The breast is central to the feminine identity and is culturally celebrated in many genres of ancient and modern art. It bears essential function relating to breastfeeding and life-sustenance. They carry significant aesthetic value and are the subject of art and envy in many.
Breast cancer is the commonest malignancy in females and cancer removal surgery may result in breast deformities that diminish individuals’ perception of femininity. Breast reconstruction serves an important role of restoring a breast mound that permits optimal fitting of clothing, improving one’s self-confidence, providing psychological support and facilitating social reintegration.
Breast lump removal may be broadly classified into wide excision of the lump, and mastectomy in which the entire breast is removed. There are various factors that influence the choice of procedure, including:
Depending on the stage and location of the cancer, the nipple may or may not be removed during the surgery. The lymph node(s) in the underarm (axilla) may require sampling or total removal and also depends on the stage of the breast cancer and its type.
Your attending breast surgeon will be the best person to advise on the optimal breast surgery tailored to your condition. The breast reconstruction surgery is tailored to the nature of the breast cancer surgery performed. Individualizing surgical solutions provides attractive and bespoke results that help females in their physical and psychological rehabilitation and social reintegration.
Breast reconstruction may be divided into the following broad categories:
Immediate reconstruction refers to reconstructive surgery performed at the same time as mastectomy surgery. Delayed reconstruction refers to reconstructive surgery performed after the completion of all necessary treatment including chemotherapy and radiation therapy. The advantages of immediate reconstruction include having a breast mound immediately following mastectomy, and the use of the native chest skin before scarring sets in, which gives the reconstructed breast mound the closest match to the unaffected breast.
Delayed reconstruction is performed where individuals may come from places where reconstructive expertise may not be available at the time of mastectomy, or where individuals initially opt for mastectomy without reconstruction and later change their minds. The advantage of delayed reconstruction is that it presents an opportunity to replace previously irradiated chest skin with new non-radiated tissue obtained from another part of the body.
The important factors considered when planning for reconstruction include:
Individuals are advised to stop herbal supplements and traditional medicine at least 7 days prior to surgery to minimize bruising and swelling.
Breast reconstruction is a safe procedure in trained and experienced hands. It creates a breast mound that is symmetrical in volume, position and shape to the unaffected breast and restores a feminine silhouette to permit optimal fitting of clothes and aids in the psychological rehabilitation following breast cancer surgery.
Prosthetic reconstruction involves the use of breast implants or expanders. Breast implants are permanent implants that contain a fixed volume of saline or silicone sealed within a silicone shell. Breast expanders are devices that contain a variable amount of saline that is adjustable in the outpatient clinic through a specially designed port from which saline is injected or removed
Individuals most ideally suited for implant reconstruction include those who have no or minimal breast drooping (ptosis), do not require postoperative radiation therapy and/or those undergoing bilateral mastectomy. Individuals ideally suited for expander reconstruction includes those have previously undergone or may undergo postoperative radiation therapy. The expander gradually expands the contracted, post-radiated chest skin to permit eventual reconstruction with implant or an autologous flap.
Preoperative assessment evaluates the size, shape and volume of the unaffected breast. The implant or expander chosen is the one that gives the best width and volume match to the unaffected breast. The shape of the unaffected breast is also used as a reference for choosing between round or anatomical (teardrop) shaped implants. With regard to the implant surface, smooth and textured implants are available and the choice will be discussed with you during the clinical assessment.
Preoperative assessment permits accurate determination of the ideal implant or expander to be inserted during surgery. This surgery is performed under general anesthesia. The mastectomy is often performed through an incision around the areola or in the inframammary fold and the prosthesis is inserted through the same incision. The implant is almost always inserted beneath the pectoralis muscle for adequate soft tissue protection. The lower half of the implant will require support by suturing a mesh or donated human skin, from the chest wall to the lower border of the pectoralis muscle.
Individuals often require an inpatient stay of one to two nights following mastectomy and prosthetic reconstruction. A drainage tube is often inserted to the wound bed during surgery to facilitate evacuation of blood and fluid and is removed after a few days. Stitch removal is usually performed after 2 weeks.
Specific pressure garments may be used to minimize fluid production and drainage volume. These garments may be used for a few weeks postoperatively to also reduce swelling and maintain implant position until wound healing is complete. Individuals who undergo expander reconstruction will have a specially designed port inserted beneath the skin at the outer chest wall to permit eventual expander size adjustment using saline injections. Volume adjustment is a simple procedure that may be performed in the outpatient clinic.
Individuals who may consider flap reconstruction are those with significant excess abdominal tissue, and/or desire a natural look. Flap reconstruction is able to recreate the natural breast droop (ptosis) in the unaffected breast for optimal symmetry, which implants cannot. Individuals who will require postoperative radiation therapy are also good candidates for flap reconstruction.
Regional flaps are harvested from tissues in the vicinity of the breast. Common examples include flaps taken from the side of the chest (intercostal artery perforator flaps), back (latissimus dorsi flaps) and abdomen (rectus abdominis or TRAM) flaps. The flap is tunneled and advanced into the breast and fixed into position.
Distant flaps are flaps that are harvested from a donor site that is anatomically remote from the recipient site with its intact blood vessels. The most common distant flaps are the rectus abdominis (TRAM) and the deep inferior epigastric artery perforator (DIEAP) flaps. Less common flaps may be harvested from the buttock or inner thigh.
The ideal flap is one that is of similar size and volume match to the existing unaffected breast. The LD flap is usually of small volume and is sometimes used together with an implant (hybrid reconstruction) to achieve similar size match. The TRAM or DIEAP flaps are harvested from the abdomen and provide good volume and sufficient skin in the majority of cases.
LD (latissimus dorsi) flaps are usually harvested using a horizontal incision in the back, which is sited within the bra line. The LD muscle is freed from its attachments to the spinal vertebra and a tunnel is created from the back into the front of the chest. The muscle is transposed into the chest defect. In many cases, the LD muscle is of small volume and may require supplementation with a breast implant for optimal size match with the opposite breast.
TRAM (transverse rectus abdominis myocutaneous) and DIEAP (deep inferior epigastric artery perforator) flaps are harvested from the lower abdomen and utilizes the same incision as in an abdominoplasty (tummy tuck) surgery. The skin, fat and rectus muscle is harvested as a single unit and a tunnel is made from the abdominal wall to the chest wall allowing the flap to be transposed into the defect. Various maneuvers are used to shape the abdominal skin and fat into a hemispherical shape closely approximating to that of the opposite breast. The abdominal incision is closed and a new opening for the umbilicus is made. The abdominal scar is often hidden within the bikini line and is not conspicuous. The TRAM flap may be used as a regional flap or as a distant flap, whereas the DIEAP flap is a distant flap.
The TRAM and DIEAP flaps are harvested from the lower abdomen and though a bikini-line incision similar to a tummy tuck (abdominoplasty). The skin and fat are raised together with the blood vessels supplying them. In the case of the TRAM flap, a small amount of muscle is included in the harvesting while preserving some of the remnant muscle and its function. This provides some additional soft tissue protection around the blood vessels. The DIEAP flap is harvested without any rectus muscle and is possible in cases where the blood vessels are of sufficient size. It permits maximal functional preservation of the abdominal muscles. Following flap harvest, the blood vessels that supply the flap will need to be connected to blood vessels in the chest using microsurgical techniques, where ultra-fine sutures that are thinner than a strand of hair are used. The abdominal incision is closed and a new opening for the umbilicus is made.
Individuals often require an inpatient stay of about one week following mastectomy and flap reconstruction. Drainage tubes are inserted to the breast and abdomen during surgery to facilitate evacuation of blood and fluid and is removed after a few days. Most individuals are able to walk with assistance on the day after surgery. Stitch removal is usually performed after 2 weeks.
Specific pressure garments may be used at the abdomen to minimize fluid production and drainage volume. Smokers are advised to abstain from smoking for at least 2 weeks postoperatively.
Structural fat grafting involves the use of an individual’s own fat tissue to reconstruct partial or total breast defects. Fat is harvested via liposuction from the lower abdomen, flanks, inner thighs or hips and are purified prior to grafting. This has beneficial effects on contouring of the breast as well as the body. This is a minimally invasive procedure with minimal scars. Fat grafts contain adipose-derived stem cells (ADSCs) that have been shown to improve the quality of post-irradiated skin. It is a minimally invasive procedure with short recovery time.
The following may consider fat grafting reconstruction:
Individuals are advised to stop herbal supplements and traditional medicine, and start special medications 7 days prior to surgery to minimize bruising and swelling.
Preoperative marking is performed to identify areas of fat excess, such as the lower abdomen, flanks, inner thighs and/or hips. Small incisions are performed near the area of intended liposuction and local anesthetic is infused for optimal pain relief. Using specialized cannulas and equipment available at Picasso Plastic Surgery, the fat is broken up and aspirated under negative pressure. The fat is purified by removal of excess fluid and grafted into the breast through 3-mm incisions hidden in the inframammary fold or underarm (axilla). Individualizing the surgical approach produces natural-looking, elegant and bespoke outcomes.
Many individuals are able to return to work between the 5th and 7th postoperative day. Depending on the extent of liposuction performed, the swelling and bruising will mostly resolve by the 14th postoperative day. Stitch removal is usually performed on the 10th postoperative day.
Showering is possible from the 2nd postoperative day onwards. Specific post-operative compression garments may be required at the donor sites in the first 2 weeks to minimize postoperative bruising and swelling, guide shrinkage of the skin and prevent formation of irregular skin folds. Bruising may be minimized by avoidance of strenuous activity for the first 2 weeks.
The nipple-areola complex is the highlight of an aesthetic breast mound. In youth, the nipple-areola complex lies on the apex of the breast mound, and the nipple adds further projection to this mound. An aesthetic nipple-areola complex lies at the intersection between the vertical midline of the collar bone (clavicle), and a horizontal line above the inframammary fold. An aesthetic nipple is one that is in the correct position, of appropriate size and projection. It adds a final touch to the aesthetic of the breast mound. Nipple reconstruction is often the final procedure performed following successful breast reconstruction.
Nipple reconstruction is required where the nipple-areola complex is removed during mastectomy. Breast reconstruction is first performed with prosthetic or flap techniques to first create the breast mound. Nipple reconstruction may be performed at the time of the breast reconstruction or in a delayed manner.
Immediate nipple reconstruction. Immediate reconstruction may be performed in cases where the individual is not likely to require further postoperative radiation therapy. It achieves breast and nipple reconstruction in a single operation for maximal convenience.
Delayed nipple reconstruction. Delayed reconstruction is performed in cases where the individual is likely to require postoperative radiation therapy and may be considered 3 months following its completion. Radiation therapy may cause alterations in the implant position or flap size and nipple reconstruction is best performed after the radiation changes have settled.
There are two possibilities for restoration of the nipple-areola complex color. The first technique is the use of darker-pigmented skin grafts for creation of the nipple and areola. This may be harvested from the groin or skin around the buttocks. The second and more common technique is to perform tattooing to the reconstructed nipple-areola complex.
Nipple reconstruction restores the final aesthetic of the breast mound and adds a small projection to its apex. It restores body image, self-confidence and improves social functioning. Nipple reconstruction is performed as an outpatient procedure under local anesthesia. A variety of local skin flaps or skin grafts may be used for nipple reconstruction. Skin flaps are commonly used and are raised from the areola skin.
Many individuals are able to return to normal activities immediately following surgery. Minor bruising and swelling is expected, and will mostly resolve by the 5th postoperative day.
Reconstruction of a beautiful breast mound is important in restoring a feminine form as well as aiding in an individual’s psychological rehabilitation following breast cancer surgery.
Dr Matthew Yeo is experienced in breast reconstruction and is also one of the selected practitioners in Singapore who are able to offer the latest generation of Motiva implants for breast reconstruction if requested. Dr Yeo is also familiar with the various different flaps used for breast reconstruction and is able to deliver attractive and bespoke results.