October is Breast Cancer Awareness Month. In honour of this special occasion, we are publishing a Breast Reconstruction Series to cover various aspects of breast reconstruction after surgery. We are starting with this introductory article to give an outline of things to consider in breast reconstruction.
INTRODUCTION
Breast reconstruction is a transformative and empowering journey for many women who have undergone mastectomy due to breast cancer or other medical reasons. It offers the opportunity to regain not only physical wholeness but also emotional and psychological well-being. In this blog, we will explore the three stages of breast reconstruction, the timing considerations between primary and secondary reconstruction, and additional procedures to ensure symmetry and balance.
Breast reconstruction is a surgical procedure that aims to recreate a natural-looking breast mound following a mastectomy or lumpectomy. It is a deeply personal choice, and every woman's journey is unique. The decision to undergo breast reconstruction can significantly impact one's self-esteem and overall quality of life.
TYPES OF DEFECTS
Mastecotmy defects (with or without nipple-areolar resection) The breast volume is completely removed. The nipple-areolar complex may or may not be preserved depending on the type of mastectomy performed.
Breast-Conservation Therapy (BCT) defects The breast volume is reduced but partially preserved. The defect could be due to signifiant reduction in size, contour irregularity, distortion of nipple-areolar complex, or a combination of these.
TIMING OF RECONSTRUCTION - PRIMARY V.S. SECONDARY
The timing of breast reconstruction can vary based on individual circumstances and preferences:
Primary Reconstruction Some women choose to have breast reconstruction immediately following their mastectomy. This is known as primary reconstruction and offers the benefit of waking up from surgery with a breast mound already in place. It is important to note that adjuvant cancer treatment (e.g. radiotherapy) may affect long-term reconstruction outcome.
Secondary Reconstruction Others may decide to postpone reconstruction for various reasons or may not initially consider it and later change their mind. Secondary reconstruction can be performed months or even years after the initial surgery. It allows women to take time to heal, weigh their options, and make an informed decision about reconstruction.
THE THREE STAGES OF BREAST RECONSTRUCTION (FOR MASTECTOMY DEFECTS)
Breast reconstruction is typically divided into three stages:
Stage I - Breast (Mound) Reconstruction
This is the first stage of reconstruction and the goal is to restore the breast mound. Options include:
Flap Reconstruction In flap reconstruction, tissue is taken from another part of the body (e.g., abdomen, thigh) and transplanted to the chest to create a new breast mound. Common types of flap procedures include the DIEP flap (Deep Inferior Epigastric Perforator) and TRAM flap (Transverse Rectus Abdominis Myocutaneous).
Implant Reconstruction In this method, breast implants are used to create a breast mound. Silicone implants of the appropriate sizes can be chosen based on individual preferences and medical considerations. The implants are generally placed under the pectoral muscle.
Fat grafting Fat grafting is most commonly performed as an adjunctive procedure in breast reconstruction to complement autologous tissue flaps and implants. However, recent studies have shown success with whole breast reconstruction using fat grafting alone. External expansion is crucial to primary breast reconstruction with fat grafting, with timelines ranging from 6 to 12 hours daily for up to 2 months.
Stage II - Nipple Reconstruction
In the second stage, nipple reconstruction is carried out to recreate the nipple and improve the aesthetic appearance of the reconstructed breast. This can be achieved through:
Local Flap Tissue from the reconstructed breast is sculpted to create a new nipple under local anaesthesia, most commonly performed in the clinic. This method is typically performed a few months after Stage I.
Prosthesis Some women may opt for a silicone nipple prosthesis, which can be attached to the breast mound.
3D Tattooing Tattoo artists specializing in medical tattooing can create the illusion of a three-dimensional nipple and areola, providing a realistic finish.
Stage III - Tattooing of the nipple-areolar complex
This stage involves fine-tuning the cosmetic appearance of the reconstructed breast. Skilled tattoo artists can add shading and color to the areola, making it look more natural. This final touch enhances the overall symmetry and balance of the reconstructed breast.
Skilled tattoo artsts will match the colour of the contralateral nipple (if only one side needs reconstruction) to add colour to the reconstructed nipple and its surrounding area. The procedure generally requires only topical numbing and can be on an out-patient basis.
CONTRALATERAL BREAST PROCEDURES
To achieve symmetry and balance, it is sometimes essential to address the contralateral breast (" the normal side"). This can be due to a variety of reasons, e.g. the patient did not like the size (too large or too small) of her contralateral breast or the contralateral breast has sagged significantly complicating reconstruction. Procedures that may be considered for the contralateral breast include:
Breast Augmentation If the unaffected breast is smaller, an augmentation with an implant or fat transfer can improve symmetry. Sometimes, implants of different sizes are inserted to augment one side and reconstruct the other.
Breast Reduction In cases where the unaffected breast is larger, a reduction procedure may be performed on the contralateral side to improve symmetry and overall function of the patient.
Breast Lift Sometimes, a breast lift is necessary to adjust the position and shape of the contralateral breast to match the reconstructed breast.
RECONSTRUCTION OF BREAST-CONSERVING THERAPY (BCT) DEFECTS
Breast-conserving therapy (also known as lumpectomy or partial mastectomy) is an option for some breast cancer patients. Although the intention was to preserve breast contour and symmetry, it may sometimes leave a noticeable defect. Reconstruction of BCT defects can improve the cosmetic appearance of the breast. Options include fat-grafting, flap reconstructions, or implant augmentation.
Radiotherapy is needed after BCT in most patients and may complicate subsequent reconstruction. Another consideration is the risk of future development of breast cancer in the remaining breast tissue.
CONCLUSION
Breast reconstruction is a powerful journey that can help women regain their self-confidence, feel whole again, and embrace life after breast cancer or other medical challenges. Thorough discussion with an experienced reconstructive team regarding various aspects of reconstruction, such as stages of reconstruction, timing considerations, contralateral breast management etc ensure that each woman's journey is tailored to her unique needs and preferences. With the support of skilled surgeons and tattoo artists, breast reconstruction can be a transformative and empowering experience.
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