For Surgeons


Breast Reconstruction - The Whole Story

This article is reproduced with the permission of Medical Chronicle.

As practitioners in all fields of medicine, we are faced with medical aids on intensive cost-saving campaigns. As such, decision are often taken restricting certain operations, or parts of operations defeating the initial objective of the surgery. One such case is breast reconstruction, in particular, tissue expansion prosthetic breast reconstruction.

In recent years, reconstructive techniques and operations for post-mastectomy patients have improved tremendously. Flap techniques, including "TRAM" flaps (rectus abdominus muscle), latissimus dorsi flaps etc. have been improved with the advent of endoscopy; flap shaping donor site refinements, etc. However, the commonest for of reconstruction worldwide still remains tissue expansion and prosthetic reconstruction.

In my hands, in the correctly selected patients, the aesthetic outcome of this type of reconstruction is the most pleasing.

Flap reconstruction I reserve for patients who have had radiotherapy of other contra-indications to prosthetic reconstruction.

The heading of this article is breast reconstruction "the whole story" as many of the medical aids tends to focus on the mastectomy breast and completely ignore the opposite side. Breasts are paired organs and as such, reconstruction must involve the pair of breasts. Simply creating a mount of tissue in the 1990's is no longer acceptable as a reconstructive operation.

Consider the complete staged prosthetic reconstruction of the breast:

The first stage involves placement of a retropectoral tissue expander at the site of the mastectomied breast. My personal preference is to do this as a delayed procedure anywhere from 6 to 12 months after mastectomy. This allows time for adjuvant therapy to be given if necessary, for diligent follow-up and for scar tissue maturity to take place. One is often forced into immediate reconstruction - I believe the risk factors are higher in these cases.

The tissue expander is an empty silicone bag attached by a tube to a valve - this valve is placed in an easily accessible subcutaneous pocket usually on the lateral chest wall. Starting approximately 2 weeks later, expansion takes place percutaneously via the valve, at weekly intervals.

Management of the opposite breast is the focus of this article. Ignoring the status of this breast in relation to the reconstructed side is tantamount to doing half the reconstruction. A ptotic drooping or large breast is a complete mismatch with an expanded opposite breast.

Expansion results in a breast mound directly in the position of the expander as opposed it an outsized breast, or one with a nipple situated far below the axis of the opposite mound. In these cases the opposite breast should be reduced or lifted to achieve symmetry.

Concerning oncology principles, I have on at least one occasion isolated an undetected second carcinoma in the resected specimen of the opposite reduced breast. As far as mammographic follow-up in concerned, approximately one year later the scar tissue has stabilised enough to mammographically examine the breast. During the first year, it should be possible to distinguish cancer from the expected scar tissue or fat necrosis accompanying surgery.

The opposite breast may occasionally need augmentation/enlargement to match the reconstructed side as the expander fills the upper pole of the breast considerably . Augmentation involves placement of the prosthesis retropectorally in the opposite breast.

Following expansion, the next stage in reconstruction involves the removal of the expander and its replacement with a definitive prosthesis.

The nipple areola reconstruction is often done as a final stage. Of late, however, I have been happy to combine this step with the second stage, limiting complete reconstruction to just two stages.

As with other

13 November 2004