1. Reconstruction using an implant.

Implant Breast Reconstruction involves restoring the shape and volume of the breast using a breast implant. Breasts reconstructed in this way tend to be close to a natural breast shape, but are firmer and move less naturally than those using your own tissue. This can mean it’s more difficult to get a natural shape when one breast, rather than both, is being reconstructed.

The reconstructed breast will not droop with age and may look higher than the other breast, particularly as you get older. If you lose or gain weight, this will affect the natural breast but not the reconstructed breast, causing a difference in shape and size. At some point you may need more surgery to the reconstructed breast, or to the other breast, for a better match.

Implant Reconstruction is often recommended for women with small and firm breasts, as it avoids the need for more extensive surgery using tissue from another part of the body.

With any type of reconstruction there is a risk of infection or other problems. If this happens with Implant Reconstruction, the implant may need to be removed.

1a. Immediate Reconstruction using an implant.

If the breast cancer can be removed without taking away too much skin (skin-sparing mastectomy) and the remaining breast is not too large and doesn’t have a significant droop, an implant may be inserted under or in front of the chest muscle . Inserting the implant under the chest muscle helps to keep the implant in the right place and hide its outline. A mesh or an acellular dermal matrix (ADM) can also be used to cover the implant.

For women with larger breasts, Implant Reconstruction may be possible using a dermal sling.

Using a breast implant alone is the simplest type of reconstruction operation and the recovery time is usually quicker than for other types of reconstruction. It’s most often done at the same time as the mastectomy (immediate).

The other option is to have an implant called a permanent tissue expander inserted at the same time as the mastectomy. This is an implant that is gradually expanded or ‘inflated’ over time. For some women a temporary tissue expander implant is used and then expanded over time. It is then replaced with a permanent silicone implant. This might be referred to as a two-stage procedure.

If you need radiotherapy, Dr. med. Strouthou may  insert a tissue expander or implant immediately after a mastectomy to create and preserve a space. The expander will not be inflated until the radiotherapy has finished. This can help to reduce the extent of any hard scar tissue (capsular contracture).

1b. Delayed Reconstruction using an implant.

A permanent or temporary tissue expander is first placed behind the chest muscle, usually through the mastectomy scar. This helps keep the implant in the right place and hides its outline. Several weeks later, when the scars have healed, a surgeon or nurse gradually inflates the implant with saline (salt water) through a small port. The saline solution is injected into the port just under the skin. This is located either in the expander so that the solution can be injected directly or is connected to the expander by a short tube.

This procedure is done during outpatient appointments, usually every one or two weeks, to slowly stretch the muscle and overlying skin. The number of appointments needed varies from person to person.

When expander implants are being filled, you’ll feel a stretching sensation and tightness within the breast reconstruction. It can be uncomfortable for a day or two after each inflating, but it shouldn’t be painful. The expander is generally inflated until the new breast is slightly larger than the other breast and then left for a few weeks so the skin stretches.

If a temporary expander is used, a further small operation will be needed to remove the expander and port, and replace it with a permanent implant, which will be your final breast shape.

If a permanent expander implant has been used, the port can be taken out under local anaesthetic, leaving the expander implant in place.

Implant Reconstruction with tissue expansion can be particularly useful if you don’t have enough skin left on your chest to comfortably cover and support an implant, especially if you’re having delayed reconstruction.

Skin is very elastic and has a surprising ability to stretch but tissue expansion may not be suitable for women who have had radiotherapy treatment. This is because radiotherapy reduces the elasticity and quality of the skin.

1c. Acellular Dermal Matrix (ADM) and dermal sling.

These products are used to support breast implants. They are attached to the chest muscle to create a pocket that holds the implant in place, like an internal bra. They help to create a natural droop, shape and contour.

ADMs are made from animal tissue (usually pig or cow skin) and look and feel like very thin leather. They are processed and preserved so they can safely be left in the body. Meshes are manmade (synthetic) supports.

An ADM or mesh is most suitable for women with small or medium-sized breasts. ADMs are not available in every hospital. You can ask Dr. med. Strouthou if it is suitable for you and discuss any possible risks or complications with this type of reconstruction.

For women with larger breasts, their own tissue (from the lower half of the breast) can be used to support the implant. This is known as a dermal sling.

2. Reconstruction using your own tissue (Tissue Flap).

A commonly used reconstruction technique uses flaps of your own tissue (with or without an implant), including the skin, fat and sometimes a muscle. This can be taken from your back or lower abdomen, or from the inner thigh or buttock. This is then reshaped to form the new breast. Because the skin used is taken from another area of the body, it may be a slightly different shade or texture to the rest of the breast.

This method is particularly suitable for women with moderate- to large-sized breasts that have a natural droop.

Tissue Flap Reconstruction is commonly used in Delayed Reconstruction, particularly if radiotherapy has been given. Flaps without implants may also be used for Immediate Reconstruction.

You may need to have an ultrasound (a scan that uses high-frequency sound waves to produce an image) or CT scan (a scan that uses x-rays to take detailed pictures across the body) before your flap reconstruction to look at the blood supply to the tissue which will be used to create your new breast.

Reconstruction using your own tissue involves a longer operation and more recovery time than an implant-only reconstruction. But you will be less likely to need further surgery in the future than with reconstruction using implants alone. A reconstructed breast using tissue instead of an implant may also provide a better match with your other breast in the long term. This is because tissue is affected by gravity, ageing and weight change more naturally.

There are two ways reconstruction with a Tissue Flap may be done:

• Pedicled Flap – the flap remains attached at one end to its blood vessels which means the blood supply to the muscle doesn’t need to be cut.
• Free Flap – the flap is completely detached from the body along with its blood vessels and reattached by microsurgery in the position of the reconstructed breast.

2a. DIEP (deep inferior epigastric perforator) Flap.

A DIEP Reconstruction uses a free flap of skin and fat, but no muscle, to form the new breast shape. The flap is taken from the lower abdomen and uses the skin and fat between the belly button (umbilicus) and the groin along with the artery and veins. It is called DIEP because deep blood vessels called the deep inferior epigastric perforators are used.

The free flap is transferred to the chest and shaped into a breast while the artery and veins are connected to blood vessels in the armpit or chest wall using a specialised technique called microvascular surgery. Rarely, if the flap of tissue doesn’t have a good blood supply it will die and the reconstruction will fail.

The advantage of this type of reconstruction is that no muscle has to be removed so the strength of the abdomen is not affected. This means there is very little chance of developing a hernia (a bulge or protrusion where the wall of the abdomen has been weakened). If you do develop a hernia it can be repaired with an operation.

The DIEP flap is a major surgery involving a long and complex operation, and you will need to be in good overall health to go through it. Ideally you should be a non-smoker, have no existing scars on your abdomen and have enough fatty tissue in your lower abdominal area.

If you’re very overweight you may be advised to lose weight before being offered this type of surgery. This is to reduce your risk of complications from the anaesthetic and the surgery.

There will be scarring on the breast, which is usually oval, and on the abdomen – usually below the bikini line stretching from hip to hip. The belly button (umbilicus) is repositioned during this type of surgery, leaving a circular scar around it.

2b. TRAM (transverse rectus abdominis muscle) Flap.

This technique uses the large muscle that runs from the lower ribs to the pelvic bone in the groin. It is called a TRAM Flap because the rectus abdominis muscle (large tummy muscle) is used and because the skin is taken from across your tummy (transversely). TRAM Flaps can be free or pedicled.

A Free Flap is the most common type of flap used. The flap is completely detached and then reattached. A Pedicled Flap is where the flap remains attached at one end to the original anchoring point and the original blood supply.

In a Free Flap the muscle, fat and skin are removed completely from the abdomen and the surgeon shapes a breast from this tissue. The blood vessels that supply the flap are reconnected to blood vessels in the region of the reconstructed breast using microvascular surgery, either under the armpit or behind the breastbone.

In a Pedicled Flap, the rectus abdominis muscle, along with its overlying fat and skin and blood supply, is tunnelled under the skin of the abdomen and chest and brought out over the area where the new breast is to be made. Usually there’s enough fat in the flap to make the new breast the same size as the other one without the need for an implant.

If the flap of tissue isn’t getting a good blood supply following the procedure it will die and the reconstruction will fail. This is rare but if it does happen further surgery will be needed to remove the flap and, if possible, perform the reconstruction again at a later date.

Both types of TRAM Flap operation may weaken the abdominal wall, which you might notice afterwards when lifting or during sport. During the operation the surgeon will put a ‘mesh’ into the abdomen to help strengthen the muscles and to try to avoid a hernia (a bulge or protrusion where the wall of the abdomen has been weakened). If you do develop a hernia it can be repaired with a fairly simple operation.

The Free Flap TRAM is sometimes a longer and more complex procedure, with a greater risk of complications than the Pedicled Flap, so a longer recovery time is usually needed.

You will need to be in good overall health to have either type of TRAM Flap procedure. You’ll need to be a non-smoker, have no existing scars on your abdomen (caesarean scars don’t always mean you can’t have this procedure) and have enough fat in the lower abdominal area.

If you’re very overweight you may be advised to lose weight before being offered this type of surgery. This is to reduce your risk of complications from the anaesthetic and the surgery.

Both types of TRAM Flap leave a scar across the width of the abdomen, from hip to hip, usually just below the bikini line. The scar on the reconstructed breast will be circular or oval and vary in size from person to person. The belly button (umbilicus) is repositioned during this type of surgery, leaving a circular scar around it.

2c. SGAP (super gluteal artery perforator) Flap and IGAP (inferior gluteal artery perforator) Flap.

SGAP and IGAP use only fat and skin taken from the upper or lower buttock to create a new breast. This involves microvascular surgery, which is the process of joining blood vessels together. Where tissue has been removed from the buttocks, there will be a scar and an indentation.

2d. TMG (transverse myocutaneus gracilis) Flap or TUG (transverse upper gracilis) Flap.

The tissue removed in this procedure is taken from the upper inner thigh and consists of skin, fat and a small strip of muscle.

The procedure may be suitable for women with small- or medium-sized breasts. The inner thigh fat feels soft and is therefore similar in texture to the breast fat. Microvascular surgery is needed to join the blood vessels.

The scar is placed in the fold of the groin and runs to the fold of the buttock area – you will also have a scar on the breast where the flap is placed. You can discuss with your surgeon how the scar will look. You may have to wear bandages or lycra shorts to reduce the risk of swelling, bruising and fluid collection for some weeks following surgery.

Immediate:

Bleeding, Infection, Bruising, Build-up of fluid or blood, Pain and discomfort.

Longer-term:

Capsular contracture: In the first year or so after an implant operation, tough fibrous tissue builds up around the implant to form a ‘capsule’. This happens because the body sees the implant as a foreign object and wants to isolate it. In most cases this capsule stays soft and supple but sometimes it tightens around the implant, making the breast feel hard and sometimes painful. This is known as capsular contracture.

Radiotherapy can cause capsular contracture. For this reason, reconstruction using an implant alone may not be recommended for women having radiotherapy.

Capsular contracture is now less common than it used to be. This might be because many implants have a textured outer surface that reduces the amount of scar tissue that forms around the implant.

Leakage and rupture: If silicone implants wear out, the silicone gel may leak into the fibrous capsule. Occasionally silicone gel may get into the breast, forming a lump. If this can be felt or a scan shows a ruptured implant, the implant may have to be removed and replaced. Modern casings are strong and the risk of leaks and rupture is small. If you notice any deflation of your reconstructed breast, or if it becomes misshapen, uncomfortable or swollen, tell your surgeon or breast care nurse.

Creasing and wrinkling: There can be noticeable skin creasing or wrinkling over the implant. It’s most common in people who are slim and have saline implants. It’s usually less obvious when you’re wearing a bra. If it becomes very noticeable the implant may need to be replaced.

Abdominal hernia

Loss of sensitivity: For many women the loss of sensitivity of the reconstructed breast can be difficult to come to terms with. You may also experience loss of sensation in the area where the flap has been taken. Some women experience nerve pain and altered sensation while their reconstruction is healing. This may improve over time, but for some people the sensation won’t return.

Fat necrosis: Sometimes a lump can form if an area of the fatty tissue in the reconstructed breast is damaged or if the blood supply is poor. It can also happen in the area where the flap of tissue has been taken. The lump can feel firm, but is likely to soften over time. This is called fat necrosis (necrosis is a medical term used to describe damaged or dead tissue).