Reconstruction

Breast Reconstruction is a very broad topic, which when discussed,   needs to cover both breast conservation surgery as well as breast reconstruction. The decision of which option to choose – breast conservation or breast reconstruction – is, usually, a combined decision made by both the breast and reconstructive surgeon, and you, the patient.

BREAST CONSERVATION
Obviously to pursue this option, you would need to be a candidate for it – i.e. to have a tumour of the necessary grade, stage and size – as well as large enough breasts to allow one to perform this procedure.

Breast conservation consists of performing a wide, local excision of the breast lump and utilising breast reduction and reconstructive, (onco-plastic) techniques to reconstruct the breast from the remaining breast tissue.   At the same operation, one would perform the necessary surgery on the opposite breast to achieve symmetry. Obviously the breast would need to have sufficient tissue that removal of a large portion would not compromise the aesthetic result, and the procedure is usually completed in a single operation. Radiotherapy is required afterwards to the affected breast.

This is certainly one of the options available to suitable candidates and, when performed, can achieve very satisfactory results.

However, each patient is an individual and, obviously, not all patients are candidates for breast conservation. The operative procedure, and options available, are discussed at your consultation.

BREAST RECONSTRUCTION
Breast reconstruction, as opposed to ‘Breast Conservation’, is reconstructing the breast post-mastectomy (i.e. removal of the breast tissue)    This is an extremely vast and complicated topic and I will attempt a broad overview here.

It needs to be reiterated that breast reconstruction is a ‘reconstructive’ procedure – and not a ‘cosmetic’ procedure – and that it is not always possible to guarantee a perfect result. There is often some compromise in the final result. Most breast reconstructions are staged procedures.   It is not possible to recreate a breast, which matches the opposite breast, as well as create the nipple and areola all in a single stage operation.

Mastectomies, nowadays, are usually skin-sparing mastectomies, where the major portion of the skin of the breast is preserved. Whether the nipple/areola complex is spared, is usually a decision made by your breast and plastic surgeons at the time of your consultation. Sparing of the nipple/areola complex is not always possible. Nipple/areola reconstruction is then performed at a later stage.

Basically, breast reconstruction can be divided into two rather broad categories – ‘prosthetic’ and ‘autogenous’ reconstruction.

PROSTHETIC RECONSTRUCTIONS  are where a tissue expander/implant is utilised to reconstruct the breast. This is, usually, a staged procedure. At the time of the skin-sparing mastectomy, an implant/tissue expander is placed under the pectoralis major muscle of the breast. This provides the necessary coverage.

The placement of a tissue expander/implant at the time of surgery only prolongs the procedure by 45 minutes to an hour.

Once healing has occurred – approximately 3 – 4 weeks – one is then able to proceed with expansion of the prosthesis. This expansion takes place, in the office, and requires three or four visits. A small volume of saline is inserted into the tissue expander port. (This port is an integrated port within the implant and not visible from the outside.)   The procedure is not painful and most patients, after the first visit, are often surprised by the ease with which this filling is accomplished.

Once a satisfactory size of the implant has been obtained, the second stage of the operation takes place. The second stage of the operation usually involves the replacement of the expander with a permanent implant. Any adjustments of the implant pocket are done at this stage. At this second stage, symmetry with the opposite breast, is obtained. The opposite breast would then either be reduced, lifted or even augmented, to match the reconstructed breast. This procedure is usually an overnight procedure and has a far quicker recovery time when compared with the first surgery.

Stages three and four of the reconstruction involves the nipple/areola reconstruction. The nipple reconstruction utilises either composite tissue grafts, local flaps or even nipple sharing). This is a day case procedure and is usually completed in an hour.

The final stage is the tattooing, which is done under local anaesthetic in the doctor’s rooms.

The prosthetic reconstruction is one of the most popular procedures world-wide. There is no associated donor site and the operative procedure is less invasive than many other options, is not for all patients and is something which can be discussed with your doctor.

AUTOGENOUS RECONSTRUCTION is when the body’s own tissues are utilised to reconstruct the breast. Here various tissue flaps such as the TRAM or DIEP or Latissimus Dorsi flaps are utilised.

These procedures involve transferring tissue from either the lower abdominal wall, upper back or buttock regions, etc. They are obviously more involved techniques in that tissue cannot merely be moved without a blood supply. This therefore requires either pedicle flaps (where the blood supply is ensured by transferring the tissue on its blood supply (ie a muscle) or by micro-vascular techniques where the blood supply is re-established by suturing the small blood vessels. These are obviously more technical and time consuming techniques.

These Autogenous procedures are slightly more complicated than prosthetic reconstructions.   They do, however, not require prostheses – and give very satisfactory and natural results. Patients obviously need to be assessed, and be candidates for, such a procedure. They need to be healthy and have the necessary fortitude to enable them to undergo the procedure, as well as sustain the rigors of the surgery.

Autogenous reconstructions are, likewise, also staged procedures (as with the Prosthetic reconstructions).

At the second stage, symmetry of the opposite breast is achieved, and the third and fourth stages, involve the nipple/areolar reconstruction.

Autogenous reconstructions are highly successful procedures, and the various options are discussed at the time of your consultation.

Breast reconstruction is an extremely broad and complex topic and this will be fully discussed at the consultation. The above is merely an outline of some of the procedures – and the various options   that may be available to you.

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