Breast Reconstruction Types
Dr. Darrell Perkins performs a range of different types of breast reconstruction so that he can offer each patient a technique that will best meet her individual needs. Breast reconstruction has helped our patients from Sydney and the South Coast feel a renewed sense of beauty and femininity.
What form of breast reconstruction is best for you?
Many factors have to be taken into account when deciding what form of breast reconstruction is the most appropriate. Certainly one of those factors is the shape and size of the other breast. A decision must always be made whether something needs to be done to the other breast to make it easier to do a reconstruction to match it. Certainly the easiest breast reconstruction is a very youthful C or B cup breast. A decision always has to be made whether the other breast has to be made bigger, smaller or even lifted up into a more youthful position. Other factors that need to be taken into account are the body shape of the patient, prior radiotherapy, the age of the patient, the general health of the patient and whether the tissues are potentially available or have been excluded due to prior surgery.
The question always comes up about who decides which operation the patient will have. It is a firm belief of mine that the patient needs to be educated as to the various pros and cons, and risks and complications of all these procedures so that they can make a valid and meaningful decision for themselves which breast reconstruction best suits themselves. Clearly technical factors and experience have to come into play and certainly I will inform my patients if something is a black and white good or bad idea. Most of the time, however, the situations are more shades of grey and within those shades of grey it is important that the patient puts her own personal factors into their decision to come up with a solution that is right for themselves.
Not all patients who seek the help of a reconstructive breast surgeon are actually seeking a reconstruction. On many occasions, the patients are not willing or desire to go through a breast reconstruction. If a lady is very large breasted on her remaining breast though, a reduction of that breast can provide great symptomatic relief to her generally. It also means that she has to wear a much smaller external prosthesis which is a much more comfortable situation. There is only one thing more uncomfortable for a lady than having two very large breasts, and that is having one very large breast. A unilateral reduction mammoplasty is a very simple, straightforward procedure and usually has excellent patient acceptability and reliably produces excellent results with a minimum of complications or problems.
The other situation that sometimes presents is a lady who has had a so-called lumpectomy. I find that many of these so-called lumpectomies remove up to half of the breast tissue and the lady finds herself in a very uneven situation with it being very difficult to wear clothes. Under the circumstances of a lady whose breast has been significantly distorted with a lumpectomy, a decision has to be made as to whether we try and reconstruct the lumpectomy defect and thus the breast on the side that has been afflicted with cancer. Another option to provide symmetry is to perform a unilateral reduction mammoplasty on the opposite breast to bring the patient into a good symmetry between the two sides.
Types of Breast Reconstruction
Dr. Perkins offers 3 types of breast reconstruction at his practice serving Sydney, Kogarah, Caringbah, and the South Coast: prosthetically-based reconstruction, autologous reconstruction, and latissimus dorsi and prosthesis-based reconstruction.
As a primary breast reconstruction, a prosthetically-based reconstruction may be done either with placing the definitive prosthesis at the time of the mastectomy, or a tissue expander.The one stage definitive prosthesis is only technically possible if all the mastectomy flaps are saved by the breast surgeon at the time of doing the mastectomy. If a significant amount of skin has to be taken at the mastectomy, then a tissue expander will be required to be placed so that this can have saline injected into it at a later to stretch the skin flaps as well as produce new skin.
For secondary prosthetic breast reconstructions, a tissue expander will have to be placed to allow the production of the skin that was removed at the time of the original mastectomy. Thus a second operation will always be required for placement of the definitive prosthesis.
A tissue expander is a prosthesis which can have saline injected into it while it is inside the patient. The modern expanders have ports which are integrated into the prosthesis and these are able to be found with a magnet and accessed by simply inserting a needle through the skin of the chest wall into the port. As the tissue expander is filled, the skin will stretch initially as a short-term phenomenon. However, over a period of time the body will actually produce more skin in response to the tension placed on the skin by the expander and thus an envelope similar to the original breast is able to be created. It is a similar situation to people who put on weight. These people do not have tight skin. They grow more skin to accommodate their excess volume. When these people then lose weight, of course, they have reams of loose skin, as we are much better at growing new skin rather than reabsorbing the skin.
The latest cohesive gel prostheses are certainly the safest products that have ever been on the market. They have a very low complication rate with capsular contraction rare,and the gel inside them, although silicone has been designed not to leak.This silicone gel is in the form of a jelly and not a liquid and even with the prosthesis bisected in half the gel will not run. Infection with a foreign body is always a risk factor and about a 1% rate of prosthetic infection would be quoted. This may necessitate the temporary removal of the prosthesis or it may mandate moving on to a different form of breast reconstruction that does not involve prosthesis. Thankfully this is a rare and unusual complication.
(a) Simple and quick.
(b) No extra scars.
(c) No donor site morbidity.
(d) If the patient does not like the reconstruction or has complications, then they have not burnt any bridges, i.e. they can go on to something else like an autologous breast reconstruction.
(a) It is a foreign body, though the current cohesive gel prostheses are extraordinarily safe and have a very low complication profile.
(c) Capsular contraction.
(d) It is difficult to make a breast shape that is not youthful, especially in secondary reconstructions.
(e) It is far from an ideal solution in the presence of radiotherapy.
Autologous Reconstruction (Own Tissue)
The most common flap used in autologous breast reconstruction is the TRAM (transverse rectus abdominus musculocutaneous). This utilises the roll of fat between the pubic hair line and the umbilicus and is the “piece of tummy” usually thrown away during a tummy tuck. A piece of muscle also has to be taken from the abdominal wall as this carries the blood supply. The abdomen after this flap is closed as for an abdominoplasty and the patient does get the same benefits as that procedure. In patients with very small breasts, it is possible that a latissimus dorsi flap may be used from the back without prosthesis. This is also the circumstance in the very overweight patient with a large roll on the back can be utilised to form a breast. Other flaps that are well described are the gluteal flap from the buttock, which I personally believe has some technical problems and leaves an unaesthetic scar. Another flap described, the so-called Rubens flap from the flank. I think provides a worse cosmetic defect than the one you are trying to reconstruct. I do not think it has any clinical application.
TRAM flaps can be done as free flaps where microsurgery is required to rejoin the blood supply of the flap, the blood vessels from the donor site to the recipient site on the chest. A TRAM flap can also be done as a pedicle flap where the fat of the abdominal wall is left attached to the rectus muscle and the rectus muscle is used as an umbilical cord or lifeline with the blood supply running through it to provide the blood supply to the tissues that are being transferred to reconstruct the breast. Both of these flaps have their pros and cons and personally I use both flaps, depending on the technical circumstances of the patient. There is a technique called “delaying of a pedicle flap” where part of the blood supply is divided to the flap several weeks before. This does make the blood supply to the pedicle flap more robust and decreases the complication or potential problems of having some of the tissue of the flap die following its transfer. The free microsurgical flap, of course, involves joining blood vessels of 2 mm to 3 mm diameter and if these vessels clog, the whole flap can die. A general failure rate of 1% of microsurgery is considered reasonable and at expert level.
Perforated flaps have been described and are used in clinical practice. These involve dissecting the small blood vessels going through the actual muscle so that the muscle can be preserved. I have done these flaps though they are not a preference in my practice as I think they have very few practical advantages for the patient and have some significant disadvantages. An extensive discussion about the pros and cons of all these different approaches, of course, is very appropriate and will be carried out at the time of consultation.
(a) Own biological tissue.
(b) Avoids foreign body (prosthesis).
(c) Natural feel. Gains and loses weight with the patient.
(d) Effective technique if there is previous radiotherapy.
(e)Can be tailored or modified easily as a secondary procedure to adjust the breast reconstruction to optimise it.
(f) Get a flat abdomen from getting a free abdominoplasty
(a) Big operation (up to eight hours).
(b) Big recovery.
(c) Donor site morbidity (possibility of hernia or bulge in the abdomen).
(d) Additional scars.
(e) Previous surgery may preclude the use of the abdomen as a suitable donor site.
Latissimus Dorsi and Prosthesis-based Reconstructions
The Latissimus dorsi is a big, broad muscle in the back and can be taken with a paddle of skin over it to replace any deficient skin on the chest wall. The Latissimus dorsi gets its blood supply high in the armpit and the flap is merely swung through to the front to provide coverage at the front. Except in the very thin or the very large, a prosthesis will be required to add sufficient volume to the breast reconstruction to match the opposite side. There is very little, if any, functional deficit from the harvest of the Latissimus dorsi muscle. As many other muscles work on the shoulder girdle, unless the patient is an elite athlete they will not notice that the muscle has been transferred.
(a) A very reliable flap and is usually always available.
(b) Leaves a cosmetically satisfactory scar which is easily hidden in clothes.
(c) A relatively quick recovery in the short and medium term.
(d) Effective technique in the face of previous radiotherapy.
(a) Does usually involve a prosthesis and therefore carries a risk of infection and capsular contraction.
(b)Does have a donor site morbidity (this is usually minor).
Arrange a Breast Reconstruction Consultation with Dr. Darrell Perkins
For more information on breast reconstructive surgery, please contact our practice in Sydney and arrange a personal consultation with Dr. Darrell Perkins.