Breast Reconstruction
Success Rate
As in many fields, success can be difficult to define. In breast reconstruction, what is judged to be successful by one patient might be judged unsuccessful by another. 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 or as a successful autologous (own tissue) reconstruction such as the TRAM flap.
As in all surgery, failure and complications can occur. In the case of microsurgical free flap reconstruction, the main concern is the possibility of the rejoined blood vessels clotting and the circulation to the flap being cut off. Left alone, this would mean all the reconstructed tissue would die and have to be removed. However, the circulation in the flap will usually be monitored every half-hour by nurses in the ward. At the first sign of circulation problems, they should notify the surgeon so that remedial action can be taken and sometimes this involves a second round of anaesthesia. However, failures of this nature occur in no more than 4% of patients.
Other Possible Complications
Complications can occur in any surgical procedure. In the case of breast reconstruction, they can include bleeding, infection, severe scarring, loss of circulation in the flap, loss of feeling in the arm or hand, and Mrug and anaesthetic reactions varying in severity to (very rarely indeed) the point of death.
With microsurgical or pedicled own tissue reconstructions such as the TRAM flap, possible complications include abdominal hernia (about 2%), small areas of hardness in the new breast called fat necrosis which might later need to be removed, and asymmetry with the other breast. Occasionally a small piece of the edge of the flap may have inadequate blood supply and need to be removed surgically within a couple of weeks of the first operation. Your surgeon will tell you in greater detail about complications that can occur, but it should be stressed that serious complications of any kind are most uncommon. The condition most often encountered in microsurgical procedures is thrombosis (clots) in the leg veins.
Precautions are taken to prevent this, but about 5% of patients will suffer from them nevertheless. In a few cases, the clots may spread to the lungs, which can be serious. If you have a history of leg vein clots or varicose veins, you must inform your surgeon.
Patients having implant reconstructions may develop hardening and pain in the reconstructed breast, caused by capsular contracture and this often requires further surgery. An infected implant also may necessitate further surgery, and usually needs to be removed to gain control of the infection. Traumatic ruptures of implants may occur, although considerable force is needed to rupture an implant in good condition. 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.
Note that self-funded (uninsured) private patients must appreciate that in the event of complications, significant extra costs may be incurred, especially in private hospitals.
Side Effects
Some side effects occur in all patients, and some in only a few. For example, in all cases, a TRAM flap reconstruction will result in some permanent loss of feeling in a patch of skin just below the navel, up to a hands breadth in area. About two thirds of patients notice return of some feeling in the reconstructed breast after six months but one third never regain feeling. Most patients will have a higher pubic hairline after the surgery. Most patients have a mild weakness in the abdominal muscles, which sometimes is permanent. This can be compensated for by abdominal muscle-toning exercises, however it is most important that you do not undertake a muscle-toning programme without consulting your surgeon, as inappropriate exercise can result in a hernia.
Most implant patients notice that the reconstructed breast is firmer than the other, does not rest like a normal breast in certain positions (eg. leaning forward) and especially if a saline-filled implant is used, may develop a rippled feeling to the touch.
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