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Breast Reconstruction at Macclesfield

Process/expectations

There are two important principles common to all types of breast reconstruction.

  1. Breast reconstruction should be viewed as a process, rather than as one finite operation. It may take a number of operations to get the desired cosmetic result, or to treat complications that develop due to the effects of time and gravity (such as capsule formation around an implant and increasing breast asymmetry).
  2. It is important to understand what can be achieved through the process of breast reconstruction. It is simply not possible to reconstruct a breast that is as good or as natural as one’s own breast. Whilst we do our best in surgery, our results are simply not as good as those achieved through nature. We aim to make a reconstructed breast that looks symmetrical with the other breast when wearing a bra. However, out of a bra, it may be obvious that the breast has undergone major surgery and a reconstruction. Also, in general, the reconstructed breast sits higher on the chest wall than the other breast, is firmer to touch, relatively insensate and much less mobile.  So, a reconstructed breast does not necessarily look, move or feel like a normal breast.

Delayed versus immediate reconstruction

There are advantages and disadvantages of immediate breast reconstruction versus delayed breast reconstruction. There are practical advantages both to the patient and to the surgeon of having an immediate breast reconstruction. From the patient perspective, a delayed breast reconstruction means two separate operations with the inpatient stay and the post-operative recovery that that entails. From the surgeon’s perspective, a delayed breast reconstruction is somewhat more difficult as one not only needs to reconstruct the missing volume of the breast but also the skin, shape and contour. Therefore, I think it is fair to say that many patients end up with a better end cosmetic result through an immediate breast reconstruction rather than a delayed one. The disadvantages of having an immediate breast reconstruction are that if post-operative radiotherapy is recommended it may damage the breast reconstruction, increasing scar tissue formation and making it more likely that revisional surgery is required in the future.

Patient Information Leaflets

Flap based Reconstruction

These techniques involve taking tissue from a distant site of the body and bringing it into the chest with its blood supply, to reconstruct the breast. This tissue can be taken from two main places, either the back or the abdomen. For more information please download the Flap Based Reconstruction document on the right.

Skin Sparing Mastectomy

When undertaking a mastectomy with a view to reconstructing the breast at the same time the method of the mastectomy is altered and is termed a skin-sparing mastectomy. This procedure normally entails removal of the breast tissue through a circular incision around the areola. Thus the breast, areola and nipple are excised. The skin envelope of the breast is left intact, which obviously can lead to long term better cosmetic results. Numerous studies have shown us that this is oncologically safe (cancer-safe procedure) with similar rates of local recurrence of tumour when compared to a standard, simple mastectomy (rates of local recurrence of about 5 – 6% at 5 years). The main drawback of this procedure is that this skin envelope is really only skin-thin, and sometimes the blood vessels that supply it are simply not good enough to keep this entire skin envelope alive. Therefore, some people do have problems with delayed wound healing or even partial loss of this skin envelope in the days that follow surgery. This is called skin flap necrosis. This complication is more likely to occur in those patients with impaired blood circulation in that area, such as patients who have had prior radiotherapy to the breast or in those who smoke. If skin flap necrosis does develop then it might require further surgery.

Implant expander technique

This involves placement of a silicone expander prosthesis deep to the muscle of the chest wall at the time of the mastectomy. This breast implant has a silicone shell and a hollow centre that contains saline, the volume of which can be adjusted with a needle and an injection. At the time of the initial operation the expander prosthesis is only partially expanded. It is gradually inflated with saline injections to achieve a similar volume when compared to the other side. These injections are undertaken over a number of weeks as an outpatient in the breast clinic. When the appropriate size has been achieved, this expander unit is changed for a permanent, shaped, silicone prosthesis at a second, much more minor operation. 

The initial operation takes slightly longer than for a standard mastectomy, but the length of inpatient stay, the amount of post operative pain and the length of post operative recovery are about the same.

Most ladies who have this done are reasonably satisfied with the end result. It has the advantage of leading to reasonable breast symmetry when wearing a bra, without the requirement of major surgery or additional scars in the body. However, I think it is fair to say that the end cosmetic result is not quite as good as that which can be achieved through flap-based breast reconstruction and that patient satisfaction levels are thus slightly less when compared with reconstruction that uses a flap. Because the implant is situated deep to the muscle of the chest wall the reconstructed breast necessarily will sit higher than the other side. This maybe fine for those women who have small, firm and very pert breasts to start off with in any case, but most breasts are not built and positioned like that, especially after the effects of time, gravity and child bearing. Also, methods of breast reconstruction that only use implants tend to be firmer and less mobile than those that use flaps.

To some extent all reconstructions that utilise an implant will be prone to a later development of a scar tissue capsule. This forms around every breast implant. In some women this scar tissue capsule becomes very firm and dense and can lead to distortion of shape of the reconstructed breast. Thus, some women will require surgery in the future, to change the implant and soften up this scar tissue capsule.

There has been a lot of debate in recent years about the general safety of silicone implants, especially in theUSA, where they were withdrawn from use by the FDA (Federal Drug Administration) for cosmetic breast augmentation. Recently the implants that we use have been ratified again for use in theUnited States. There have been a large number of studies undertaken inEuropeto carefully analyse any possible side effects of breast silicone implants. Thousands of women have been studied. No evidence has been uncovered to suggest that silicone breast implants are associated with any adverse effects elsewhere in the body, such as arthritis or connective tissue disorders. That is not to say that silicone implants are not without their problems, but those problems are generally local ones confined to the breast, such as capsule formation. 

We have recently started doing an implant expander reconstruction which in 50% of patients can be done as a single stage procedure with the use of a Strattice (collagen obtained from Porcine dermis)