Although most breast care centres have associated specialist doctors and nurses they are often enormously overstretched and furthermore rarely have the ability to offer a full range of reconstructive opportunities. The Reconstructive Plastic Surgeons at McIndoe (one of the largest breast reconstructive private hospitals in Western Europe), will offer you impartial and practical advice on all reconstructive techniques, best suited to your individual needs.
Not all breast cancer is managed by surgery. Those cancers that do require an operation may be dealt with in the following ways :
- Lumpectomy (removal of lump with a covering layer of normal breast tissue). Partial mastectomy (when part of the breast is removed).
- Total mastectomy (when all the breast tissue is removed).
Breast cancers can spread to the lymph glands in the armpit so the best procedure is often followed by examination of these glands. Cancerous cells will be removed with the breast as an axillary clearance or axillary dissection. Depending on the various features of the breast cancer other treatments may be required such as radiotherapy or manipulation of hormones.
Reconstruction of the breast usually revolves around replacing the missing volume of breast tissue removed as a mastectomy, and secondly replacement of any skin deficiency. Sometimes, when a small volume of breast tissue has had to be removed, especially in larger breasts, the remaining breast tissue can be reshaped to create a very satisfactory smaller breast form.
This approach is known as oncoplastic surgery. Of course the other breast may need to be reduced in size to regain a matching pair. Where small volumes of breast tissue have been removed it may be possible to fill out the resulting indentation by injecting fat taken from the lower part of the abdomen. Occasionally there is adequate skin laxity on the chest to allow the breast mound to be formed by simply inserting a breast implant underneath the chest wall muscle (pectoralis major muscle).
This approach however, is usually only suitable for fairly small high breasts with minimal droop. If there is not enough skin, then often it is possible to stretch it by blowing up a balloon (tissue expander) placed underneath the chest wall muscle.
The stretching gradually occurs over 3 or so months and when adequate skin has developed the balloon can be replaced by a definitive breast implant as a second operation. Alternatively, a combined expand/implant (Becker implant) can be used, which once expanded, is kept in place. As with simple implant reconstructions this approach is usually only suitable for relatively small, high breasts unless you are happy for corrective surgery to be carried out on the other breast to create a better match.
Chest wall skin can be supplemented by transferring a skin elipse from the back, round under the arm to the front. This is brought round attached to the latismus dorsi muscle (LD flap). This flap can be combined with associated neighbouring fat, which may allow a small breast to be formed without the requirement for breast implant (extended LD flap).
Often women approach McIndoe to reconstruct a breast for them without the need for an artificial implant. They may be concerned about the durability of such implants (particularly when subjected to radiotherapy).
They would instead prefer to use their own body tissue. This can be taken from the lower abdomen (TRAM or DIEP flap) as part of a tummy tuck procedure, the buttock (SCAP flap - Superior gluteal artery perforator) or the upper inner thigh (TUG - Transverse upper gracilis).
All three are used as free flaps i.e. are taken from the body to include an artery and a vein. These blood vessels are then reconnected to similar ones on the chest wall.
Many plastic surgeons now use the DIEP flap as a primary choice, which comprises of skin and fat, without any sacrifice of muscle. TRAM flap involves removing either a very small section of muscle (a muscle sparring TRAM) or the full width of the six pack (rectus abdominis muscle) as a TRAM flap proper. The DIEP type reconstructions take a little longer than the combined operating time of the multi staged implant approach when carried out by a specialist surgical team such as those based at the McIndoe. Due to the amount of abdominal tissue often available it is unusual not to be able to match the other breast in size and shape very accurately. Because the skin is of a similar quality (soft and supple) a much better nipple can be made compared to thick skin from the back. Once completed, the DIEP breast is there for life.
This is of course only a brief overview of techniques available. If you are considering breast reconstruction, take the opportunity to discuss your wishes with one of the specialist breast reconstruction plastic surgeons here at McIndoe. Simply contact our Helpline on 0800 917 in the first instance.
Thanks to Peter Arnstein for his assistance with the article.