What is an immediate breast reconstruction?

This is a reconstruction of the breast mound which is carried out at the same time as a mastectomy. The aim of breast reconstruction is to produce a replacement breast with a satisfactory appearance with or without clothes, avoiding the need for an external prosthesis in a bra. This can be achieved in the following ways:

• Producing a replacement size and shaped breast to the one which has been lost aiming to match the other breast.

Or

• If it is not possible to replicate your other breast your surgeon may suggest reducing the affected breast. If this is the case you may need further surgery to the other breast in the future to match your breast reconstruction.

 

General

Reconstructions are challenging operations and not suitable for all women. Sometimes it is better to wear a prosthesis in the bra than to undergo reconstruction. Where a reconstruction can be done at the time of the mastectomy it is called an ‘immediate reconstruction’. Often it represents the first operation, and others are needed to finish and improve the result. Where it can’t be done immediately, it is called a ‘delayed reconstruction’. This can be even more difficult as the chest wall is flat to start with and may have been affected by your cancer treatments ie radiotherapy. A delayed reconstruction might be considered a year after completing radiotherapy or sometimes many years later depending on the advice of the reconstructive breast surgeon, breast oncologist and desires of the patient.

The reconstructive surgeon who performs Immediate reconstruction will consider the different options and discuss these with you. An immediate reconstruction is broadly accomplished using one of three different techniques: using breast implants on their own, using breast implants in combination with a tissue flap, or just using a tissue flap. There are pros and cons to each approach and no single technique is suitable for everyone.

Reconstruction with Tissue flaps with or without implants

The type of tissue flap that is taken from the back is called the Latissimus Dorsi flap (the LD flap). The flap is composed of skin, fat and muscle. It retains it’s blood supply from blood vessels under your arm. It can sometimes be big enough to fully replace your breast (a fully autologous flap) and involves a long incision across the back. If you are very slim you would not have enough tissue from an LD flap to match to your breast and then it is more

common to have a silicone breast implant placed under the flap to boost its size (implant assisted LD flap). Mr Turton can assess your suitability for an LD flap. He regularly carries out the extended autologous LD and implant-asssited LD flaps.

This series of photos shows a patient that Mr Turton performed a fully autologous extended LD flap immediate right breast reconstruction 10-years ago. All of the tissue to reconstruct her right breast has come from the right side of her back. She has maintained a very stable result. Mr Turton commonly uses the LD flap in his reconstructive practice both in the immediate and delayed setting.

Some women have a sufficiently flabby fold of excess skin and fat across their lower tummy that may match the size of the breast being removed. A flap from your lower tummy is called a TRAM or DIEP flap. It is usually removed completely dividing it’s blood supply in the process (it is called a free flap as a result). The flap is brought up to the chest area and new joins (anastomosis) are made to blood vessels near you breast bone – this involves a microscope and very delicate surgery from a plastic surgeon who is expert in microsurgery. If there is a problem with the new join it can interfere with the blood into the flap via it’s artery or back out via it’s vein- if this happens it is possible the flap would die and need to be removed straight away. Tissue flaps always create a degree of tissue injury from the site they are taken and this can lead to a longer recovery and unwanted consequences at those sites, or complications from wound healing. However, the payoff where there is sufficient fatty tissue is that the reconstruction can match very well to a fatty breast, sometimes feeling softer and more natural than might be achieved with another technique. A tissue flap also allows for replacement skin to be brought into the mastectomy area, which is useful if skin has to be removed as part of the mastectomy. A good quality fatty tissue flap is generally less likely to need additional surgery in the long term. Otherwise other procedures to supplement them with fat (lipomodelling), or to remove fat (liposuction) and adjust the shape on either side might be considered.

 Where  you might be suitable for a TRAM or DIEP flap, if you have sufficient tissue and want to consider that type he can refer you to one of his plastic surgery colleagues who carries out that type of surgery. Other tissue flaps are much less commonly performed and include those from the buttock or thigh.

Reconstruction with Implants and ADM

The commonest type of reconstruction in the UK is called the ‘implant ADM’ breast reconstruction. This has superseded the ‘expander-implant’ technique that was more commonly performed a decade ago. Before we adopted the implant-ADM technique we used to place a tissue expander under the chest muscles at the time of the mastectomy, and this often produced a lot of pain. It had to be inflated gradually in the weeks and months after surgery and was often unsightly, became poorly positioned and a second operation to replace it with the proper implant was needed. Now it is possible to perform the mastectomy and place the implant at the same operation, without using a tissue flap.

This is done by placing the implant behind your chest wall muscle (the pectoralis muscle) which covers the top half and a  piece of animal derived skin called an Acellular Dermal Matrix (ADM) which covers the bottom half of the implant. It is called an ADM because it has had the animal’s cells removed chemically so it is ‘acellular’ and because it is from skin it is called ‘dermal’.

 

These photos shows a patient of Mr Turton’s who has had a left nipple-sparing mastectomy and immediate Implant-ADM reconstruction. You can see a very fine scar that runs just under the left nipple and across the side of the breast. Through this incision, the whole breast was removed (the mastectomy) and then the chest wall muscle was lifted to create the space that is enough to cover the upper half of a silicone implant. The ADM was then used to cover the lower half of the implant, before closing the skin.

Because the skin is often thin you will often feel the structures immediately behind and it will feel firmer than a natural breast. However, it works very well for most women and no tissue flaps are used to create it, so there is no additional ‘donor’ site to heal. Future revisions are probably more likely to deal with the long-term management of the implants – these do not last for life and they can be associated with complications.

 

Using an implant and Acellular Dermal Matrix

This next section discusses more about the different types of mastectomy and the implant-ADM technique.

Skin sparing mastectomy what is it?

If an immediate breast reconstruction is suitable, the breast tissue with or without the nipple is removed preserving the overlying breast skin. The aim of the mastectomy is to delicately remove the breast tissue from inside the breast skin envelope and only remove any involved skin.  In the majority of cases the breast skin is perfectly healthy and can be preserved to retain the original breast shape.

Reduction pattern skin sparing mastectomy

The skin envelope is reduced or make into a more ideal shape or size. Usually involves a vertical scar down the front of the breast (the nipple is removed) and a long scar across the crease. It creates a smaller breast without sag.

Nipple preserving, skin sparing mastectomy

In certain circumstances a patient may be able to retain their nipple. The incision is usually under the areola and then across to the side of the breast. If you have had radiotherapy before to the breast this would not be recommended.

Nipple sacrificing, skin sparing mastectomy

Where the nipple needs to be removed at the time of mastectomy. The nipple might be reconstructed later, or a tattoo done if the skin is too thin- this would be done  in the future once the breast reconstruction has fully healed. The scar for this approach usually goes horizontally across the front of the breast and the breast looks smaller, and often more rounded than the other side. Surgery is therefore often done to adjust the other side at a later date (mastopexy/uplift procedure).

What is acellular dermal matrix (ADM)?

ADM is a biological mesh derived from animal skin that has been processed making it completely safe to use in humans. The animal cells are removed leaving just a sheet of collagen.  ADM acts like a scaffolding framework for your own blood vessels and tissue to infiltrate. The implant will be covered by your own muscle at the top and by the matrix at the bottom giving a more natural breast shape. Some other types of matrix are available that are synthetic and not derived from animals.

Who is suitable for this type of surgery?

It is most suited to those with small to moderate breasts where there is minimal breast droop (ptosis) or where a bigger breast is deliberately reduced in size as part of the reconstruction. A breast reducing (and uplifting) technique is something that large breasted women often request. This method of reconstruction allows a quicker recovery time than reconstruction involving tissue transfer from other parts of the body (flap based reconstruction).

Some patients may not be suitable for an immediate  breast reconstruction, this may be due to the type of cancer, need for further treatments, underlying  medical problems or risks .  Also this type of reconstruction may not be suitable for smokers, diabetics and those with increased body mass index as serious complications are more frequent.

What will happen to me?

The surgery and possible risks will be discussed by your breast surgeon and consent will be obtained. You will also spend time with your breast care nurse who will support you throughout the process and she will also carry out pre-operative investigations including blood tests.

The majority of patients spend one to two nights in hospital however you will be assessed to ensure you can manage safely on discharge.

Pain will be managed by local anaesthetic which is put into the breast wound at the time of surgery which should last around 4-6 hours. Oral pain killers will be encouraged once you are managing oral fluids. You will be given tablets to take home; it is recommended that you take these for at least a week. Please remember all pain relief can lead to constipation a mild laxative may be required.

Your surgeon will insert wound drains in your breast to drain away blood and tissue fluid. This is produced as a result of your surgery. These are likely to remain in place for two weeks, and as a consequence of these you will be required to take oral antibiotics for two weeks also. The breast care nurses will advise you in managing your drains.

The stitches used are dissolvable and under the skin surface. At the end of surgery steristrips are used to cover the scar lines. Dressings are used to cover your wound. These must be left in place until you see your surgeon in outpatients. Dressings need to be kept dry; however you may have a very shallow bath if you can keep the water completely away from dressings.

The physiotherapist may visit you on the ward and give you written information with regard to arm movement. However, this should be avoided for the first two weeks whilst the drains are in place and Mr Turton will advise you in out patients himself. These can be performed once you have been reviewed and assessed as ok to start doing them.

Initially you will wear a tubigrip to support your breasts and following removal of your drains a soft medium support bra may be worn. Clothing with front fastening is always easier to apply and comfortable to wear.

Are there any specific risks from this type of operation?

Partial or full skin flap loss (necrosis )

This is a rare but serious complication which may result in the implant and the affected skin having to be removed. If the circulation to the skin over the reconstruction is compromised, then some or all of the skin may not be healthy enough to survive. In some cases with appropriate dressings healing may occur but in more serious cases the skin and reconstruction cannot be saved.

Infection

If the implant becomes infected it is not usually possible to save it with antibiotics and it will need to be removed. On average in the UK this is seen to occur in 5-10% of patients within the first 6-weeks after surgery. Mr Turton’s techniques have reduced the rates of this occurring to his own patients to under 5%.

Seroma

This is a collection of plasma like fluid under the skin or around the implant. If the seroma persists for a number of weeks post drain removal it may be necessary for the fluid to be drained but this will be at the discretion of your surgeon. Too much movent too early will encourage seroma. Seroma can increase the risk of infection and losing your implant due to complications.

Red breast syndrome

Occasionally there is a transient immune reaction to the acellular dermal matrix causing the skin to become red, whilst this is not an infection it is best treated as such in order to reduce the risk of implant loss- It is not initially obvious if infection is causing the redness or a reaction.

Numbness

The tiny nerves and nerve endings, which supply the skin’s sensation are divided or disturbed by surgery when the breast tissue is removed. It is therefore common to experience numbness, which is often permanent, though usually lessens over the first few years.

Nipple complications

If your nipple has been preserved it will be numb and unable to become erect when cold or touched.

If your nipple has been preserved there is sometimes a partial loss of colour and it often becomes flatter.

The majority of nipples survive well but in the early post-operative weeks the nipple tip and areola have the potential to develop some scabbing or discolouration.  Surgical intervention is not usually required and will settle within a month. If the nipple or areola does not survive it may be possible to perform a nipple construction or tattoo at a later date.  Where the nipple does not survive it may need to be removed to prevent it from becoming infected and then deeper infection spreading to the implant and the ADM.

Implant complications

No breast reconstruction can replace the breast you have lost in terms of feeling and movement and on touching the breast you may be able to feel the implant edges under the skin and muscle. The implant will move a little when the chest wall muscles are tensed and return to its normal position when relaxed again. Because the chest wall muscle is just under the skin this looks odd as it happens. Subtle rippling of the implant surface may also be noticeable with softer implants and in general a firmer gel implant that has an tear drop shape is used to minimise this. The temperature of the breast often feels cooler.

Implant Rotation and malposition

Sometimes an implant will move out of its best position. A tear drop implant can sometimes rotate. It is better not to sleep on your front if you have an implant. If malposition occurs you may need further surgery.

 Capsular contracture

A contracture is a tight fibrous capsule that the body forms around the implant causing the breast to look less natural and feel hard. This is one of the more frequent problems in the long term and affects around 1-2% of patients per year. Smoking and radiotherapy and any deep infections  are known to increase the risks greatly. If it becomes severe, salvage with a tissue flap based reconstruction or removal of the reconstruction altogether might be required.

Need for further surgery

It is not possible to predict how your breasts will change; over time the shape and volume of your natural breast may be affected by weight loss and gain and the natural ageing process.

There is a significant chance that you will need some further aesthetic surgery at some stage-  this may be adjustment to the reconstruction or implant replacement as time progresses. Surgery may be required to the contralateral breast to improve symmetry. It is not always possible to obtain good symmetry due to the limitations of this type of surgery.

Implant rupture

Modern generation silicone breast implants have a well established safety record.  However they are not devices that will last for the rest of your life. The rupture rate is thought to be between 5 and 10% within the first 10 years after surgery. It is generally advisable to consider implant exchange after 10 years in any event.

Other Rare Implant Systemic Symptoms

It is possible in a small number of individuals that there can be unexpected systemic symptoms. The research in this area has usually discounted any association with systemic symptoms such as tiredness, dry eyes, muscle or joint aches, or automimmune disorders. Some of these problems may happen in association but purely by chance (as they would occur in women with out implants) and therefore not be related to the implants. But there have not been large enough volume, or high enough quality research studies to prove or disprove any link conclusively, and although previous studies have stated there are no links, it is fair to say there is still the possibility of a link that can affect a small percentage of susceptible people, but it has not yet been proven.

 

Implant related cancer (Anaplastic large cell lymphoma – BIA-ALCL)

There is a rare implant-associated cancer of the tissue-based white blood cells found in the capsule or fluid around the implant that is very occasionally seen years after reconstruction. A sudden effusion around the implant like a bag of fluid would always need to be assessed just in case it was caused by this rare condition. However, there are many totally innocent causes of fluid to form around an implant such as trauma, or infection, or implant rupture. However, to check for BIA-ALCL you should been seen and assessed by your specialist if it did occur. The occurrence of ALCL is difficult to quantify and some estimates put it as rare as 1 in 100,000, but in some countries such as Australia it has been estimated to affect around 1 in 3800 with some implant types. If it occurs it can usually be successfully treated by removing the implant and the capsule fully.