Reconstruction of the breast after a mastectomy operation is considered desirable by many women and most Breast Surgeons performing mastectomies will readily agree to refer you to a Specialist Plastic Surgeon for the reconstructive stage of the procedure. If possible, the best time to see the plastic surgeon is before the mastectomy. In some cases, the reconstruction may be performed during 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 Breast Surgeon performing the mastectomy 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. 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 Transverse Rectus Abdominus Musculocutaneous (TRAM) Flap Method for Breast Reconstruction
Following studies performed in Sweden in 1978, Australia in 1979 and the United States 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 children, have lax lower abdominal skin and fat which they are quite happy to have removed.
By also taking a small piece of attached abdominal muscle and two blood vessels that run through this muscle into the fat tissue, 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, generally 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 procedures using techniques requiring implants.
The donor area of the abdomen is closed in a similar way to the abdominoplasty 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.
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.
Sometimes your surgeon will suggest using a Latissimus Dorsi muscle and skin flap from the back to provide a greater quantity of skin. 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, and a slight hollowing under the shoulder blade. However, this operation is often the best reconstruction for women who have had the older, more radical type of mastectomy where the surgeon has removed the pectoral muscle on the front of the chest, as the Latissimus muscle acts as a replacement.
In other cases where abdominal tissue is unsatisfactory, it may be possible to use similar tissue from either the buttock or upper hip areas, although this may cause some visual imbalance in the donor area. The first of these is called the Gluteal flap, taken from the upper, middle or lower parts of the buttock. Usually it is necessary to take some of the gluteus muscle with the skin and fat, which may have a weakening effect on the muscle (usually only of importance to women involved in athletic pursuits). Most suitable for the Gluteal free flap are younger women who have had no chilren, and thus have tighter and flatter tummies, and particularly those women who are having a subcutaneous mastectomy or partial mastectomy. Note though, that the Gluteal flap has a much higher failure rate, as high as 20%, and is not routinely recommended. As well, it is usually necessary to take a segment of vein from one leg as a vein graft, to allow the blood vessels to stretch to the armpit, as the vessels in the Gluteal flap are usually too short to reach. This will produce a scar or scars on the patients leg. All these matters should be fully discussed with your surgeon.
Another flap occasionally used is the roll of skin and fat on the upper hip area, commonly called the “love handle” area. This procedure is usually reserved for women in whom the abdomen or buttock is for some reason unsatisfactory, as hip tissue may be less than ideal in terms of breast shape, and it will also create a difference in the shape of one hip.
In some patients it is possible to place an empty silicone bag under the skin of the mastectomy area, usually also under the muscle of the chest wall, which has a small valve attached and concealed under the skin. This first operation usually takes less than an hour. The bag or expander is usually partly filled at the time of surgery with sterile saline solution, then gradually further expanded over the course of several weeks or months with a once or twice-weekly injection through the skin into the valve, to pump up the expander. Often the expander is inflated deliberately to a size much larger than the normal breast, stretching the skin more into a better shape. After a defined period, from several weeks to months, another operation is performed to replace the expander with a permanent implant, either saline-filled or silicone gel-filled. The second operation is usually also short less than one hour.
A good tissue-expanded breast reconstruction may look very like the other breast in the vertical position, but will not fall naturally to the side when lying down, or fall forward when leaning forward. Further, the texture is never quite normal, usually feeling firmer than the other breast, occasionally with a a rippled effect under the fingers. Note that permanent implants can not be considered as lifetime devices and may require replacement in the future, but it is sometimes possible to replace an old implant with your own tissue.
Patients suitable for the tissue expansion and implant method might be those requesting immediate reconstruction at the time of mastectomy (especially young women with little loose abdominal tissue), patients having bilateral mastectomies, and those who cannot accept the restrictions on heavy lifting and other activity, associated with the abdominal procedure. The operation might also be more suitable for patients with a high risk of developing breast cancer, who elect to have subcutaneous mastectomy, preserving the nipple.
The Best Option
Choice of procedure will depend on many factors, including age, state of health, size and shape of opposite breast, sufficiency of loose abdominal skin etc. Your surgeon will discuss this with you and recommend the best option in your own case. Not all patients are suitable for microsurgery, and in some instances the use of tissue expanders and implants may be the best way to go. In other cases, the Latissimus Dorsi flap may have advantages. It is wise to be guided by your surgeon in these matters.
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 drug 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.
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 (e.g. leaning forward) and especially if a saline-filled implant is used, may develop a rippled feeling to the touch.
In cases of implant reconstruction using tissue expansion, blood transfusion is rarely necessary. Other flap repairs, such as the Latissimus Dorsi procedure, occasionally require blood.
Wherever possible, most surgeons recommend autologous transfusion for the TRAM flap and other microsurgical reconstruction operations. That simply means that the Blood Bank will take two or three bottles of your own blood from you over a period of four weeks or so before the operation, allowing your body time to replace the blood taken. This is stored under refrigeration, to be used if you require a transfusion. In rare cases of abnormal bleeding, blood from the general Blood Bank might be necessary, but that would only be used if the doctors felt your health was in serious danger without it. When you have autologous blood taken, the Blood Bank tests for HIV (AIDS), as well as Hepatitis B & C.
Dependent on your age and state of health, your doctor might request several pre-operative tests to determine your fitness for surgery. The minimum requirement would be for a full blood count, usually performed after you have completed giving your own blood. However, your doctor might also order a cardiograph (ECG), chest x-ray, spirometry (lung function tests), a screening test for Hepatitis & HIV (AIDS), and sometimes tests to check the level of electrolytes in the blood, particularly if you are taking diuretics. You will receive an account for these tests that can be submitted to Medicare. The final judge of your fitness for anaesthetic is the anaesthetist, who will see you just before surgery. In rare cases, anaesthetists are compelled to cancel operations because they believe the patient might be at risk, particularly in the cases of a recent chest infection or chest pain.
During the operation, your surgeon will remove scar tissue from the mastectomy area, and sometimes tissue from the chest or armpit. It is routine to send these tissue specimens to pathology to be checked for the presence of cancer, although a positive result is very rare. You will receive an account from the pathology provider for this. You will also probably have a blood count in the first one or two post-operative days to check whether enough of your own blood has been given to you.
As breast reconstruction is usually elective, there is time to make some lifestyle changes that will be beneficial. If you are overweight, it might be wise to lose some weight and at the same time improve your fitness. Walking for a minimum half-hour a day to the puffing level is good and swimming is even better. A low fat diet with plenty of fresh fruit and vegetables is advisable. Smokers should quit smoking completely, and must be totally off all cigarettes and nicotine substitutes (such as patches, gum, etc.) three weeks before TRAM flap surgery, as smoking greatly increases the risk of failure. If you are taking Aspirin, Disprin, Cardiprin, Cartia or any of the non-steroidal anti-inflammatory agents such as Naprosyn, Indocid, Feldene, Brufen, Orudis and Voltaren, you must inform your surgeon as these drugs increase the risk of bleeding and should be discontinued at least four weeks before surgery.
In most cases, nipple reconstruction is no problem, but this small operation is usually performed at least three months after the main breast reconstruction because the new breast will be typically higher than the other and will sag somewhat over time. This means that if reconstructed too soon, the nipple may end up too high or too low. The nipple is usually fashioned from a small tongue of skin lifted up from the mound of breast tissue previously created by the flap. A small skin graft is necessary to replace the tongue of skin and form part of the areola (the brown skin around the nipple). The graft is usually taken from one or other end of the abdominal scar, and is a day procedure with a very light anaesthetic.
Sometimes the surgeon will take the opportunity to slightly refashion the breast shape at that time by revising the breast scars, occasionally also using liposuction and in these cases an overnight hospital stay could be advised. The finishing touches to the nipple come about six weeks later when the surgeon will arrange for the colour of the nipple and areola to be matched to 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, which then has to be reconstructed, activities stressing the abdominal wall are to be limited for three months. This would include exercises such as sit-ups and the so-called tummy-tightening exercises often used in aerobics programmes. Also restricted for three months is heavy lifting (i.e. weights more than about 10 kilograms) and this includes lifting up small children. Light exercise after the surgery is encouraged, especially walking and swimming, although you shouldn’t swim for about three weeks after the operation, and then, start slowly.
A common question from patients is whether breast reconstruction increases a risk of recurrence of breast cancer. Studies from the Cleveland Clinic in the United States and other respected institutions indicate that breast reconstruction has no adverse effect on the course of breast cancer.
There have been some concerns in the past about reconstruction disguising a possible local recurrence of breast cancer however, newer diagnostic techniques such as CT and MRI scanning allow such recurrences to be detected fairly early, even underneath the new breast. In any case, local recurrence is uncommon after the application of modern surgical mastectomy techniques.
Studies in the United States indicate that women who have TRAM flap reconstructions may successfully undertake pregnancy with little risk to the baby. However, there may be reasons to do with management of breast cancer that limit this option and you should discuss this with your Oncologist. It is also not advisable to fall pregnant for about one year at least after TRAM flap reconstruction to reduce the risk of hernia formation, which is greater if pregnancy occurs, even years after the reconstruction.
The Other Breast
As a general rule, plastic surgeons try to match the reconstructed breast to the normal one. However, some women with very large or floppy breasts often prefer the reconstructed breast to the normal one. In these cases it is possible to reduce, uplift or reshape the other breast to create a better shape. This is usually done at the time of nipple reconstruction. Some women have had their opposite breast enlarged with an implant, as in some circumstances, the reconstructed breast is larger than the normal one. In certain cases, your surgeon will indicate that they might not be able to make a breast the same size or shape as the opposite one and will recommend surgery on the other breast.
Additional costs will be incurred for these extra procedures, but Medicare rebates and private health fund cover usually apply.
Medicare and Private Health Fund Coverage
Post-mastectomy surgery qualifies for a Medicare rebate and private health fund cover. Private health fund cover applies when you have been in a health fund for longer than 12 months, according to pre-existent condition rules.
Note however, not all the costs of the surgery will necessarily be met by Medicare and your private health fund, depending on the level of fees charged by your surgeon, anaesthetist, assistant surgeon etc. Discuss this with your surgeon or their secretary before your operation. Implants are usually covered by your private health fund, but you should check this in advance. Some private health funds have exclusion provisions or upfront payment rules for these types of operations, although most will agree to cover hospital costs according to their policy rules. That said, forewarned is forearmed, so check with your private health fund first.
Most surgeons will be happy to introduce you to a patient who has had breast reconstruction.
How much does this procedure cost?
Please contact us online or call us on (08) 9380 0333 and one of our medical secretaries can provide you with more information. Please note that pricing does vary from case to case.
The Australian Foundation for Plastic Surgery (part of the Australian Society of Plastic Surgeons) is a helpful and reliable source of information online. Their website is an excellent place to research a range of surgical procedures and non-surgical treatments, and view video animations. Click here to visit their website.