There are many techniques available to reconstruct a breast that has been removed due to cancer, or which has failed to develop. Your consultation with Dr Scamp, will be to inform you and help you select a procedure that will best suit your body and your wishes. Remember the aim of Breast Reconstruction is to make two breasts that match.

Naturally, these should be two breasts that you like. One of the most important things to consider at the very beginning, is whether you have a desire to make any alteration to your normal breast. Some people feel they are too big, too small, or sag too much. The appropriate surgery for the opposite breast can be included in the plan to reconstruct your breast.

In most cases, two operations at separate stages, some months apart are required. But even after the first operation, at least a breast "mound" will have been created which will make dressing and wearing of normal clothes much easier for you. In warm climates, one really needs to be able to wear a swimsuit or a t-shirt to get through normal daily activities. The aim of Breast Reconstruction is to make this possible.

Dr Scamp has a special interest in Breast Reconstruction. He trained in Australia, Britain, Europe and USA on Breast Reconstruction techniques. The following web site will answer some of the basic questions about Breast Reconstruction. More detailed information can be found in a book called "A Woman's Decision" by Karen Berger and John Bostwick 111, M.D. This is published by Quality Medical Publishing Incorporated St. Louis, Missouri.

This book is commonly provided for patients to read after consultation with Dr Scamp. If you are travelling from a distance to see Dr. Scamp, ask his staff to send you the book in advance or get a copy from a bookstore. It is very readable and contains a lot of very useful information.

Who Can Have Breast Reconstruction?

Any patient who is medically fit for surgery and who desires Breast Reconstruction is a suitable candidate. Naturally, it is best if the breast cancer is under good control. Reconstruction will not increase your risk of the breast cancer coming back. If you have any doubt, you may ask the surgeon performing the mastectomy, when he feels the right time would be.

Naturally you want to be in the best of health for Breast Reconstruction surgery. Cessation of smoking and attention to things such as obesity and high blood pressure would be prudent. Even if you decide to defer Breast Reconstruction, or not to proceed at all, you may find some comfort in knowing that these options are open to you.

 

When can I have breast reconstruction?

In many cases it is possible to perform Breast Reconstruction at the same time as the Mastectomy. This requires cooperation between the surgeon performing the Mastectomy, and the Plastic Surgeon who does the reconstruction. If your Mastectomy Surgeon feels that this would be unwise, he will inform you of this. But feel free to ask him if he thinks that this might be possible.

If Breast Reconstruction is not performed at the same time, it can be performed at any later stage, when you are recovered from the initial surgery. Some of the procedures for a Breast Reconstruction are complex and have a significant recovery period. It may be that you simply don't have time to proceed with a Breast Reconstruction at the time of your Mastectomy. However, knowing that you can proceed at a later date at your convenience, will give you a bit more hope to see you through the hard times. For women where a breast has failed to develop on one side, Breast Reconstruction can be tailored to be performed as a teenager and adjusted as they grow.

 

Why should I have breast reconstruction? Although the Breast Reconstructions can look remarkably life-like, and feel quite real, you will never have your true breast back again. What you will have is something that helps you dress more easily, and pass unnoticed in most social situations. A successful procedure will permit you to wear a swimsuit and the usual casual clothing that you wear now. It will also save you the bother of worrying about an external prosthesis, which may fall out, or feel hot and uncomfortable. Reconstruction of the nipple is commonly performed at a second stage and this makes the reconstruction look just that bit more life-like.

 

How is the breast reconstruction done? Broadly speaking, Breast Reconstruction can be performed by use of prostheses, or by use of your own tissue. Sometimes a combination of both are required. Prostheses are often used in a two-stage procedure known as tissue expansion. Tissue expansion involves insertion of the tissue expander (an inflatable prosthesis) at the first stage. The wound is closed and over the ensuing months, in the doctors office, saline (salt water) is injected into a valve within the tissue expander to "blow it up".

The skin there gets a gentle but persistent stretch and is moulded into the shape of a new breast. When the skin has stabilised and the internal scar has matured (usually 3-6 months after the first operation), the second stage procedure is performed. In this procedure, the tissue expander is removed and the final prosthesis is inserted. This prosthesis may be either made of silicone gel (cohesive "leak proof" gel) or salt water (saline). You will be asked to choose your prosthesis type, after being informed of the alternatives.

 

Reconstruction of the nipple is usually performed at the second operation.

Tissue expansion may be performed as a day patient, as the surgery is less extensive than techniques which use your own tissues. Insertion of a tissue expander, runs much the same risks as you will see on the "Breast Augmentation" web site. The second stage of this surgery can also be performed as a day patient.

Tissue expansion therefore suits somebody who has a busy lifestyle, who would find it difficult to get enough time away from their activities to recover from a larger procedure. In the long-term, tissue expansion suffers from some of the risks seen in "Breast Augmentation". A tissue- expanded Breast Reconstruction feels less natural than a breast that has simply been enlarged cosmetically, as there is less healthy normal tissue overlying the prosthesis.

It is however a particularly useful technique where two sides have been removed [for example as a precaution to prevent the development of cancer in someone with a strong family history of breast cancer]. Previous radiotherapy does not make tissue expansion impossible, but it does substantially increase the risk of complications occurring.

Sometimes tissue expansion is combined with the use of a flap of your own tissue, such as the latissimus dorsi flap. This provides a bit more healthy tissue in front of the prosthesis to make it feel a bit more life-like. In most cases (where there has been no radiation) however, this is not usually required, but it may produce a more life-like result.

 

Safety of Silicone Breast Implants Reconstruction using your own tissues is most commonly done these days by means of the Tram Flap (Transverse Rectus Abdominis Myocutaneous Flap). This ingenious operation uses your "spare tyre" to create a breast made of the skin and fat of your abdomen with a small piece of the muscle attached.

In most cases, no prosthesis is required to reconstruct the breast and these reconstructions are commonly the softest and most natural to feel. The added benefit is of course removal of your "spare tyre". Thus, the successful Tram Flap patient gets a trimmer tummy as well as a new breast. Again, nipple reconstruction is commonly performed at a second stage.

If your tummy is small, you may be unsuitable for a Tram Flap, or you may require insertion of a prosthesis beneath the flap at a second stage to provide adequate size. Dr Scamp will advise you on the method that he thinks will best suit your physique and your wishes. The Tram Flap procedure is a bigger operation. You may be asked to give your own blood prior to surgery, in case transfusion is required. This avoids the risk of blood transfusion.

You will be in hospital for approximately five nights and it will take you 3 or 4 weeks to get your old strength back. You may be started on iron and foliate pills (FEFOL) prior to surgery, to "build up" your blood level. Patients who have gone through this procedure, feel that the benefit of having a reconstruction made from all their own tissues and getting a trimmer tummy as well, makes the extended recovery period required worthwhile.

The Tram Flap is often called the "Rolls Royce" of Breast Reconstructions, as it can provide particularly life-like results. The Tram Flap is moved based on the blood supply that comes through the muscle beneath it. In the "free" Tram Flap procedure, the smallest piece of muscle possible is taken with the blood vessels attached to it coming up from your pelvis. These small blood vessels are divided and reattached beneath the microscope, to blood vessels in your breast region. The alternate technique to this, the pedicled Tram Flap uses the more distant blood vessels that run down the muscle from above.

A larger piece of the muscle is taken to shift the pedicled Tram Flap, and this may weaken the abdomen more. This can cause a hernia. The latissimus dorsi flap was the most popular method of reconstructing the breast with your own tissues, before the advent of the Tram flap. It uses a piece of skin and muscle from your back, which is "tunnelled" through your armpit and brought to the breast. Usually a prosthesis is required with this flap, as the flap is not sufficiently bulky to reconstruct an entire breast. However, it may be a useful technique for bringing in healthy blood supply to an area that has had radiotherapy, so that tissue expansion can proceed more safely, or to cover a prosthesis where the overlying skin and fat is very thin.

It is also useful to "patch" lumpectomy defects. The latissimus dorsi muscle is mostly used in climbing or rowing, and is not missed by most people. It does leave a scar on the back and we try to design this to fit into the line of your swimsuit or bra. Nipple reconstruction is performed usually by taking a graft of slightly darker skin high up in your groin crease and performing a flap on the breast mound to provide projection. Tattooing can be used to better match the colour.

The reconstruction of the nipple can be remarkably life-like, and make the reconstructed breast look more natural and less "surgical". As said above, the nipple reconstruction is usually performed at the second stage of either the tissue expansion or TRAM flap procedure. If you feel your other breast is too large, a Breast Reduction can be performed to better match the size. This may be performed at the first or second stage of your reconstruction. If the size is good but there is too much sag, a lifting procedure (Mastopexy) can be offered to better match the two breasts.

Where the size of your other breast is too small, Breast Augmentation can be offered to achieve the size that you desire. Some patients have even said they feel their breasts look better than before their Mastectomy! This is certainly the aim of the reconstructive procedure, but cannot be promised.

 

Where is breast reconstruction performed?

A Tram Flap is performed as a hospital inpatient, usually for five nights. Tissue expansion can be performed as a day patient, under a general anaesthetic, or in hospital with an overnight stay, as you prefer. This is particularly used if surgery to the other breast is done at the same time, although this can also be performed as a day patient. The nipple reconstruction at the second stage is usually done as a day patient. You will be asked to decide whether you would prefer to have your surgery performed as an in-hospital patient or as a day surgery patient. In both cases general anaesthesia is used for your comfort.

 

Remember there are risks

The general risks of surgery such as bleeding, fluid collection, excessive scarring or anaesthetic difficulties, also apply to Breast Reconstruction. Fortunately these are relatively uncommon. Smokers increase their risks of surgery substantially, and you will be asked to cease smoking for at least six weeks prior to undertaking this surgery.

Remember, we both want you to have the smoothest perioperative course and the best possible result. Nicotine patches also need to be ceased 6 weeks prior to surgery. Where complications are severe, secondary surgery may be required. Where an implant is employed, the risk associated with breast prostheses, such as hardening (capsular contracture), also apply. This is due to shrinkage of the scar tissue around the prosthesis and may require an operation to divide this hardened scar tissue. The tissue expanders used are designed to weaken the scar as much as possible and reduce the risk of this occurring. Capsular contracture does not occur where a Tram flap is employed and no prosthesis is required.

Infection can occur around the expander or the final prosthesis. If it does occur, usually these need to be removed for at least three months. This is obviously disappointing, as it will leave you with a flat chest for three months while your body recovers. Fortunately infection is uncommon (2-4%). Your reconstructed breast and nipple will never have normal sensation, but remarkably, some sensory recovery does occur. Minor adjustments to the scar, or to the opposite breast for a better match may be required. We try to give you a perfect breast, but realistically our aims are to enable you to dress comfortably and wear the clothes you like.

On the positive side, research has shown the remarkable psychological benefit of breast reconstruction surgery. This is particularly true when reconstruction is performed at the same time as the Mastectomy.

 

Planning your surgery

After your consultation with Dr Scamp, you will be given a book to read on Breast Reconstruction ("A Woman's Decision"). When you have read this book, you will return for your second consultation with Dr Scamp. At that stage a firm plan for your surgery will be made. In the interim, Dr Scamp's staff will provide you with an idea of costs for each of the alternative procedures you may be considering. Plan your time off work to rest at home.

Arrange your surgery for when you can get sufficient support to make your recovery better. The more warning you give us, the better we are able to fit in with your timetable.

 

Preparing for surgery

Apart from ceasing smoking and nicotine patches at least six weeks prior to surgery, you should try to get yourself in the best possible condition. Obesity increases your risks of almost all perioperative complications. It is a substantial risk to your heart. Getting fitter prior to surgery will hasten your recovery from surgery. Avoid Aspirin and high-dose Vitamin E for at least two weeks prior to surgery, as these compounds can make you bleed.

 

Recovering from surgery

As mentioned above, it may take you up to four weeks or more to get back to feeling your old self (less if a tissue expander is used). Swelling at the operation site may take even longer to disappear. The swelling may cause some difficulty with dressing. Tissue expanders commonly sit a little high and cause excess fullness at the upper pole of the breast in the initial stages of expansion. This may mean that you will have to adjust the clothes that you wear to mask this at first, but of course it will be less inconvenient than the mastectomy was.

Most patients find that this surgery does an enormous amount for their self-esteem and the quality of their life. Write down any questions you have and ask Dr Scamp at the time of your consultation.