Breast Reconstruction Surgery

Women are the backbone of today's society. They are the centre around which the whole family runs. From going through pregnancy, giving birth to children, waking up at odd times to feed the child, tolerating all the pranks of the children, feeding them what they like, teaching them after they come back from school women are really busy in taking care of the family. In addition, they excel in reading, work and are an important earning member of the family. Juggling between work and family is never easy and they do it very well everyday. They are also the stars of today's society hitting the headlines for their accomplishments.

Immediate Reconstruction

For women, the most common cancer is breast cancer. It accounts for around one-third of all the cancers (Fig 1). The incidence of breast cancer is increasing day by day which is shown in Figure 2 where the incidence of breast cancer is increasing in all the cities in India. Due to the changing lifestyle, it now affects younger people than before. 25 years back, breast cancer was affecting women predominantly above 50 years. Now, there is a significant amount of women who get breast cancer in their 30s and 40s which is the age where they are building up their careers and looking to have a good social life. As part of the treatment, a lot of women have their breasts removed. With advances in medicine, the average 10-year survival rate of breast cancer is around 83% depending upon the stage of presentation. Many women beat the disease and want to forget it. But each time they see the mirror they get reminded of it. They are not able to wear clothes of their choice. They get noticed when they go for public functions and women are very conscious of this throughout their lives.

This can be a thing of the past. While removing the breast cancer, the breasts can be reconstructed in the same operation to remove the breast (Mastectomy) or even later. We prefer to reconstruct breasts in the same operation as the mastectomy due to the following reasons

• Women wake up with the breast and they never feel sad or depressed that they don’t have a breast any time
• It is all done in the same operation. A lot of women just want to get it done all at once
• Reconstructing the breast at the same time allows us to preserve the shape of the breast as well as the skin over the breast which can make the breast look better than when done later
• The flaps take radiotherapy well

The drawback of doing the reconstruction at the same time as the mastectomy is that it may take an additional 2 hours for surgery. With modern good anaesthesia techniques and experienced anesthesiologists, immediate breast reconstruction at the same time of the mastectomy is the standard of care worldwide.

Delayed Reconstruction

Some women might have had their breast removed and not reconstructed either due to ignorance or personal preference. They might have had their radiotherapy as well. Breast reconstruction can be done for these women as well. By using autologous reconstruction with the patient’s own tissue, it not only gives them the aesthetic breast but also give them additional skin from the abdomen which replaces the skin on the chest which was affected with radiotherapy.

There are several ways to do breast reconstruction. The surgeon would have to decide according to each woman based on the need for radiotherapy, comorbidities of the patient, previous surgeries underwent by the patient, availability of tissue in the patient and the patient’s own expectations. It is also important that the surgeon chooses a method with the least complications as this will delay radiotherapy and chemotherapy for breast cancers. Accordingly, breast reconstruction can be broadly divided into

• Autologous Reconstruction
• Reconstruction with Implants
• Combination of Autologous Reconstruction with Implant Reconstruction

Autologous Reconstruction

In this method, the patient’s own tissues are taken along with its blood supply and connected to the blood vessels in the chest or in the armpit to make a new breast. Depending on where the patient has enough tissue we choose that area for our reconstruction. The tissues can be taken from

• The lower abdomen ( DIEP flap)
• The Inner thigh (TUG Flap)
• The lower Back (LAP flap)
• Latissmus Dorsi Flap (LD Flap)

Advantages of Autologous Reconstruction

• As the patients own tissues are used the breast has the same texture as that of the breast
• The breast will have a natural droop and will mirror the other breast while ageing
• Both breasts will gain and lose weight and change shape over time as the other breast
• The finished appearance of the breast will look better with time
• Autologous reconstruction can withstand radiotherapy better
• By taking tissues from the abdomen, inner thigh or the lower back the patient often looks better

Disadvantages of Autologous Reconstructions

• Takes longer time to do the surgery compared to implant reconstruction
• Surgery is done in another area of the body and leads to additional scars

Advantages of Implant Reconstruction

• Takes shorter time to do implant reconstruction
• No additional scars on the body

Disadvantages of Implant Reconstruction

• Implants do not stand radiotherapy well and have high complication rates such as infection and implant extrusion with radiotherapy
• As the implant is covered only by the skin and muscle, the breast may feel different compared to using your tissue
• The breast reconstructed with an implant will not droop will not droop in proportional to the other chest resulting in breast asymmetry with time
• The breast reconstructed with an implant will not add or lose weight corresponding to the other breast.
• Over time a scar forms around the breast implant which may contract, make the breast look more spherical, feel harder and in some patients may even cause pain. This is called capsular contracture. Hence patients may opt to replace their implants with time
• Breast implants may be associated with other complications like rupture, rippling, infection and animation deformity which may necessitate change of implants

Once the breasts have been reconstructed the patient finishes the rest of the treatment like chemotherapy and radiotherapy. If the patient desires nipple reconstruction can be done under local anaesthesia as a day case. Medical tattooing is done to recreate the areola.

Breast reconstruction definitely makes women feel better compared to those women without reconstruction as they can get into clothes of their choice, socialise with people better, don’t get noticed when they go out, don’t get repeatedly asked about it and face the world with much more confidence.