Introduction

Breast cancer is common, affecting one in nine women. Breast preserving techniques (where just the tumour is removed, preserving the rest of the breast) can be used in the treatment of the majority of cases of breast cancer. Radiotherapy is given to these patients once they have recovered from removal of the lump. This treatment option is called “lumpectomy and radiotherapy”.
However, there are situations where the whole breast needs to be removed. The surgical procedure to remove the entire breast is called a “mastectomy”. The most common indications for a mastectomy are:

• Large breast cancers
• The presence of more than one focus of cancer within a breast
• Where despite multiple attempts at removing just the tumour, the cancer still remains at the margins
• Where a cancer has re-occurred in a breast that has previously had surgery, especially if radiotherapy has been used
• Where a patient prefers to have the whole breast removed, rather than just a lumpectomy
• Where a patient has a genetic diagnosis meaning that there is a high risk of breast cancer (eg BRCA gene carriers). These patients are advised to undergo prophylactic mastectomies (removing the normal breasts before a cancer can develop).
• Where a patient wishes to have a prophylactic (probably better called a “risk reducing”) mastectomy when the other breast has been removed for cancer. Patients may elect to undergo a prophylactic mastectomy for peace of mind or to improve symmetry.

Although mastectomy is a safe and effective procedure to remove breast cancers and prevent the development of new ones, it is a procedure that changes the appearance of the chest, can result in significant asymmetry, has an impact on a patient’s self image and self esteem and can impact almost every facet of a patient’s life. The goal of breast reconstruction is to recreate a breast moundin order to improve symmetry and self confidence.

There are three basic ways to perform breast reconstruction

1. Using a breast implant.
2. Using the patient’s own tissues.
3. A combination of an implant with a patient’s own tissues

There are no “right” and “wrong” answers when it comes to a choice for breast reconstruction. The different options all have potential advantages and disadvantages.

Timing of Breast Reconstruction

Breast reconstruction can often be performed at the time of mastectomy. This is called an “immediate reconstruction”. Once the breast surgeon has completed the mastectomy, the plastic surgeon will either insert either a breast implant, or a tissue expander (an implant that can be progressively filled with saline over a period of weeks to months and later exchanged for either an implant or a flap) or a flap can be performed at the time of mastectomy
Immediate breast reconstruction offers several advantages and disadvantages that patients must carefully consider.

Advantages:

1. Psychological Benefits: One of the primary advantages of immediate breast reconstruction is the positive impact on a patient’s psychological well-being. By waking up from surgery with a reconstructed breast, patients may experience improved body image and self-esteem, mitigating the emotional impact of breast cancer surgery.
2. Preservation of Breast Skin Envelope: Performing reconstruction immediately allows for the preservation of a large amount of the patient’s breast skin, facilitating a more natural-looking result. This can enhance the final aesthetic outcome and reduce the need for additional procedures. Preserving the skin envelope is an important consideration in situations where it is not clear if radiotherapy will be required after the mastectomy. An implant or tissue expander can be used as a temporary reconstruction with the plan being for a free flap reconstruction using the patient’s own tissue to be performed following the completion of radiotherapy
3. Single Surgical Episode: Immediate reconstruction streamlines the treatment process, combining mastectomy and reconstruction into a single surgical episode. This can result in less overall treatment time, reduced costs, and potentially less disruption to a patient’s life.

Disadvantages:

1. Prolonged Surgery Time: Immediate breast reconstruction typically requires more time in the operating theatre compared to a mastectomy alone. Prolonged surgery time may increase the risk of complications, such as infections or blood clots.
2. Potential for Delayed Adjuvant Therapies: In some cases, immediate reconstruction may delay the start of adjuvant therapies, such as chemotherapy or radiation therapy. This delay must be carefully weighed against the benefits of immediate reconstruction.
3. Risk of Complications: While all surgeries carry inherent risks, immediate breast reconstruction may pose an increased risk of complications due to the combination of mastectomy and reconstruction. Complications can include infection, implantor flap issues (depending on the type of reconstruction). These complications may delay adjuvant therapies, as noted above.

Patients considering immediate breast reconstruction should engage in thorough discussions with their healthcare team to assess individual risks, benefits, and preferences. Ultimately, the decision between immediate and delayed reconstruction hinges on the unique circumstances of each patient, and an informed, collaborative decision-making process is crucial to achieving the best possible outcomes.

Breast Reconstruction – Reconstructive Options Overview

Here is a brief overview of the most common breast reconstruction options. More information can be found on specific pages dedicated to the various breast reconstruction techniques in the drop down menu.

I. Reconstruction with Implants

This is the most common type of breast reconstruction performed worldwide

Advantages:

1. Least Invasive Option: Breast reconstruction with implants is a less invasive option compared to flap reconstruction techniques. The only scars are those related to the mastectomy. No new incisions are made anywhere else on the body
2. Quicker Recovery: The recovery period is generally shorter than that of flap reconstruction, allowing patients to resume normal activities sooner.
3. Customization: Implants offer flexibility in size and shape, allowing patients to be involved with decisions regarding their desired breast size.

Disadvantages:

1. Longevity Concerns: Implants may require replacement over time due to wear and tear, leakage, change in shape or rupture.
2. Potential for Complications: Risks include infection (up to 10% of cases0, implant displacement, and capsular contracture, a condition where scar tissue forms around the implant, causing it to harden. Rarely, implant capsules may be associated with Anaplastic Large Cell Lymphoma (ALCL) – a rare type of blood cancer that can develop in the capsule surrounding textured breast implants.
3. Less Natural Feel: Some patients may find that implants do not provide the same natural look and feel as their original breast tissue. Implants can feel “cold” and do not behave like normal breast rissue.

Recovery:

Patients will go home with drains in place. Patients measure their own drain output twice a day, and once the drainage is less than 30mls/day for two days in a row, the drain can be removed. Patients need to keep their wounds and breasts dry until the drains have been removed. Patients need to wear a soft bra (with no underwire that has clasps in the front) day and night until the drains are removed. Patients can drive with drains in place. Antibiotics are usually only given for a few days. Patients see A/Prof Marucci once a week until the drains are removed.

II. Reconstruction with DIEP Flap

Many patients have excess skin and fat in their lower abdomens. This is the tissue that would normally be removed as part of an abdominoplasty (“tummy tuck”) procedure. The tissue in the lower abdomen receives it blood supply from blood vessels that travel up from the groin, behind the muscle, then pierce the muscles to reach the skin. The skin and fat of the lower abdomen can be isolated on these blood vessels and then transferred to the chest to make a breast. The blood vessels from the groin are reconnected to blood vessels behind a rib to reestablish circulation to the tissue. The name of the blood vessel from the groin is the Deep Inferior Epigastric Artery (DIEA). As the flap is raised on branches of the DIEA that perforate the muscle, the flap is called a Deep Inferior Epigastric artery Perforator (DIEP) flap.

Advantages:

1. Autologous Tissue: The DIEP flap procedure uses the patient’s own abdominal tissue, resulting in a more natural look and feel, which loses weight and gains weight with the patient. The reconstructed breast tends to be soft and warm like a normal breast.
2. Long-lasting Results: The reconstructed breast maintains its appearance over time, eliminating the need for implant replacements.
3. Abdominal Contouring: The procedure includes an abdominoplasty(tummy tuck), providing a secondary benefit of abdominal contouring.

Disadvantages:

1. Longer Surgery Time: The DIEP flap procedure is more time-consuming than implant-based reconstruction. The DIEP flap is a more significant operation than the mastectomy itself.
2. Extended Recovery: Patients may experience a more extended recovery period due to the complexity of the surgery. In general, A/Prof Marucci advises his patients that they will need 3 – 4 weeks off work and can’t lift anything heavier than 3 Litres of milk for 4 weeks after the surgery
3. Donor Site Scarring: While efforts are made to minimize scarring, there will be a long scar on the abdomen extending from one hip to the other hip. There will also be a scar around the umbilicus (belly button)

Potential Risks and Complications:

Complications associated with DIEP flap reconstruction may include issues with blood supply to the flap, fat necrosis (where part of the flap dies), and abdominal hernias. Close monitoring during the recovery period helps identify and address these complications promptly.

Recovery:

Recovery after DIEP flap reconstruction involves several weeks of limited physical activity. Patients may need support in the initial stages of recovery due to temporary restrictions on movements.

III. Reconstruction with Latissimus Dorsi Muscle

The latissimus dorsi muscle is one of the main muscles on the back and one of the largest muscles in the body. It can be swung around from the back to the front in order to contribute to breast reconstruction. Often a latissimus dorsi flap is used in conjunction with an implant to reconstruct a breast. This is most commonly performed in patients who are not suitable for an implant only reconstruction (usually because they have previously had radiotherapy) and who do not have sufficient abdominal tissue for a DIEP flap.

Advantages:

1. Autologous Tissue:Similar to the DIEP flap, the latissimus dorsi flap uses the patient’s own tissue for reconstruction.
2. Reliable Blood Supply: The latissimus dorsi flap has a reliable blood supply, reducing the risk of complications. There is no microsurgery required.
3. Option for Implant Use: The latissimus dorsi flap can be used in combination with implants to achieve the desired breast volume.

Disadvantages:

1. Decreased strength around the shoulder: Harvesting the latissimus dorsi muscle can lead to a decreased force of muscle strength around the shoulder (although normally only keen kayakers or rock climbers notice any significant issues).
2. Donor Site Scarring: A scar is present on the back where the muscle tissue is taken, which may be visible, particularly in clothing with low backlines.
3. Limited Tissue Volume: The amount of tissue available for reconstruction may be insufficient for larger breast sizes. In these cases, an implant may be required to achieve the desired breast volume. The use of an implant brings with it all the potential risks associated with implants – capsule formation, infection, Anaplastic Large Cell Lymphoma, rupture, leakage and malpositioning.

Potential Risks and Complications:

Complications associated with latissimus dorsi flap reconstruction include infection, seroma formation (fluid accumulation in the back space), and changes in muscle function. Close monitoring during the recovery period is crucial for early detection and management of these complications.

Recovery:

Recovery after latissimus dorsi flap reconstruction involves a period of restricted activity, particularly focusing on avoiding strain on the back and shoulder muscles. Physiotherapy may be recommended to restore muscle function.

Conclusion

Breast reconstruction is a deeply personal decision, and the choice of technique depends on various factors, including patient preferences, medical history, and surgeon recommendations. Each reconstruction method has its unique advantages and disadvantages, and understanding these factors is crucial for making an informed decision.

While implant-based reconstruction offers a quicker recovery with less invasive surgery, autologous tissue reconstructions like the DIEP flap and latissimus dorsi flap provide more natural results and potential long-term benefits. Patients should consult with an experienced reconstructive plastic surgeon, like A/Prof Damian Marucci, to discuss their individual goals, concerns, and expectations to determine the most suitable reconstruction approach for their unique circumstances. Regardless of the chosen method, ongoing support and follow-up care are essential for a successful and satisfying outcome in the journey of breast reconstruction.

It is important to choose an experienced surgeon to perform your breast reconstruction. Look for a surgeon who is a Fellow of the Royal Australasian College of Surgeons (FRACS) and is a member of the Australian Society of Plastic Surgeons (ASPS) as well as the Australasian Society of Aesthetic Plastic Surgeons (ASAPS). A/Prof Marucci has a FRACS in Plastic and Reconstructive Surgery. He is on the Education Committee of ASPS and is on the Board of ASAPS. A/Prof Marucci is registered a specialist in Plastic and Reconstructive surgery with AHPRA.