Mr A. O. Grobbelaar  MBChB  MMed(Plast)  FCS(SA)(Plast)  FRCS(Plast)

Breast Reconstruction

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Introduction

Breast reconstruction after cancer surgery should be offered to all suitable patients before surgery and adequately discussed. Therefore, a team approach involving breast surgeon, reconstructive plastic surgeon, oncologist, breast care nurse and various counsellors is of the utmost importance.

Since the early eighties it became clear that breast reconstruction performed at the time of mastectomy in cases of early breast cancer is indeed safe and not compromising the oncological treatment or outcome for the patient.  Should immediate breast reconstruction be contra-indicated due to advanced disease or other problems then a delayed reconstruction is always an option once a disease free period has lapsed. Significant improvement in body image and quality of life scores have been shown in-patients after reconstruction especially the younger patient groups.

Several accepted surgical alternatives are available.  Breast reconstruction after mastectomy neither prevents early detection of disease recurrence nor precludes the use of chemo or radiotherapy.

Once the necessity for surgery has been established a detailed discussion should follow regarding surgical options:

Studies have shown this discussion is very important and only 39.7% of patients recalled mentioning breast reconstruction pre-operatively and only 54.9% recall that lumpectomy had been discussed! This emphasises the continuing inadequacy of patient information.

Whereas not all women may wish to assume an active role in treatment decision-making, it is important to be well informed about all options available.

Options available:

A

 

Implants

In small-breasted woman an implant only may be suitable which can be inserted through the incision that was used for the mastectomy. Silicone gel or salt water containing implants is currently available for use.

B

 

Tissue Expansion

A balloon type device placed under the chest wall skin during an operation that can be inflated after insertion to stretch the skin and produce more skin to improve symmetry with the other breast. Inflation or stretching is normally done over a period of time until the right volume and amount of skin is reached, sometimes overcorrecting to achieve a similar amount of droop to the healthy side. This option is not indicated if radiotherapy to the chest wall has been given or is to be done post-operatively.

C

 

Latissimus Dorsi Flap and Implant

Latissimus Dorsi Flap and Implant

The muscle from the back with an amount of back skin can be used to replace the skin taken during a mastectomy. An implant is normally used with it to provide the bulk for the newly created breast. This obviously leaves a linear scar on the back of the patient where the skin and muscle have been taken.

D

 

TRAM Flap

TRAM Flap

Skin and fat from the lower abdomen can be used. The patient then has a "tummy tuck" type of scar on the lower abdomen. Enough tissue has to be available for transfer. No implant is used. Various techniques can be used to make this option reliable. It can be "pedicled", free or a DIEP technique can be used.  Whether no muscle is taken and the blood supply re-attached under the microscope (DIEP), a small amount of muscle taken and the blood supply reconnected under the microscope or the whole muscle used to carry the blood supply of the fat and skin to the new position on the chest, depends on individual patient circumstances.

The operation

The surgery can be performed at the time of the mastectomy or later during a second operation. Hospital stay varies with each technique and between patients and range from 3-7 days. Early post-operatively you will have surgical drains coming out of the wound to drain away excess fluid. The nurse normally removes these on day 2 or 3 after the operation. Sutures are normally removed between 8-12 days post-surgery. A recovery period from between 6 weeks and 3 months should be expected.

Conclusion

Breast reconstruction should be offered as an option to all patients undergoing mastectomy, partial mastectomy or lumpectomy. Recent studies have confirmed the belief that a woman undergoing breast reconstruction has significant psychological benefits in a wide array of psycho-social measures. Patients undergoing immediate reconstruction did not show the same poorer pre-operative body image compared to patients undergoing delayed reconstruction, however, both groups benefit significantly from reconstruction.  The type of reconstruction does not appear to influence patient satisfaction.

If you require further information or want to schedule a consultation please contact Mr. Grobbelaar's secretary details on the Contact page