Breast Reconstruction surgery aims to recreate the shape and appearance of the breasts following a mastectomy.
Western Australian Plastic Surgery Centre in Perth provides the highest level of personalised service and care for all our patients.
Reconstruction of the breast after a mastectomy operation is considered desirable by many women and most surgeons performing mastectomies will readily agree to refer you to a plastic surgeon for the procedure. If possible, the best time to see the Plastic Surgeon is before the mastectomy. In some cases, the reconstruction may be performed at the same operation, although this is only advisable when it is judged that the reconstruction will not interfere with any subsequent treatment of the breast cancer.
There are three primary ways of reconstructing the breast after mastectomy. All typically involve the provision of more skin, (since the mastectomy surgeon usually removes the large fold of skin covering the breast) and more bulk to produce the best shape and texture. Two of these methods require the use of implants, which contain silicone. Saline-filled implants are also available but it is estimated that about 6% of saline-filled implants will deflate within ten years, so they cannot be considered a permanent replacement. Reconstructions involving implants have a greater long-term complication rate, and do not look or feel as natural as your own tissue. For that reason, the third method of reconstruction, using the patient's own natural fat and skin tissue has become the gold standard, however this requires a longer period under anaesthetic, a longer hospital stay and can require a longer period away from work.
The Microsurgical Tram Flap Method for Breast Reconstruction
Following studies performed in Sweden in 1978, Australia in 1979 and the US in the 1980s, it was found that a large piece of skin and fat taken from the abdomen could be transferred almost anywhere else in the body, and used to reconstruct a surgical defect such as a mastectomy. The tissue which is removed is similar to that removed in the abdominal lipectomy procedure (the so-called tummy tuck). Many women, especially those who have had chilMren, have lax lower abdominal skin and fat which they are quite happy to lose!
By also taking a small piece of attached abdominal muscle and two blood vessels that run through this muscle into the fat tissue (Fig. 1.) a large piece of fat and skin sufficient to reconstruct almost any size of breast may be transferred to the chest. Using an operating microscope, the two blood vessels are joined to other blood vessels in the armpit to re-establish circulation in the new free flap taken from the abdomen. Occasionally it is necessary to join the flap vessels not to vessels in the armpit, but to ones just under the ribs near the breastbone and in that case, a small piece of rib might need to be removed. The flap of tissue is then formed into a breast shape and stitched into position.
The free TRAM flap operation is a one-stage technique, but it does require a longer operating time than some of the more traditional methods five to seven hours compared to three or four hours for the Latissimus Dorsi technique. Recently a device called a micro-anastomotic stapler has become available which reduces operating time by about half an hour. Breasts reconstructed by the free 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 in a similar way to the tummy tuck operation. However, it is necessary to repair the muscle defect with special techniques, sometimes involving the use of a synthetic patch of Teflon called Gore-Tex. Post-operative restrictions apply for several months until the abdominal muscles regain strength in order to avoid the possibility of hernia.
The TRAM flap can also be performed without microsurgery, using most of one of the abdominal muscles as a pedicle to bring blood into the flap. This muscle remains attached to the under-rib area, and the fat of the lower abdomen pivots on it as it is moved under the skin through a tunnel to the breast area. Because more muscle is used in the pedicle technique, abdominal weakness is potentially a greater problem than with the microsurgery. The blood supply to the flap is also weaker, with a higher rate of flap failure. Blood supply can be enhanced by performing the operation as a two-stage technique with a surgical delay of one week to two weeks between operations.
Figures 2 & 3 illustrate the results of free TRAM flap reconstruction in two different patients. It has to be emphasised that the result of the surgery depends on many factors, and not every patient will be able to achieve the same quality of reconstruction. This is something you need to discuss with your surgeon and you might choose to seek a second opinion.
Note also that some patients with serious medical conditions may be unsuited to such a long operation. Still others may be unsuitable because of previous abdominal surgery, although there is now a modification of the operation that allows many of these women to undertake the procedure safely.
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