Breast Reconstruction

In Israel, one in eight women is likely to be diagnosed with breast cancer throughout her life. Due to increased awareness in recent years, the disease is diagnosed at an earlier stage than in the past. Breast cancer can be treated with excision of the tumor along with chemotherapy and/or radiotherapy as necessary.  Body-image among women is crucial, and the majority of patients are interested in breast reconstruction to improve quality of life and increase self confidence. For further information regarding the disease, please visit one of the many websites available via the national cancer foundation. With the help of reconstructive plastic surgery, it is possible to sculpt a new breast after partial or full excision.

The process of reconstruction may start at the same time of excision, immediately after resection of the tumor or breast. Or, one may prefer a waiting period after the excision is complete and the disease is cured. The timing of reconstruction is the patient’s choice, in accordance with and recommendation from the treating oncologist, breast surgeon, or plastic surgeon.

It should be noted that breast reconstruction does not yield a complete breast instantaneously, and at times involves a long process that may necessitate more than one surgery. In many cases, once the breast is complete, it is necessary to redesign the other breast in order to achieve symmetry (for example, reduction or lift of the healthy breast).

The last phase of breast reconstruction involves nipple reconstruction.

Two kinds of reconstruction exist:

• Alloplastic reconstruction- reconstruction via a tissue expander, ultimately to be replaced by a permanent silicone implant.
• Autologous reconstruction- reconstruction via relocation of tissue from another location in the body, with or without a breast implant. The tissues most commonly used are muscle and skin from the back or abdomen.

Breast reconstruction via tissue expander is a simple procedure with a brief recovery period. This kind of reconstruction is suitable for women with small to medium sized breasts. In this surgery, a tissue expander is inserted beneath the muscle tissue of the breast. Two weeks after the surgery the tissue expander is gradually inflated in order to reach the desired volume. Inflating the expander is performed in a medical clinic setting, and is achieved via injection of physiologic sterile fluid (saline) into a valve that is accessible right below the skin layer.  A few months after the desired volume is achieved, the tissue expander can be replaced by a permanent silicone implant.

Breast reconstruction via relocation of tissue from another location in the body is a somewhat more complicated operation, and may necessitate a few days of hospitalization. Recovery may be long and tedious, and similarly the return to normal daily activities may be lengthened. This operation is suitable for women with medium to large sized breasts, or for women that are not interested in having an implant inserted into their body. This surgery takes a number of hours, after which there are scars on the lower abdomen or back in addition to the scars on the breast. Not every woman is suitable for reconstruction from the back just like not every woman is suitable to reconstruction from the abdomen. This issue is further discussed during the consultation.

Major risk factors for reconstructive surgery are prior radiation therapy (for alloplastic reconstruction mainly), propensity for increased bleeding (due to blood thinner medications), high blood-pressure, smoking, and diabetes.

Radiation is part of the treatment for breast cancer. Radiated skin does not heal well. It is important to stop smoking and taking blood thinners at least 2 weeks prior to surgery. Furthermore, one must achieve normal blood pressures and glucose values prior to surgery.

For pre-surgical consultation, one must provide the necessary medical documentation, authorization from an oncologist and breast surgeon. Breast reconstruction is a multidisciplinary process, necessitating cooperation between breast surgeon, oncologist, and plastic surgeon.

In most instances, insertion of draining tubes at the surgical sites is necessary, and they are removed in the medical clinic after several days.

The initial recovery period can be painful, along with areas of edema, swelling, varying degrees of sensation in the overlying skin, and bleeding. Furthermore, these symptoms may appear in the area where the donor tissue was taken from (in autologous reconstruction). It is advised to avoid physical exertion for at least two weeks.

The final breast shape will be noticed only after several months, and in any case it will be difficult to achieve complete symmetry between the reconstructed and healthy breast.

The second stage of breast reconstruction is the final tailoring of the breast, replacement of the tissue expander to a permanent implant (in alloplastic reconstruction), contouring the healthy breast to match the reconstructed breast. Nipple reconstruction is performed in the third stage, and can be done under local anesthesia.

The second stage surgery is performed under general anesthesia. Recovery from this surgery is usually brief and without complications. After this second stage, one must wait at least three months in order to see the final breast shape.

Complications of breast reconstruction are rare. Possible complications are:

-Bleeding that may necessitate drainage in the operating room

-Seroma

-Hardening of the implant shell (capsular contraction)

-Infection – usually treated conservatively

-Hypertrophic or Keloid scarring

-Opening of sutures

-Asymmetry between breasts

-Necessity of additional surgeries

-Patient dissatisfaction with results

-Weakening of abdominal wall (in cases of autologous reconstruction from the abdomen)

Nipple reconstruction:

This is the third phase of breast reconstruction. As noted, this surgery can be done under local anesthesia. In this surgery, a nipple is reconstructed from local tissue. The sutures placed are absorbable, and there is no need to have them removed. The patient must wear a “nipple protector” until full recovery of the surgical site. The areola is reconstructed mainly via medical tattoo. Complications of nipple reconstruction are extremely rare, and include: bleeding, local infection, opening of sutures, necrosis of tissue, flattening of the nipple, necessity for additional operations.