ONCOPLASTIC SURGERY

Breast reconstruction is surgery to make a new breast shape after removal of the breast (mastectomy). A mastectomy means that Miss Mullan removes all your breast tissue. You may be recommended to have a mastectomy if you have a large breast cancer, or if several areas in your breast have been found to show cancerous cells. Usually, Miss Mullan will preserve your skin which covers your breast (a skin sparing mastectomy) but she may need to remove your nipple.

The main ways of making a new breast shape include

• Removing the breast tissue, then inserting a tissue expander implant under the skin. The expander can be inflated with sterile saline (salty water) in the Consulting Suites by Miss Mullan. At a later date, as a second operation, the expander is removed and replaced with a 100% silicone implant. This is not suitable for women who have previously had radiotherapy, as the skin becomes less elastic. It is also unsuitable for women with very large breasts as it is difficult to make a good match, unless a breast reduction is being considered on the unaffected side.

• Removing the breast tissue, leaving your skin envelope, and putting in a 100% silicone implant. The implant can be covered by some of your own tissue (myodermal sling technique) or using a sheet of Acellular Dermal Matrix to cover the implant. Miss Mullan will be able to tell you which of these two techniques are most suited to your breast size and shape.

• Reconstruction with your own living tissue taken from another part of your body (either your back muscle, a latissimus dorsi flap reconstruction, or your tummy fat, a DIEP reconstruction).

You will need to speak to Miss Mullan to find out which type of reconstruction is most suitable for you.

Miss Mullan aims to create a breast similar in size and shape to your own breast. But a reconstructed breast won’t be identical to your remaining breast. When you are undressed you are likely to notice differences in symmetry and shape.

After your reconstruction, you may need to have further surgery to create a nipple or change the shape of your other breast to match your reconstructed one.

When to have breast reconstruction

You can have reconstruction at the same time as your breast cancer surgery (immediate reconstruction) or sometime later (delayed reconstruction). It is a very personal decision and you can choose what feels right for you.

If you are having a mastectomy Miss Mullan will discuss with you whether you want to have immediate breast reconstruction. She will advise you, taking into account

• The type and stage of your cancer
• Other treatments you are likely to need
• Your feelings and preferences
• The pros and cons of immediate reconstruction

An immediate reconstruction gives you a new breast straight away. However a reconstructed breast will not look or feel exactly the same as the breast you have lost, but some women find that immediate reconstruction helps them cope more easily with their feelings about the loss of a breast.

• You will have your new reconstructed breast when you wake up after your mastectomy or breast conserving surgery.
• You have fewer operations, so fewer anaesthetics.
• Your finished breast may look better because the surgeon is usually able to use the breast skin already there
• You will have less scarring on the reconstructed breast itself – usually you have a small patch of skin where your nipple was, with a scar around it

Drawbacks of immediate reconstruction

You may not have as much time to decide on the type of reconstruction you want

If you are having radiotherapy after surgery for breast cancer, it may damage the reconstruction.

Miss Mullan may advise you not to have an implant based reconstruction if you are having radiotherapy afterwards, but you may have a temporary implant inserted prior to you having radiotherapy (to preserve your skin envelope, “tissue banking”) with a view to Miss Mullan performing a second reconstruction operation after the radiotherapy has finished.

If you have complications of reconstructive surgery, it may delay any chemotherapy you need. The last point is an important one. Chemotherapy stops the body from being able to heal itself so well. So if you have any problems with wound healing after your reconstruction, you won’t be able to start chemotherapy until the problems have cleared up. Chemotherapy at this time would stop the wound healing and you could get a serious infection. There is good research evidence that chemotherapy works best if you start it within 6 weeks of your cancer surgery. And that may not be possible if things don’t go according to plan with the reconstruction.

Delayed reconstruction

Some women prefer to get over the mastectomy and breast cancer treatment before they think about reconstruction.
With delayed reconstruction

• You have more time to look at your options and discuss them with Miss Mullan
• Your breast cancer treatment will be finished and won’t be affected by your reconstruction surgery
• You may have a larger scar on the reconstructed breast

Remember that if you are interested in immediate reconstruction (during your mastectomy surgery) talk it over beforehand with Miss Mullan. She will be able to tell you if it is advisable or not, and can talk through the pros and cons with you.

Who can have breast reconstruction?

Breast reconstruction is possible for most women who have had their whole breast removed. Even if you

Have had a radical mastectomy
Have had radiotherapy
Have large breasts

If you are well enough, you may have a breast reconstruction at any age. But reconstruction may be difficult in women who currently smoke, are very overweight, or who have illnesses that increase the risk of a long operation/general anaesthetic. Miss Mullan will discuss this with you, and if you are smoking, she will ask you to stop smoking.

Therapeutic Mammoplasty

Reshaping of your breast may be an option if you need to have part of your breast removed and you have quite large breasts. This operation is called therapeutic mammoplasty. Miss Mullan will perform a “breast reduction” type operation and during this procedure, she will remove the breast cancer and an area of healthy surrounding tissue. She will then reshape the remaining breast tissue to create a smaller breast. You will need radiotherapy to the remaining breast tissue to reduce the risk of the cancer coming back. At the same time as having a therapeutic mammoplasty surgery, you can also have surgery to make your other breast smaller (breast reduction) so that they match in size. However, Miss Mullan may advise you to wait six months or so after your therapeutic mammoplasty before reducing your other breast. If necessary, the Breast Care Nurses can give you a temporary “filler” to go in your bra, whilst waiting for your symmetry surgery.

Fat transfer to the Breasts is a minimally-invasive treatment offering subtle enhancement to the breasts. It is a popular choice for women who are looking to add shape and volume to their chest, whilst removing stubborn pockets of fat elsewhere on the body.

Breast size and fullness can have a huge effect on body confidence. Factors such as weight loss, pregnancy/breast feeding, or ageing can cause breasts to look emptier or lose their shape, while many others are born with naturally smaller breasts which can leave some feeling insecure.

While breast implants and breast uplifts are popular ways to address the issue not everybody wants serious surgery requiring general anaesthetic, nor are synthetic implants the best way forward for everyone. Stubborn areas of fat around the body can be difficult to rid of through exercise and diet alone and, for some, a form of body contouring treatment can be the only way to achieve an end goal.

Breast Enlargement with Fat Transfer involves removing pockets of fat from other areas of your body (such as the legs or abdomen) and transferring the fat into the breast area to increase volume and shape in a subtle, natural-looking way.

Am I Suitable for Breast Fat Transfer?

Fat Transfer is suitable for those wanting to shape their figure while achieving subtle enhancement to the breasts. Fat Transfer is not recommended if you:

Want a significant increase in breast size.
Don’t have enough fat to transfer.
Require an uplift.
Are considering having children within the next year.
Are solely after breast augmentation, without liposuction.

You will need to have enough fat to transfer for treatment, meaning it is not always suitable for those with low body mass, and we advise all patients to be cautious with their expectations. Breast Fat Transfer will add shape and definition but will not provide a substantial increase in size (for which we recommend implants).

The Fat Transfer Procedure

A Fat Transfer procedure removes fat from the donor site via liposuction. The extracted fat is then refined before it is carefully injected in layers into the breasts to create volume and definition. Not all of the fat will survive after transfer, especially if you are smoking.

The Breast Fat Transfer Results

A subtle fullness is restored to the breasts. As implants are not used the final results are soft and natural-looking. Areas of the body that the fat is harvested from are slimmed and toned, with greater definition and an improved overall shape.

Downtime

Downtime is minimal. However, because there may be some bruising and swelling, it is best to wait a few weeks before you hit the gym or do any rigorous physical activity. You may be recommended to undertake a course of massage to aid your recovery, which your team will advise on during consultation.

After implant reconstruction or autologous reconstruction, you can decide if you’d like to have your nipple reconstructed, too. Some women do and some don’t — the choice is up to you. You have time to make that decision. Nipple reconstruction is done after the reconstructed breast has had time to heal — at least 3 or 4 months after reconstruction surgery. But you can take longer to decide if you’d like.

The nipple may be reconstructed from the surrounding skin at the site desired for nipple placement. Miss Mullan makes small incisions and then elevates the tissue into position, forming and shaping it into a living tissue projection that mimics the natural nipple. Older techniques, which used donor tissue from the genital region or elsewhere, have become less favoured over time.

Before nipple reconstruction surgery:

Nipple reconstruction surgery is usually done as outpatient surgery, which means that you don’t stay overnight in the hospital. Miss Mullan will give you a list of instructions on how to prepare for nipple reconstruction surgery. You’ll probably be told not to eat or drink anything and there will be medications that you shouldn’t take before the surgery.

Miss Mullan will draw markings on your breast (and donor site if skin from another area of your body is being used) to show where the incisions will be made. Usually this is done with a felt-tip marker. You’ll probably be standing up while this happens.

Nipple reconstruction is often done under local anaesthetic. This means that Miss Mullan will use a needle to inject numbing medication into the area where the reconstructed nipple will be. If you have local anesthetic, you will be awake during the procedure.

Skin to create the new nipple is usually taken right from the site where the new nipple will be located. This has become the favoured approach. However, you may have a “nipple share”, where a small part of your normal nipple (from the opposite breast) is removed and grafted to your reconstructed breast. Make sure you’re clear about how the reconstruction is being done and why, especially if a graft is recommended. If Miss Mullan is taking skin from another place on your body to reconstruct the nipple, that area will be numbed with local anaesthetic as well. Only a small amount of skin is needed to recreate the nipple.

If you and Miss Mullan decide that nipple reconstruction surgery should be done under general anaesthesia, an intravenous infusion (IV) line will be inserted into your hand or arm and taped into place. You’ll be given relaxing medication through the IV line.

During nipple reconstruction surgery:

Typically, a small incision is made at the site where the nipple will be made. The skin is formed into a nipple shape and small sutures (stitches) are used to secure the form. The new nipple and surrounding areola can be tattooed about 3 months after surgery.

If Miss Mullan plans to use grafted skin as part of the nipple reconstruction, there will be an incision in the area from which the skin was taken. Again, be sure to clarify whether this will be necessary or not, and if so, why. Grafted nipple reconstructions can sometimes have a “stamped on” appearance where the edge of the reconstructed areola meets the surrounding breast skin.

Once the nipple is sewn into place, a nipple shield (a protective covering shaped like a tiny hat with a wide flat brim) is filled with antibacterial ointment and taped over the reconstructed nipple to protect it.

The length of nipple reconstruction surgery can range from 30 minutes to an hour or so. Tattooing, which happens about 3 months after the nipple reconstruction surgery, usually takes 30 to 40 minutes.

After nipple reconstruction surgery:

If you’ve had local anaesthesia, you’ll be able to go home after the nipple shield is in place. If you’ve had general anaesthesia, you’ll be moved to a recovery room after surgery, where hospital staff members will monitor you. Once you’re awake and Miss Mullan has checked your heart rate, body temperature, and blood pressure, you’ll be allowed to go home. No matter which type of anaesthesia you have had, make sure you arrange for someone else to drive you home.

Miss Mullan will give you specific instructions to follow for your recovery.

The nipple shield is usually left on for about 3 days. After it’s removed you can shower. Your reconstructed nipple will probably look pointed and somewhat larger than your other nipple. After the stitches are removed — usually after 2 weeks — the nipple will begin to flatten out and look more like your other nipple.

The reconstructed nipple can be tender for a week or so. Ask Miss Mullan for medicines you can take to ease any pain you may have.

For women with moderate to large sized breasts, Michelle may be able to remove the breast cancer (therapeutic) and the reshape the breast by removing skin and breast tissue (mammoplasty) to try and preserve a normal breast shape which will usually be smaller and more uplifted. If there is a significant difference between the 2 breasts afterwards, the breast on the other side may also need to be reduced to give a better match in size and shape if so desired. This is known as symmetrisation surgery and will be performed at a later date.

Michelle will be able to tell you if you are suitable to have this sort of surgery, and explain in detail about the pros and cons of therapeutic mammoplasty.