Plastic Surgery & Reconstructive Procedures

Breast Reconstruction / Oncoplastic Surgery

Breast
  • About

    Women who need a mastectomy or have had a mastectomy in the past for breast cancer can have a reconstructive procedure to recreate a new breast. The latter to be performed at the same time as the mastectomy or a later stage.

  • Breast Reconstruction Options

    There are many choices involved in the breast reconstruction process.

    Today, most women who have mastectomies are good candidates for breast reconstruction. After a mastectomy, women choose to have breast reconstruction for many different reasons. Some no longer feel whole, or they don’t feel as feminine. Others don’t want to bother with the day to day hassle of wearing a breast prosthesis.

    Whatever the reasoning might be, for many women breast reconstruction is an excellent way to feel better about themselves and make a fresh new start in life.

    What is a Mastectomy?

    A mastectomy is the removal of breast tissue due to the presence of a cancerous or precancerous growth. The amount of tissue removed during a mastectomy is not always the same; it will vary based on:

    • The size and stage of your cancer
    • Your body type
    • Your personal preferences

    Breast Reconstruction timing

    Breast reconstruction can be done during the same operation as your mastectomy. The latter is called immediate reconstruction.

    It can also be done weeks, months or even years after your mastectomy. The latter is called delayed reconstruction.

    Based on your circumstances, you and your doctor can decide which method is best for you.

    Immediate Reconstruction

    The advantage of having immediate breast reconstruction is that your breast is reconstructed during the same operation as your mastectomy.

    Delayed Reconstruction

    The advantage of delayed reconstruction is that it allows you first to rebuild your strength.

    Breast Reconstruction Options

    There are different ways to reconstruct your breast. The method you and your doctor choose depends on several factors, including:

    • Your health & lifestyle
    • Your body type
    • Your breast size
    • Your personal choice
    • The amount of remaining skin and tissue

    Breast reconstruction can be done using your body tissue, by using breast implants or by using a combination of your tissue with a breast implant.

    Using your tissue for Breast Reconstruction

    Latissimus Dorsi Flap

    During this procedure, a section of your skin and muscle is removed from your back or from under your arm and moved to the breast area, where it is used to reconstruct your breast.

    Because the skin and muscle from your back area usually are relatively thin, this method is sometimes used along with a breast implant, to give your new breast a fuller look and a more natural shape.

    The TRAM Flap

    Another way to reconstruct your breast using your tissue is called a TRAM Flap. This procedure involves removing fat and muscle from the stomach area and placing it in the chest area to reconstruct your breast.

    Sometimes the blood supply and connection to the stomach area can be preserved. When it’s not, blood vessels from the stomach tissue must be attached to the chest area using microsurgery.

    Breast Reconstruction with Implants

    During a mastectomy, the surgeon removes skin and breast tissue, leaving the chest tissues flat and tight. Before placement of a long-term implant, the breast tissue needs to stretch to make space for it. This process is called tissue expansion. The latter can take place in either one or two stages.

    How it works

        • A temporary breast tissue expander is placed in the chest.
        • Over weeks, your physician gradually fills the expander with saline, which is similar to saltwater.
        • During this process, your skin will gradually stretch and grow to make room for the implant as it expands.
        • Your body will slowly adjust to the growth of the implant in the same manner a woman’s body adjusts to the gradual change of her abdomen when she is pregnant.
  • Breast Conservation Surgery

    Breast conservation surgery is a procedure available to certain patients. Your breast surgeon will inform you if you are a candidate for breast conservation surgery.

    To be a candidate for breast conservation surgery, some specific prerequisites must be met. Some prerequisites include the size of your breasts, the size and location of the tumour and your ability to receive radiation.

    One of the reconstructive options available to a patient with an adequate tumour to breast ratios is wide local excisions via a reduction pattern.

    During breast conservation surgery, the breast cancer surgeon removes the tumour and a rim of surrounding normal tissue. A pathologist will assess the excised breast tissue to make sure that the tumour is completely excised. Rearrangement of the remaining breast tissue is done in such a way as to reconstruct the breast mound via breast reduction techniques.

    Breast reduction patterns approach the breast via incisions that surround the nipple and areola, a vertical component with or without a horizontal component – the so-called inverted T-incisions. These incisions facilitate the movement of the nipple and areola into a new position and removing breast tissue, fat and skin. Once the breast tissue is excised, arrangement of surrounding breast takes place to give a cosmetically pleasing shape.

    The breast size is reduced to accommodate the oncologically excised tissue. Should you wish to have an even more significant reduction, that too can be accommodated. The amount of breast tissue removed is determined by the oncological requirements firstly and secondly by patient preference.

    The reconstructive surgeon arranges the breast tissue and moves the nipple and areola into its new position. In most cases, the nipple and areola remain attached to their blood vessels and nerves. However, if the breasts are very large and pendulous, the nipples and areolas may have to be removed entirely and grafted into the correct position. The graft will result in complete loss of sensation in the nipple and areola. In cases where the tumour is close to the nipple and areola, placement of a clear disc of the skin in the position of the nipple and areola allows for nipple and areola reconstruction at a later stage. Once again, all sensation will be lost as the nipple and areola are removed.

    In Post Breast Conservation Surgery, the patient receives radiation therapy. Radiation therapy affects the breast in various ways and thus has to be compensated for, if possible, during the initial reconstruction. These changes include, but are not limited to:

    • Loss Of Volume: To account for loss of volume, the breast operated on will, initially, be made slightly larger than the opposite breast.
    • Fat Necrosis: Death of fatty tissue and formation of hard lumps. These may be managed conservatively and may perhaps be best not to interfere and cause further fat necrosis. The reconstructive surgeon may elect to excise the hard tissue or inject some fat to improve the condition.
    • Skin Changes: Breast conservation surgery via reduction techniques is a safe procedure, but as with any surgery, there is always a possibility of complications. These include bleeding, infections and anaesthetic related complications. The procedure leaves noticeable, permanent scars and some patients have poor healing around the nipples and at the inverted T-junctions, worsened by smoking.

    The Procedure

    You will receive a general anaesthetic. The reconstructive surgeon draws the appropriate access incisions on your breast either before or during the procedure.

    Firstly, the oncological surgeon removes the breast tissue and necessary lymph nodes via the predetermined incisions. The pathologist determines adequate tumour removal intra-operatively, and once the margins are clear the reconstructive surgeon proceeds.

    The breast tissue gets arranged in a way to accommodate the excised tissue and to reduce the breast to the required size. The nipple and areola are positioned in the appropriate position, grafted or replaced by a clear disc depending on the oncological and size requirements. The opposite breast gets reduced similarly.

    Two drains are placed – one in each breast. These drains will remain until the drainage is less than 30ml in 2 consecutive days. The wound is closed in layers, and appropriate dressings applied.

    The patient is placed in a supportive bra intra-operatively. Thus, It is essential that the patient come to the theatre with an appropriate sports bra without any wire insertions, preferably in a dark colour.

    Recovering

    You would have to stay in the hospital for 2-5 days during the healing process. We will teach you how to empty the surgical drains and to keep a record of the drainage.

    We will prescribe and provide Antibiotics and pain medication for you to take home. The drains will be removed once it drains less than 30ml in 2 consecutive days.

    Do not rush to get back to work. Allow yourself 6 weeks for recovery. You will not be allowed to drive for two weeks following the procedure and will need to follow up with both the reconstructive as well as the oncological surgeon on the dates given at discharge.

    Pain, bruising and swelling will gradually disappear over the next few weeks, and slowly your breast will settle into the new shape. This process may take six months to a year. You will be required to wear supportive bras for up to 4 months.

    Complications

    Below follows a list of some of the more frequent complications associated with breast conservation surgery via breast reduction techniques:

    • Local Complications (Around The Breast):
      • Haematoma formation
      • Seroma formation
      • Delayed wound healing
      • Wound sepsis
      • Wound breakdown
      • Sensory changes in the breast
      • Pain
    • Systemic Complication (Your Body):
      • Fluid and electrolyte abnormalities
      • Deep vein thrombosis
      • Postoperative lung complications
    • Long Term and Cosmetic Complications (The Way It Looks):
      • Asymmetries of the breast nipples (pre-existing asymmetries will still be noticeable)
      • Poor scarring
      • Dog Ears and irregularities of the wounds
      • Change in the sensation of the nipple and surrounding breasts
      • Inability to breastfeed post-operatively
      • Complete nipple loss
      • Pain, from many causes including muscle spasms and nerve injury
      • Secondary procedures to improve the appearance, e.g. fat fills
  • Tissue Expansion

    Tissue expansion is a process whereby existing tissue overlying the breast is slowly stretched by a balloon-type device to create sufficient tissue with which one can create a breast.

    Placement of a temporary breast tissue expander in the chest. The tissue expander can be placed at the time of breast cancer surgery (Mastectomy) or a later stage. Over weeks, the reconstructive surgeon gradually fills the expander with saline solution. During this process, your skin will gradually stretch and grow to make room for a new breast as it expands. Your body will slowly adjust to the growth of the implant in the same manner a woman’s body adjusts to the gradual change of her abdomen when she is pregnant.

    Eventually, when the desired size has been achieved, the newly created space can be filled with an appropriate reconstruction. The second stage reconstruction is done at approximately 3-6 months after the desired expanded size has been achieved. The delay allows the tissue to soften and permanently acquire the expanded shape.

    The reconstructive options range from prosthetic or implant reconstruction to any type of flap reconstruction. Often we place a silicone implant alone or in combination with a latissimus dorsi flap from the back to provide additional coverage over the implant. The latissimus dorsi flap lends itself well to gradual expansion and allows for added coverage.

    Free flap reconstruction with your tissue could also be used to fill the cavity so created for the breast. This type of reconstruction requires a minimum of two operations.

    Should you develop complications, wish to delay your nipple and areola reconstruction or want to have alteration in the shape of your breasts, you would need additional surgery.

    The initial procedure involves the placement of the expander. Gradually the desired size will be reached during the expansion process. The second or definitive reconstruction will depend on the type of reconstruction decided upon by you and your doctor.

    The nipple and areola may be reconstructed at the second stage or a delayed third stage. Delaying the nipple-areola reconstruction allows the breast to settle in the correct shape and allows for a correct positioning of the nipple-areola.

    The Procedure

    You will receive a general anaesthetic. The reconstructive surgeon draws the appropriate access incisions on your breast either before or during the procedure.

    Firstly the oncological surgeon removes the breast tissue and necessary lymph nodes via the predetermined access incisions.

    The expander is placed under the existing breast tissue and muscle.

    A drain is placed at the surgical site. These drains will remain until the drainage is less than 30ml in 2 consecutive days. The wound is closed in layers, and appropriate dressings applied.

    You would have to stay in the hospital for 1-2 days during the healing process. You will be taught to empty the surgical drain and to keep a record of the drainage. Antibiotics and pain medication will be given to take home. The drains will be removed once it drains less than 30ml in 2 consecutive days. You need to follow up with both the reconstructive as well as the oncological surgeon on the dates given at discharge.

    Pain, bruising and swelling will gradually disappear over the next few weeks. The first expansion will occur in the surgeon’s rooms approximately two weeks after the initial expander placement. The patient and surgeon will proceed with weekly increase until the desired size is reached, and as the patient tolerates the development.

    Should any complications arise, the surgeon may attempt salvage of the expander. Still, in the case of infection, the expander would have to be removed and the reconstruction delayed to a period of 6-12 months.

    Complications

    Below follows a list of some of the more frequent complications associated with tissue expansion. (Please note that the complications below have an increased incidence in patients who have previously received radiation therapy or in those who are smokers.):

    • Local Complications (Around The Breast):
      • Haematoma formation
      • Seroma formation
      • Delayed wound healing
      • Wound sepsis
      • Wound breakdown
      • Sensory changes in the breast
      • Pain
    • Expander Complications
      • Expander deflation
      • Expander rupture
      • Expander extrusion
      • Capsular contracture (hardening of the expander)
    • Systemic Complication (Your Body):
      • Fluid and electrolyte abnormalities
      • Deep vein thrombosis
      • Postoperative lung complications
    • Long Term And Cosmetic Complications (The Way It Looks):
      • Reconstruction malposition
      • Breast Asymmetries
      • Poor scarring
      • Secondary procedures to improve the appearance, e.g. fat fills.
  • Silicone Breast Impants

    Breast implants are medical devices that are implanted under the breast tissue, chest wall muscle or breast skin and muscle. They are used to increase the size of breasts (breast augmentation) or to rebuild breast tissue after mastectomy or other damage, breast reconstruction. Silicone breast implants may also be used in revisions surgery to correct or improve the result of previous surgery.

    There are two types of breast implants approved for use:

    • Saline-filled
    • Silicone gel-filled breast implants

    Both types have a silicone outer shell. Dr Liezl mostly uses silicone implants as we feel it provides an improved cosmetic appearance.

    More than 1.5 million American women currently have silicone breast implants. The majority of patients (two thirds) had silicone implants to improve the appearance of their breasts via breast augmentation. The remaining one-third of patients received implants for breast reconstruction either before (prophylactic) or after the development of breast cancer.

    Today the safety of silicone breast implants have been proven, albeit a long controversial history. A Feb 2013 news release from the United States Food and Drug Administration confirms the safety of silicone breast implants. The purpose of this pamphlet is to inform the patient that wants to have silicone implants regarding possible complications associated with the procedure.

    We hope for the patient to make an informed decision regarding their choice of silicone breast implants.

    Risks: Silicone Implants

    There have been recent media reports regarding breast implants and a rare form of cancer. The FDA recently updated information regarding this disease (Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL)). The American Society of Plastic Surgeons is working closely with the FDA in monitoring the condition.

    BIA-ALCL is not a breast cancer, but a rare and treatable T-cell lymphoma that usually develops as a fluid swelling around breast implants. The lifetime risk for this disease appears to be about 1 case for every 30,000 textured implants. This equates to a 0.003 percent risk. Thus far, there have been no confirmed cases of BIA-ALCL in women who have had only “smooth surface” breast implants.

    The FDA is not recommending removal of textured implants. Rather, the FDA recommends that every woman conduct regular self examination. If you develop swelling or a lump in your breast, contact my office right away. Dr Liezl will comprehensively evaluate you and order the appropriate tests to determine if any treatment is indicated.

    Women who develop BIA-ALCL can often be cured by simply removing the implant and the scar tissue surrounding it. Some patients may require additional treatment (such as radiation or chemotherapy). Following removal, replacement with a smooth surface implant may be an option.

    For additional information about BIA-ALCL, consult the American Society of Plastic Surgeons website at www.plasticsurgery.org/alcl. Of course, Dr Liezl is happy to answer your questions personally.

    What you should know about breast implants:

    • Breast implants are not lifetime devices
      The longer a patient has implants, the greater the chances of developing complications – some of which will require more surgery. The “life” of these devices varies according to the individual. Some may need replacement surgery in just a few years; others may last 10-20 years and some even a lifetime. There are several different reasons why patients may need implant replacement surgery. Sometimes it is a matter of choice like size or implant style change and sometimes removal and replacement is necessary because of a complication such as deflation, capsular contracture (hardening), pain or shifting of the implant.
    • Monitoring is crucial – mammography and breast implants
      Breast implants make standard mammography difficult due to the displacement and atrophy of the native breast tissue. Thus it is important to inform your radiologist that you have implants. Special displacement views and additional views will be taken to improve the accuracy of the mammogram. Even in cases of bilateral skin-sparing mastectomies, mammography is still necessary to evaluate and follow up any breast changes as well as implant characteristics over time.
    • How long should i wait before i resume exercise and other strenuous activities?
      During the first two weeks post-surgery you should avoid soaking the wounds by bathing and showering. Overall avoid any strenuous exercise during the first four weeks and certainly while you experience any pain or discomfort. The larger the implant you receive the heavier the breast will be. You should wear good support bras while running to minimise pull on the skin and ptosis (drooping) of the breasts.
    • Tanning salon or sunbathing
      Tanning salons and sunbathing will not harm the implant but may worsen the scarring. You should avoid getting sun or tanning rays on the incisions for at least one year after the surgery as the UV rays may darken the incisions permanently.
    • The effect of smoking on the healing process
      Smoking causes the blood vessels to constrict, reducing the blood supply and the oxygen carried by the blood to the surgical area. The tissues need blood and oxygen carried by the blood to heal. When the blood supply is reduced, the tissue heals more slowly and is prone to bacterial infection. This may ultimately lead to skin necrosis or death of patches of the skin and poor scarring compromising the aesthetic result.
    • Nipple sensation
      There will be changes in nipple and breast sensation after surgery. The feeling may increase or decrease and may vary in different areas. The sensory changes may be temporary or permanent.

    Complications

    Below follows a list of some of the more frequent complications associated with breast implants:

    • Local complications (Around The Breast):
      • Haematoma formation
      • Seroma formation
      • Delayed wound healing
      • Wound sepsis
      • Peri-implant infection
      • Sensory changes in the breast
    • Systemic Complication (Your Body):
      • Fluid and electrolyte abnormalities
      • Deep vein thrombosis
      • Postoperative lung complications
    • Long Term And Cosmetic Complications (The Way It Looks):
      • Rippling and contour deformities
      • Malposition and displacement of the implant
      • Asymmetries of the breast
      • Capsular Contracture (hardening of the implant, often painful caused by fibrous tissue around the implant
      • Visibility of the implant around its edges
      • Implant rupture, which can cause the silicone gel to leak out into the neighbouring tissue or even parts of the body
      • Pain from many causes including muscle spasms and nerve injury

More information about precautions, preparations & planning before, on the day & after surgery is listed below.

  • Prior to Surgery
    • Do not stop any of your routine medication unless specifically told to do so by the doctor.
    • Typically Aspirin, Ecotrin, St John’s wort, nonsteroidal anti-inflammatories, Arnica tablets & Omega fish oils should be stopped at least 1 week before surgery.
    • Cardiac patients on blood thinners for stents or those on Warfarin require specific instructions and this must be discussed 3 weeks in advance of surgery.
  • Recovery

    The combination of decreased activity and pain medication may promote constipation, so you may want to add more fruit and fibre to your diet. Be sure to increase fluid intake. Movicol may also be used as a stool softener.

  • Activities
    • Start walking as soon as possible. This helps to reduce swelling and lowers the chance of blood clots.
    • Avoid strenuous exercise and activities for 4-6 weeks.
    • Social and employment activities can be resumed in 7-14 days.
  • Incision Care
    • No soaking in the bath while sutures or drains are in place.
    • Avoid exposing scars to the sun for at least 12 months.
    • Apply Micropore to the incision lines for 3 months. Change every 7-10 days. Do not remove the tape every day as it will cause irritation of the surrounding skin.
    • Keep incisions clean and inspect through Micropore daily for signs of infection or oozing.
    • Incision areas must be massaged through the Micropore for the first 3 months.
    • ScarScience, Kelocote or Silderm can be applied from 6 weeks postoperatively, over the Micropore for another 6 weeks, and then on the incision directly for another 3 months postoperatively.
    • Support garments should be worn 24/7, and only removed for short periods while taking a shower. You should wear the postoperative bra day and night for 6 weeks, and thereafter for 6 weeks during the day.
  • What to expect
    • Discomfort will be maximal in the first 3 days, improving each day thereafter.
    • You may experience temporary pain, soreness, numbness, dry breast skin, swelling, discolouration and incision discomfort.
    • There may be a loss of nipple sensation, which should normalise in time (less than 5% of patients never regain nipple sensation).
    • Sagging or enlargement of breasts can occur with the ageing process, pregnancy and weight changes.
    • Scars will fade in several months to a year.
    • Breastfeeding may be possible after a breast reduction, but might be of insufficient volume to support the child.
  • Follow-up care
    • Drains will be removed when drainage is less than 50ml for 24 hours.
    • Most of the sutures are dissolvable in 6-8 weeks.
    • Any stitches will be removed in 7-10 days.
  • When to Call
    • If you have increased swelling or bruising.
    • If swelling and redness persist after a few days.
    • If you have increased redness along the incision.
    • If you have severe or increased pain not relieved by medication.
    • If you have any side effects to medications, such as rash, nausea, headache, vomiting.
    • If you have any drainage from the incisions or notice a foul odour.
    • If you have bleeding from the incisions that does not stop with light pressure.