Breast reconstruction involves making a new breast either at the same time, or sometime after, a mastectomy. There are several different ways of doing a breast reconstruction and many things to consider before deciding to have one. Many women decide not to have a breast reconstruction and have a simple mastectomy and wear an external prosthesis in the bra. All women who need a mastectomy should however, have the option of breast reconstruction. Even if you are fairly sure that you don't want one it is, perhaps, good to know a little bit about what can be done. In this way you make the decision that is best for you being fully aware of the options.
Issues to Consider
One of the first issues to consider is "Do I want a breast reconstruction or not?" To answer this question you need to know what is involved with a breast reconstruction and what options there are. Once you know this, as a guiding basic principle, if you are not convinced about having a breast reconstruction, then the best thing to do is not to have one.
Another important issue, on which you will be strongly guided, is whether or not a breast reconstruction performed during the same operation as a mastectomy (immediate breast reconstruction) is a good option for you. For most women it is a good option and there are very few cases nowadays in which an immediate breast reconstruction is not possible. However, there are risks to all surgery and for some women these risks are higher than others. Very occasionally, you may be advised that surgery should be kept as simple as possible and reconstruction would be much better performed once all the breast cancer treatment is finished (delayed breast reconstruction).
All breast reconstruction involves additional surgery and additional risk of complications. It therefore involves more time in hospital (in the ward or clinic) than if the simplest surgical procedure was performed. If you are advised that a breast reconstruction is an option for you then this advice is based upon the fact that a breast reconstruction will not adversely affect your treatment in any way.
Types of Breast Reconstruction
In general terms, a breast is either reconstructed from artificial means (silicone implants) or from your own tissue (flap reconstruction). Sometimes a combination of the two is used. Not every woman is suitable for every option. Some women may have two or three options for breast reconstruction available, others have only one and just occasionally there are no good options. Having more than one option is good but this can also mean that you have more information about pros and cons of different types of reconstruction to consider. Where possible, if you have more than one option for breast reconstruction you will be advised about which is the one you are most ideally suited for.
Preserving the Nipple
Many women who require a mastectomy have the option of keeping their own nipple. This is determined by two main factors. The first is if there is any cancer risk to the nipple (in which case it needs to be removed). The second is if the nipple will survive - the blood supply to the nipple can be badly affected by removing the breast tissue in some breast shapes and sizes.
Immediate Breast Reconstruction (at the same time as a mastectomy)
Everything is done at one operation. You never have to have a flat chest. A lot of your own skin overlying the breast can be preserved and used as part of the reconstruction, which then looks more natural and has minimal scarring.
See "Complications - What can go wrong?" Delayed breast reconstruction refers to a breast reconstruction performed sometime after having a simple mastectomy.
Delayed Breast Reconstruction (at some time after a mastectomy)
If you are not convinced about a breast reconstruction it gives you time to think. It keeps the surgery as simple a possible at the time of your cancer treatment. You may decide that you don't want a breast reconstruction and are comfortable living without one.
A second operation is required with its associated time in hospital and recovery time. There will usually be more scarring as part of the reconstruction. Also see "Complications - What can go wrong?"
This can often be performed at the same time as an LD flap of DIEP/TRAM flap reconstruction. If not it can be performed (under local anaesthetic) once breast reconstruction is complete. The area around the nipple can be tattooed. Most reconstructed nipples tend to flatten with time. Some women choose not to have a nipple reconstruction. They have the option of having a mould made from the other nipple that can be worn as required. See separate page on Nipple Reconstruction and Tattooing.
Admission and Aftercare
You are generally admitted on the day of surgery, occasionally the day before. You will be re-examined and the site of the scar / scars drawn on your body. The length of the operation will vary depending on the extent of surgery required as outlined above. Dissolvable stitches are used and a waterproof dressing consisting of a special type of glue is applied. Sometimes a support dressing is used for 24 hrs and you may be advised to wear a supportive bra or specialist garment day and night for a couple of weeks.
Complications - What can go wrong?
Any operation can be associated with infection or bleeding. Wound healing can be particularly affected by infection and smoking. If you are a smoker you will be strongly advised to stop smoking before having a breast reconstruction. Any operation can be associated with anaesthetic problems (nausea in particular), venous thrombosis (although precautions are taken routinely) and allergic reaction to drugs or dressings. Any breast reconstruction will feel quite numb. It is probably fair to say that you are less aware of this with time.
Having little sensation can mean that a reconstructed breast is a little more prone to injury such as sunburn or rubbing from a poor fitting or under-wired bra. Other complications are listed under the "cons" for various methods of breast reconstruction above. Some are worth a more detailed mention:
Capsule formation: This refers to the scar tissue that forms around silicone implants. It is the body's way of walling off the implant. The amount of capsule that develops is largely unpredictable. Some women form very soft capsule that causes no problems and some women form a dense capsule that distorts the breast shape, compresses the implant and is painful and tender. Capsule formation is inevitable after radiotherapy, which is why the combination of an implant reconstruction and radiotherapy is best avoided if possible. In the absence of radiotherapy, only a small minority of women have troublesome capsule formation. However over the long-term revision of an implant reconstruction because of capsule formation is reasonably common.
Flap failure: This refers to the situation where the blood supply fails to the tissue that is being transferred. It is extremely rare for LD flaps, but occurs in about 1 in 40 cases for a DIEP or TRAM flap. If this problem did occur you would have a big scar on your tummy and you would have gone through a big operation but there would be no breast reconstruction to show for it. Sometimes a second option for breast reconstruction can be used, sometimes a skin graft is necessary.
Weakness after LD flap: The muscle used for a LD flap is a "climbing muscle". Most women have some shoulder stiffness in the first few weeks after surgery. In the long term it is difficult to demonstrate any difference in ability to do all normal activities including average sporting activities. If you are a competitive sportswomen then it is possible that some effect would be noticeable depending upon your sport.
How do I decide?
You may need more than one consultation to fully appreciate all the options and pros / cons. The breast care nurse will help guide you and direct you to other sources of information. Once you are focused on one or maybe two options, you should ideally have a chat with someone who has undergone that operation. This will give you the best insight into what it is like and a realistic impression of what can (and can't) be achieved. Again, if you are not convinced about undergoing a breast reconstruction then the best thing to do is not to have one.
Finding a "Positive" out of a "Negative"
Some women would ideally wish to have larger breasts, or smaller breasts or breasts that are a different shape. If a new breast is being reconstructed by whatever means, it is worth considering whether you wish the normal breast to be adjusted so that you have a different overall breast size or shape. This is particularly the case if you require a bilateral (double) mastectomy.
Q. Are implants safe?
Answer - Yes. They are not without problems as detailed above but they are not in themselves harmful or toxic. All the implants that Mr Macmillan uses come with a lifetime guarantee. As such, the risk of the implant failing in some way is very unlikely. Problems with implants are more related to how your body reacts to them being there and how the remaining skin and tissue changes over the years. A very rare problem that is thought to be caused by implants is a condition called ALCL (Anaplastic large Cell Lymphoma).
Q. What is ALCL?
Answer - Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a very rare type of blood cell cancer, which has been described in relation to breast implants. The first UK case was reported in 2012 and the most up to date figures indicate an estimated risk of around 1 case of BIA-ALCL for every 25,000 implants sold.
BIA-ALCL can appear several years after the implant surgery and usually presents with rapid, painless swelling of one breast as a result of fluid collecting around the implant. It is diagnosed by sending off a sample of this fluid to be analysed in a laboratory. BIA-ALCL is very treatable and, if diagnosed early, is most often treated with surgery alone. Surgery involves removing the implant and the capsule surrounding it. Very occasionally treatment also involves a type of chemotherapy.
The reason why breast implants can cause BIA-ALCL is not fully understood and may involve a variety of factors. One of the suggested theories is that it is caused by the way some patients react to the surface texture of implants. Another theory is that it is caused by a low-grade chronic infection around the implant. Research is on-going but is yet to provide a definitive answer.
In the UK and in Europe in general, the vast majority of implants used are textured. This is because texturing of an implant surface reduces the risk of capsule formation (scar tissue that forms around implants) and in naturally shaped implants it also reduces the risk of implant rotation. Hence textured implants are generally preferred over smooth implants. Preventing infection in breast implant surgery is always of the utmost importance for many reasons and lots of steps are taken to avoid it.
In my practice I have almost always used textured implants and have always chosen those that I believe to be the best that are available. Since being alerted to the risk of BIA-ALCL this rare risk has been included in my discussion about risks of implants and problems that we see with them, of which there are many. However, implants remain extremely safe and the benefits of using them in the right situation massively outweigh the risks.
There is no evidence for and hence no need for anyone with breast implants to have their implants removed or to change their implants because of the recent publicity around BIA-ALCL. However, anyone with breast implants who is aware of breast swelling, particularly one that just affects one side and has appeared quite quickly should see their GP and be referred for an examination and ultrasound scan.
Q. Could having a breast reconstruction delay my cancer treatment?
Answer - Sometimes. The need for more operating time or two surgeons to be available means that your operation may be scheduled for a couple of weeks later than if you were having a simple mastectomy with no reconstruction. In practice this is more common with the DIEP or TRAM flap reconstruction when surgery needs to be coordinated with the availablity of the microsurgeon. As stated, all breast reconstruction involves additional surgery and additional risk of complications. In theory therefore, you could have a complication that delayed additional treatment such as radiotherapy or chemotherapy. In practice this happens very rarely and any complications that do occur are dealt with early to avoid this scenario.
Q. Will a breast reconstruction affect the effectiveness of my breast cancer treatment?
Answer - No. If that were thought to be a risk, you would be advised against having a breast reconstruction.
Q. If I have a breast reconstruction will it be more difficult to detect a recurrence of my breast cancer if I were unlucky enough to get one?
Answer - No. If you did develop a recurrence in the breast reconstruction area, it would be superficial to the reconstruction. The reconstruction would not make it more difficult to feel.
Q. If I have my other (normal) breast adjusted, will it mean that it will be more difficult to detect a cancer in that breast should it occur?
Answer - Firstly it should be stated that most women are very unlikely to develop a second breast cancer in the other breast and breast cancer does not spread from one breast to the other. If you have the other breast augmented (made bigger with an implant), this usually reduces the sensitivity of mammography. This may be a bigger problem for some women than others. If the other breast is adjusted without the need for an implant, this will not affect our ability to detect a problem in that breast should it occur.
Q. What is the recovery time for breast reconstruction?
Answer - This obviously varies depending on various factors (additional treatments, your general fitness etc) but as a rough guide most women will be back doing all the regular activities you were doing before surgery: 4-6 weeks after implant reconstruction 2-3 months after LD flap reconstruction 3-4 months after DIEP/TRAM flap reconstruction