Breast Reconstruction

There are two main ways to rebuild a breast. Implant-based reconstruction uses a silicone implant, placed either directly at the time of mastectomy or after a tissue expander, a temporary balloon-like implant that is gradually filled with saline over several weeks to stretch the skin before it is exchanged for a permanent implant. The implant may sit in front of or behind the chest muscle, often supported by a biological or synthetic mesh. Autologous reconstruction uses your own tissue. In a DIEP flap, skin and fat from the lower abdomen are moved to the chest with their small blood vessels, which are reconnected to vessels in the chest under a microscope; the abdominal muscle is kept, and the abdomen is closed like a tummy tuck. Other flaps take tissue from the inner thigh or buttock. The latissimus dorsi flap moves a back muscle with skin and fat, often together with an implant. Fat grafting transfers liposuctioned fat to refine contour, and the nipple can be rebuilt with a small skin flap or a three-dimensional tattoo.

Reconstruction is offered to most people having a mastectomy for cancer or for risk reduction, and to people who had a mastectomy in the past and now want a breast shape. It can also correct a dent, asymmetry or contracture after breast-conserving surgery and radiotherapy. Choosing not to have reconstruction is equally valid. The choice of method depends on several factors. Implants suit people who prefer a shorter operation and recovery, have little spare tissue, or need both sides reconstructed with a modest size. Flaps suit people with enough abdominal or thigh tissue, those who have had or will have radiotherapy, and those who prefer a result without an implant that will not need future exchanges. Radiotherapy affects timing: it can harden and shrink tissue around implants, so many teams delay a flap until radiotherapy is complete, sometimes keeping the skin with a temporary expander. Your breast surgeon and plastic surgeon plan the cancer operation and the reconstruction together.

All main stages are done under general anaesthesia. In direct-to-implant reconstruction, the plastic surgeon places the permanent implant through the mastectomy incision; with an expander, the expander is inflated in clinic every one to two weeks through a small port under the skin, and a second operation about three to six months later exchanges it for the permanent implant. A DIEP flap usually takes about 4 to 8 hours for one side. The surgeon raises an ellipse of lower abdominal skin and fat with the perforator vessels that supply it, prepares recipient vessels in the chest, usually behind a rib cartilage, and joins artery and vein under a microscope before shaping the flap into a breast. The abdomen is closed with a new navel opening. A latissimus dorsi flap is turned from the back under the skin to the chest. Later stages, often done as short operations, include fat grafting, adjusting the other breast for symmetry and nipple reconstruction.

Good candidates are in reasonable general health and have realistic expectations about a breast that looks natural in clothes but differs from the original in feel and sensation. Smoking greatly raises the risk of wound healing problems, flap loss and implant infection, so stopping well before and after surgery is essential. A high body weight, poorly controlled diabetes and some blood clotting disorders raise risks and may favour one method over another. For a DIEP flap a scan of the abdominal blood vessels, usually a CT angiogram, is often done to map the perforators, and previous abdominal operations are reviewed. Preparation includes blood tests, an anaesthetic assessment, a medicine review, and photographs and measurements. If reconstruction is immediate, the plan is coordinated with the breast surgeon and the oncology team. International patients can send records, photographs and scans in advance for a remote consultation, and the number and timing of visits should be agreed before the first trip.

After implant reconstruction most people go home after one or two nights, sometimes with drains, and return to light activity within about two weeks and to most activities in about four to six weeks. After a DIEP flap the flap is checked frequently for the first two days to confirm its blood flow, and the hospital stay is usually about three to five nights. Walking starts the day after surgery, slightly bent at first because of the abdominal closure. Lifting and strenuous exercise wait about six weeks, and full recovery often takes two to three months. For travel, stay near the hospital for about one to two weeks after implant surgery, and typically a few weeks after a DIEP flap, because of the higher risk of blood clots and the need for wound checks before a long flight. Plan for further visits for later stages, or arrange for them to be completed near home.

Breast reconstruction is well established, but each method has specific risks in addition to bleeding, infection and blood clots. With implants, the main problems are infection that may require removal of the implant, capsular contracture, where scar tissue tightens and hardens around the implant, rippling, rupture and the possible need for further operations over the years. Breast implant associated anaplastic large cell lymphoma is a rare lymphoma linked mainly to textured implants. With a DIEP or other free flap, the blood supply can fail; total flap loss is uncommon and is usually identified early, when a return to theatre may save it. Areas of hardened fat, called fat necrosis, can form in the flap. At the donor site there may be weakness, a bulge or a hernia, and wound healing problems. The reconstructed breast usually has reduced sensation. Most people are satisfied with their reconstruction, and a result that looks natural in clothing is a realistic goal.