the original shape and appearance of the breast and match it with the other side.
This can be done simultaneously with a mastectomy/lumpectomy or some time after the original surgery. As well as reconstructing the concerned breast, we would also consider operating on the other breast to ensure optimal symmetry.
A breast can be reconstructed using several techniques, depending on your wishes, how much tissue is missing and what spare tissue is available. This may, however, require more than one operation.
The options are:
- Breast implant
- Fat grafting
- Local flap – Latissimus Dorsi reconstruction from the back muscles (LD)
- Free flap – Deep Inferior Epigastric Artery Perforator flap from the abdomen (DIEP)
A silicone breast implant can be used to replace breast tissue, especially if the breast skin is preserved during the mastectomy (skin sparing mastectomy). This is the simplest option. It gives a breast shape that will look good in a bra but does not necessarily give a natural appearance to the breast. It can be performed in either one or two operations. The two-stage operation is suitable for patients who have already had a full mastectomy and do not have enough breast skin to cover an implant straight away. The first stage involves placing a tissue expander in the breast. An expander is an empty bag, which can be filled up with fluid to slowly increase the size of the breast. When it reaches an acceptable size, the expander is removed and replaced with a definitive implant at a second operation. This is normally 3-6 months after the first procedure. Implant reconstructions can be combined with a fat grafting procedure, which thickens the soft tissue cover of the implant to hide it a little better and improve the overall cosmetic result.
Implant based reconstruction is best for smaller breasts and patients who have not had or are not expected to have radiotherapy. Those patients who have radiotherapy and a pure implant reconstruction have a high rate of implant related complications. For this reason, patients with breast cancer who need radiotherapy are advised to have a flap of tissue to protect the implant and make the result more natural.
For more detailed information, please review the breast augmentation section of the website.
The full potential of fat grafting is still being established, but it is proving to be more beneficial than we could have hoped. It offers minimally invasive surgery, which can be used to fill a defect or even create a complete breast without implants. It is a scarless procedure as the fat is injected with a fine needle. Unwanted fat is harvested with liposuction. It is then specially prepared and re-injected into the breast or mastectomy site. It can be considered as the ultimate in green surgery – recycling of fat from an area where you don’t want it to an area where you do. As well as creating a new breast, it can dramatically soften any radiotherapy changes and improve skin quality and existing scars. It is not possible to inject massive volumes, as there has to be enough space to allow the fat to develop its own blood supply. Thus several procedures are often necessary to achieve the desired result. However, when the grafting is completed, the final result is permanent.
For more detailed information, please review the fat grafting to the breast section of the website.
In this operation, skin, fat and muscle from your back is repositioned (tunneled) to the chest area, while keeping its connection and blood supply intact. The LD flap can be used alone if you only require an A or B cup, but if you are larger then a small implant is often necessary. It gives a good aesthetic result and covers the implant to reduce potential complications. It is therefore particularly useful if you have had or are going to have radiotherapy. As implants are not your own body tissue they may need maintenance in the future as for any patient with breast implants.
A Deep Inferior Epigastric Perforator (DIEP) free flap is considered to be the gold standard plastic surgical technique for breast reconstruction. This ‘autologous’ procedure involves completely detaching excess tissue from the abdomen and transferring it to the chest to create a breast. In the DIEP flap, we only take the fat roll from the abdomen with its blood supply, but completely preserve the muscle. Thus, the muscle is undamaged and continues to support the tummy as normal. In addition to the breast reconstruction, you will have a tummy tuck or abdominoplasty as an added benefit. The flap is reattached end to end to vessels in the armpit or in the chest. This operation takes longer than the other procedures and there is a very small chance that it will fail. The results are the most natural and they will be permanent. The flap will put on or lose weight as you do and there is no implant to consider.
Patients who have had lymph nodes removed as part of breast cancer treatment are at risk of developing lymphoedema in their arm. Lymph node transfer is a relatively new procedure, which is proving to be very successful in the management of lymphoedema as a result of surgical removal of lymph nodes or trauma. It was originally described by French surgeon Dr Becker and has shown to be of great benefit to patients plagued by lymphoedema. I am one of the few surgeons in Europe offering this technique and have had very promising results with several years follow up.
The procedure involves harvesting several superficial lymph nodes from the groin area. These nodes do not drain the leg itself and therefore there is minimal risk of developing swelling in the leg. In patients requiring breast reconstruction, the lymph nodes are taken attached to the DIEP flap. In those patients not requiring breast reconstruction or who have lower limb lymphoedema, the lymph node transfer can be performed as an isolated procedure in its own right.
Lymph node transfer is a relatively new procedure that is proving to be very successful in the management of lymphoedema as a result of surgical removal of lymph nodes during breast cancer treatment. The lymph nodes can be taken as an isolated flap of tissue in patients who do not require a breast reconstruction – normally patients who have had a wide local excision only or who have already had a breast reconstruction. If patients have not had a breast reconstruction then they may be best suited to a combined lymph node transfer and DIEP breast reconstruction. It was originally described by French surgeon Dr Becker and has shown to be of great benefit to patients plagued by lymphoedema. I am one of the few surgeons in Europe offering this technique and have had very promising results with several years follow up.
The procedure involves harvesting several superficial lymph nodes from the groin area. The superficial lymph nodes are not responsible for draining the leg and therefore it is unlikely that you would develop lymphoedema of your leg.