A mastectomy is the removal of the entire breast including the nipple. The muscle that the breast lies on is usually not removed unless the surgeon suspects it has been affected by cancer. In selected cases, the patient’s skin and/or nipple need not be removed together with the breast and can be preserved for breast reconstruction.
Wide excision (commonly known as lumpectomy) involves removing the cancer by excising a cuff of normal breast tissue followed by radiation therapy to the breast. This method of surgery is aimed at conserving as much of the breast as possible while ensuring the safe and effective total removal of the cancer from the breast.
Breast reconstruction is a series of plastic surgery procedures that attempts to rebuild and restore the look and feel of the breast after a mastectomy.
There are two types of breast reconstruction: implants and own tissue.
Although breast reconstruction can rebuild your breast, there are certain limitations.
- Your reconstructed breast will not look and feel exactly the same as the breast it replaces.
- There will be visible incision lines on your breast as a result of the mastectomy and reconstruction.
- The surgical techniques will also leave incision lines at the donor sites such as the back, abdomen or buttocks if you have had own tissue reconstruction.
- Radiotherapy might affect the appearance of your reconstructed breast.
- The reconstructed breast might not be symmetrical to the opposite breast in terms of size and position.
- Reconstructed breasts don’t usually have nipples, but they can be created during surgery at a later day.
As with any surgical procedure, there are possible risks in breast reconstruction. As such, it is your personal decision to undergo breast reconstruction having considered the risks and potential complications.
The possible risks of breast reconstruction include, but are not limited to:
- Bleeding
- Infection
- Poor healing of incisions
- Anaesthesia-related complications
Besides a change in physical appearance, having a mastectomy can also affect a woman’s self-image and mental well-being. You may choose to have immediate breast reconstruction (IBR), delayed breast reconstruction (DBR) or no breast reconstruction. This is a personal decision and there is no right or wrong choice.
Reconstruction can be immediate (at the same time as the mastectomy) or delayed (at a later time). This depends on the characteristic and stage of the breast cancer. In many cases, immediate reconstruction is a reasonable and safe option.
Depending on the extent of the breast removal, you might require reconstruction of the entire breast or reshaping of the remaining breast (oncoplastic surgery).
Radiation therapy is a form of cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or prevent them from growing. The way it is administered depends on the type and stage of cancer being treated. Radiation therapy following reconstruction with a breast prosthesis may affect the appearance of the breast or increase incidences of capsular fibrosis, pain or the need for implant removal.
Immediate reconstruction combines two major surgeries i.e. the mastectomy and reconstruction into one, reducing your overall time spent under general anaesthetic. This, in turn, means a shorter recovery period and lower hospital and medical costs. In addition, you avoid the anxiety of another operation and time away from your family and work commitments.
The reconstruction process is also easier as the skin that covers your breast (the skin envelope) and the infra-mammary fold (the lower border of your breast) is preserved and your plastic surgeon can easily mould the new breast into this skin envelope. That way, you maintain the same confidence you had prior to your mastectomy.
Additional post-surgery therapy e.g. radiotherapy can cause scarring in the skin of the chest wall, which can affect the shape and size of a reconstructed breast. Delaying the reconstruction allows these effects to settle in the skin.
One of the considerations for patients undergoing breast reconstruction during mastectomy is the fear that such an extensive surgery may lead to a delay in the start of chemotherapy. This can result in a less than optimal long-term outcome including a reoccurrence of the cancer.
However, studies have shown that as long as treatment is conducted no later than three months following the removal of the tumour, there is no impact on the cure rate. In other words, undergoing breast reconstructive surgery at the time of mastectomy is unlikely to impact adversely on the cure rate of chemotherapy as the delay, if any, is usually minimal.
You may prefer to go through (or are advised to go through) your full cancer treatment and mastectomy first to allow yourself time to heal and to adjust to the emotional and physical changes before making another big decision. Breast reconstruction can be done after completion of additional post-surgery therapy i.e. chemotherapy and radiotherapy.
This is because additional post-surgery therapy e.g. radiotherapy can cause scarring in the skin of the chest wall, which can affect the shape and size of a reconstructed breast. Delaying the reconstruction after radiotherapy allows these effects to settle in the skin to produce a more optimal breast shape and size.
Undergoing two separate operations means a longer operating and recovery time and increased medical costs. There is also the increased risk of general anaesthetic complications as well as increased time away from work and family.
Some women might also experience a lack of confidence or femininity after their mastectomy. In addition, breast prosthetics can be quite uncomfortable.
Abdominal flap
- What is an abdominal flap?
The lower abdomen is the most common site for retrieving the tissue needed to reconstruct the breast. There are many names for the abdominal surgery used for reconstruction, including TRAM, DIEP and SIEA, depending on the source or pattern of blood supply to the abdominal skin and fat.
- TRAM flap
The “Transverse rectus abdominis myocutaneous” (TRAM) flap is the most common option for creating a new breast after mastectomy. There are several types of TRAM flaps, depending on whether the blood supply comes from blood vessels coursing through the rectus abdominis muscle from the rib margin above or pelvis below.As part of the procedure, the rectus muscle is removed along with the skin and fat to ensure a constant blood supply. However, with recent advances, there are new techniques that avoid the sacrifice of the rectus muscle to varying degrees.
- Pedicled TRAM flap
consists of skin and fat from the lower abdomen and rectus abdominis muscle. The blood supply comes from the superior epigastric vessels, which emerge from under the ribcage and course down the rectus abdominis muscle to reach the skin and fat of the lower abdomen. In this case, the entire row of the rectus muscle on one side is taken so that the blood supply is preserved.
- Free TRAM flap
also consists of skin and fat from the lower abdomen. The difference is the blood supply comes from the deep inferior epigastric vessels, which emerge from the groin and course through the rectus abdominis muscle from below to reach the lower abdominal skin and fat.The vessels are disconnected from the groin and placed at the chest to create a new breast. They are then reconnected to blood vessels in the chest with the help of a surgical microscope. This procedure is known as free tissue transfer.
Due to the complexity of this procedure, the risk of failure is higher. However, the advantage is less muscle sacrifice (and fewer complications associated with muscle loss) and better blood supply to the skin and fat.
- MS TRAM
or muscle sparing TRAM is similar to Free TRAM flap except that the aim of this procedure is to spare as much muscle loss as possible. As such, only a small cuff of rectus muscle is removed together with the flap. This results in less abdominal complications compared to a TRAM flap.
- DIEP flap
A deep inferior epigastric perforator (DIEP) flap consists of skin and fat from the lower abdomen only. The deep inferior epigastric blood vessels providing blood supply to the tissues are dissected from the rectus muscle and reconnected in the chest or armpit. That way, no muscle is sacrificed. With this technique, the risk of abdominal wall weakness-related problems is the lowest.
- SIEA flap
A superficial inferior epigastric artery (SIEA) flap consists of lower abdomen tissue similar to that used in DIEP and TRAM but with a different blood supply. As the blood supply to this flap runs separately from the rectus abdominis muscle, the muscles will not be affected in this surgery. However, as these vessels are not always large enough to be used, it is only recommended for a select group of patients.
What are the common complications of TRAM flap reconstruction?
- Abdominal wall weakness
TRAM flap reconstruction can result in weakness of the abdominal wall after surgery due to sacrifice of part or whole of the rectus abdominis muscle.This weakness in the abdominal wall can manifest as a slight bulge in the abdominal wall. In rare cases, when the weakness is severe, the bulge can be large enough to contain the bowel. This is known as a hernia. Abdominal wall weakness can usually be repaired with minor surgery.
- Abdominal numbness
Some patients experience numbness along the abdominal scar, particularly at the midline, after TRAM flap surgery. This is due to sacrifice of the nerves that emerge from the muscle wall of the abdomen. While abdominal numbness usually improves with time, in some cases, it can be permanent.
- Flap failure
In free tissue transfer (e.g. free TRAM flap), the blood vessels are reconnected. This is successful in more than 9 of 10 patients. However, should the reconnection fail, the skin and fat will not be viable and another surgery is required to remove the non-viable tissue.
- Fat necrosis
If the blood supply is inadequate, hardness in the reconstructed breast due to non-viable fat may occur. Generally, the hardness should improve with time. However, if it is persistent, further surgery may be required.
What can I expect after surgery?
After surgery, you will be nursed in a ‘bending’ position. Tubes will be inserted into your wounds to drain excessive fluids from surgical sites. In addition, you may experience tightness in your abdomen, which should subside in 2-3 weeks.
Your total hospital stay can be between 4-10 days and you would be expected to be out of bed and mobile 1-2 days after the surgery. Upon discharge, you may still have one or two tubes in your wounds to drain any excess fluids, but these will be removed at follow-up appointments at the out-patient clinic.
Thigh flap
What is a thigh flap?
Extra skin and fat known as Transverse Myocutaneous Gracilis (TMG) or Transverse Upper Gracilis (TUG) flap from the inner thigh can also be used for breast reconstruction.
In this procedure, the gracilis muscle in the inner thigh and its blood vessels are removed together with its overlying skin and fat, disconnected and transferred into the breast pocket to reconstruct the breast.
The blood supply to the gracilis muscle and the overlying skin is then reconnected to keep it alive. This requires microsurgery expertise. Usually, blood vessels in the chest are used.
Who is suitable for thigh flap reconstruction?
Women who have smaller breasts (A or B cup) with some excess in the inner thigh are good candidates for this surgery. This technique will also produce a better result for those with less droopy breasts.
Those who do not have sufficient tissue in the inner thigh or who have had thigh lifts or liposuction to the inner thigh are not suitable candidates.
What are the pros and cons?
Thigh flap reconstruction produces a breast that looks and feels natural. In addition, you also enjoy the added benefit of lifting and tightening of your inner thigh. However, as this is a microsurgery technique, the operation might take longer, usually lasting up to 6-8 hours. There is also a risk of failure when re-establishing blood flow to the gracilis flap.
What are the common complications?
As tissue is taken from the inner thigh, it might result in asymmetry, where one thigh is slimmer than the other. However, the difference is usually very slight. Symmetry can be restored with a short quick surgery, which can be timed together with nipple reconstruction, at a later date.
What can I expect after surgery?
You will have a drain inserted into the thigh wound and another 1-2 drains in the breast wound. These will be removed after a few days when the excess fluids have been drained.
Gluteal flap
What is a gluteal flap?
In gluteal flap breast reconstruction, the gluteal flap, which consists of skin and fat from the buttock, is transferred to the breast. There are two types of gluteal flaps: the SGAP flap, in which the upper buttock skin and fat is used, and the IGAP flap, where the skin and fat of the lower buttock is used. Once the tissue has been transferred, microsurgical techniques are used to re-establish the blood flow into the flap.
Who is suitable for gluteal flap reconstruction?
Gluteal flap breast reconstruction is ideal for patients who have smaller breasts and have excess fat and skin on the buttock. It is also recommended for those who are physically active and desire preservation of their abdominal muscles.
Patients who should not consider gluteal flap breast reconstruction include those who are poorly controlled diabetics, or have large breasts or have undergone previous buttock surgery.
What are the pros and cons?
Generally, a gluteal flap harvest offers the additional benefit of giving the buttock an appearance similar to that produced by a “buttock lift”. It also does not sacrifice any muscle.
In cases, the surgeon may only be able to take a flap from one buttock. As the gluteal flap is also smaller in volume than the abdominal flap, it can lead to uneven breasts in patients with larger breasts. In addition, the scar on the upper or lower buttock might make it painful for patients to sit in the month following surgery.
What can I expect after surgery?
After surgery, you will have to stay in the hospital for observation for a week. During this time, doctors and nurses will review your flap on a regular basis. Following discharge, there will be certain restrictions on your activities. You may resume your normal activities in 2-3 months.
Back flap
What is a back flap?
The back flap or latissimus dorsi (LD) is a broad muscle in your back. In this procedure, the LD muscle, along with its overlying skin and fat, is transferred to the front of the chest for breast reconstruction.
But with improved surgical techniques, it is now possible to take only skin and fat tissue from the back. Located in the same region as the LD flap, the thoracodorsal artery perforator (TAP) flap is a small flap that can be used for reconstructing small/partial breast defects, such as in lumpectomy patients. This flap preserves the LD muscle and consists of only skin and fat.
What if I don’t have enough tissue for the breast reconstruction?
If added fullness is needed in the reconstructed breast, a breast implant can be inserted under the LD muscle. This allows complete coverage of the implant and protects it from infection, scarring and exposure.
An adjustable breast implant (tissue expander) can also be used if a lot of skin is removed during mastectomy and extra skin is needed to reproduce the natural breast contour. When the tissue has healed after mastectomy, this can be filled with saline progressively to stretch the skin. The adjustable implant can eventually be replaced by a silicone implant after the skin has been expanded adequately.
Who is suitable for back flap reconstruction?
Reconstructive options using tissues from the abdomen and lower limb are generally preferred because they allow body contouring at the same time (tummy tuck, thigh and buttock lift). When patients are not candidates for these options, an LD flap may be a suitable alternative. Using the LD flap also allows one-stage reconstruction for patients who prefer a quicker option.
However, LD flap surgery is not recommended for patients who perform a lot of repetitive or strenuous overhead activities with their arms.
What are the pros and cons?
When used with an implant, the LD muscle allows complete coverage of the implant and protects it from infection, scarring and exposure.
However, after surgery, many patients experience back pain. Some also require physiotherapy to recover their shoulder functions. In addition, the aesthetic contour of the back might be affected.
What are the common complications of back flap reconstruction?
After the operation, there will be a large raw area under the skin of the back. This might cause a seroma, the collection of fluid under the skin after the drains are removed. However, this can be easily and painlessly removed by draining the fluid with a syringe and needle.
The removal of the LD muscle might also cause slight limitations in actions such as climbing or pushing off with the arm. However, this will not affect your normal activities.
What can I expect after surgery?
You will have a drain inserted into the back wound and another 1-2 drains in the breast wound. These will be removed after a few days when the excess fluids have been drained.
| Implant | Own tissue | |
|---|---|---|
| Scarring | Scar on breast. Possible circular scar around nipple or inverted T-shaped scar under breast. | Scarring on breast and donor sites. |
| Risks | Distortion of the breast, rupture or deflation of the implant or protrusion of the implant through the skin. | Dependant on donor site. Visit our ‘Know your options’ page or consult your plastic surgeon for further information. |
| Sensation in breast after surgery | Little or none | Little or none |
| Approximate length of surgery | 3 hours | 4–8 hours, depending on the donor site |
| Approximate recovery time | 6–8 weeks | 6–12 weeks |
| Considerations | Not recommended for those who have undergone radical mastectomy or previous radiotherapy. Might not be suitable for large droopy breasts. Suitable if no excess tissue is available. Will need future surgery to change implants. | Must be in good physical health. Not suitable for those who are underweight or overweight, diabetic or smoke. |
Implant breast reconstruction uses breast implants to restore the shape and volume of the breast. There are two main types of implants available: silicon and saline. Depending on the condition of the breast after mastectomy, implant breast reconstruction may be done in one or two stages.
Implants, however, may not be suitable for every woman, particularly those who have undergone radical mastectomy (with removal of chest muscle) or previous radiotherapy. Talk to your surgeon about the options available to you.
For a one-stage reconstruction to be possible, nearly all of the skin of the breast must be preserved during the mastectomy. As part of the procedure, the implant is inserted under your chest muscle, which supports and protects the implant.
This implant can be a fixed volume or an adjustable implant (Becker implant). The implant acts like an inflatable balloon, allowing saline to be injected though a valve to increase its size. When the desired volume is achieved, the tubing and valve for injection are removed, leaving a tissue expander as the permanent implant. One advantage of the one-stage reconstruction is that it minimises the need for multiple surgeries with general anaesthesia.
Some women may not have enough skin after a mastectomy to cover an implant. A two-stage procedure is used to overcome this, and involves inserting a tissue expander to create the breast mound. The tissue expander is then gradually filled with saline to enable the skin to stretch. The expansion procedure may be repeated over 12-24 weeks until the desired breast volume and amount of skin stretching is achieved. The tissue expander will then be replaced with a permanent implant.
Implant reconstruction is a simple surgery that can be performed quickly and has a short recovery time. It only causes very minimal scarring.
There have been concerns that silicone implants could cause connective tissue or autoimmune diseases such as rheumatoid arthritis. A great number of studies have been done to investigate the connection between silicone and these diseases. However, to date, no reviews have found substantiating evidence of harm caused by silicone implants. If you are still concerned about having silicone implants, do talk to your surgeon about other available alternatives.
The use of implants may result in the gradual hardening of the breast due to ‘capsular contracture’. This occurs when a foreign body is introduced in our bodies, which causes the body to form a layer of scar tissue around it. As the capsule thickens, it could result in pain in the breast and a distortion of the breast’s shape. Further surgery may be required to correct this.
There is also the risk of implant rupture or deflation and the protrusion of the implant through the skin. In these cases, the implant would need to be removed.
While the implant-reconstructed breast might not be the same size and shape as the other breast, it is possible to have surgery to augment or reduce the size of the opposite breast to make both breasts as symmetrical as possible.
In general, an implant-reconstructed breast will always feel different from a natural breast as it is likely to be firmer and less responsive. However, the contour of the new breast can be restored to a silhouette similar to what you had before mastectomy.
It is particularly difficult to replicate the droop of saggy breasts. In such cases, the aim is to achieve symmetry when wearing a bra. Alternatively, a breast lift on the other side can be performed to achieve symmetry.
Mammography is not usually performed on reconstructed breasts as the mastectomy would have removed most of the breast tissue.
| Implant | Own tissue | |
|---|---|---|
| Scarring | Scar on breast. Possible circular scar around nipple or inverted T-shaped scar under breast. | Scarring on breast and donor sites. |
| Risks | Distortion of the breast, rupture or deflation of the implant or protrusion of the implant through the skin. | Dependant on donor site. Visit our ‘Know your options’ page or consult your plastic surgeon for further information. |
| Sensation in breast after surgery | Little or none | Little or none |
| Approximate length of surgery | 3 hours | 4–8 hours, depending on the donor site |
| Approximate recovery time | 6–8 weeks | 6–12 weeks |
| Considerations | Not recommended for those who have undergone radical mastectomy or previous radiotherapy. Might not be suitable for large droopy breasts. Suitable if no excess tissue is available. Will need future surgery to change implants. | Must be in good physical health. Not suitable for those who are underweight or overweight, diabetic or smoke. |
Oncoplastic surgery involves the use of plastic surgery techniques to reshape the remaining breast or reconstruct the breast after breast cancer surgery. It corrects the imbalance between the unaffected and affected breast after removal of the tumour and prevents undue scarring and deformation of the breast for an aesthetically pleasing outcome.
There are two types of oncoplastic techniques: volume replacement and mammoplasty volume displacement.
In this procedure, tissue flaps are imported either locally (local flap) or from other areas of the body. These flaps might contain muscle, fat and skin in various combinations depending on the defect that needs to be corrected.
Volume replacement oncoplastic techniques are recommended for patients who do not wish to undergo surgery to the other breast, or have inadequate remaining tissue to reshape the breast after removal of the breast tumour.
This is a breast reduction technique suitable for patients with larger breasts. It is performed as part of the tumour removal process, and the breast is reshaped at the same time. This results in a smaller but more aesthetically shaped breast.
Surgery to the opposite breast may be required to achieve symmetry.
The removal of more than 10-15% of breast volume may result in deformity. This is particularly the case for women who have smaller breasts as the removal of small tumours may result in contour irregularities, puckering of the skin, unacceptable scarring, displacement of the nipple and areola and asymmetry. Oncoplastic surgery reduces the risk of deformity by rearranging the breast tissue to fill in the defect.
Oncoplastic breast surgery techniques enable surgeons to achieve ideal breast size and shape. Surgeons who are trained in oncoplastic surgery are also less likely to leave deformities in the breast, increasing the margin of safety for breast conservation surgery.
When a cancerous lump is removed, it is checked under the microscope to see if all of it has been removed. If there is cancer left behind in the breast, even though it has been reshaped with oncoplastic breast surgery, you will need further surgery to clear it. This involves either taking out more breast tissue (wide excision) or removal of the entire breast (mastectomy).
Oncoplastic surgery usually takes longer as it is more complex. There are also fewer surgeons trained to perform oncoplastic surgery techniques.
You should be able to eat and drink after surgery and should be up and moving around by the second day. Depending on the type of surgery, you may be discharged 1-5 days after surgery
Upon discharge, you will have to return to the hospital for outpatient appointments for check ups and wound care. If non-degradable sutures are used, you will also need to return to have your stitches removed. In addition, you will have follow up appointments with your breast and plastic surgeon.