Plastic and reconstructive surgery

When a patient needs to undergo some form of tumour excision, which will alter the appearance of the breast, she may wish to consider surgery to restore breast symmetry, or to fully reconstruct her breast in the case of mastectomy.

There are an array of procedures, which are available to work towards this ultimate aim of achieving symmetry of good breast shape with a desired breast volume:

• Breast Reconstruction
• Breast Reduction
• Breast Augmentation
• Mastopexy (breast lift)
• Nipple/areola reconstruction

Within each of these groups of procedures there are a number of alternative techniques which a Plastic surgeon would discuss with you, bearing in mind other factors such as your health, age, work, lifestyle, sporting/recreational activities, to help select an appropriate surgical plan. This may provide the opportunity to alter the final size and shape of your breast to suit changes previously considered but not acted upon. For example, the reconstruction of a smaller breast after mastectomy, with reduction of the other breast for symmetry.

Breast Reconstruction

The essential aim of Breast reconstruction is the restoration of whatever volume of breast tissue has been lost, and the replacement of the skin envelope where required. Immediate reconstruction at the time of mastectomy, where appropriate within the overall plan for disease management, offers the advantage of frequently preserving the natural breast skin envelope.

The volume of the breast is restored either by the transfer of the patient’s own fat tissue, or by the use of a breast prosthesis, or by a combination of the two. Procedures involving the transfer of the patient’s own tissue are typically a little more complex, but have the advantage of reconstructing a soft, warm, pliable breast of quite natural texture, and which ‘moves’ in the same way as a normal breast. The tissue most frequently used in this fashion is the TRAM flap – redundant fat and skin from the lower abdomen, below the level of the navel, transferred with a very small piece of abdominal muscle, which carries a blood supply. This technique has become popular over a period of almost 20 years, partly because it incorporates a tummy tuck as the repair of the abdominal donor site, leaving a scar hidden by most underwear and swimming costumes.

Other donor areas do exist, including buttock, hip and thigh, but have more obvious scarring and a higher surgical complication rate.

Where an implant is utilized, it may be filled either with saline or cohesive silicone gel. Unlike TRAM flaps, implants do not inherently bring adequate skin cover with them, and so must be paired with a surgical technique to provide adequate cover. This is most commonly achieved either by tissue expansion techniques, or by the simultaneous transfer of a latissimus dorsi flap, muscle/skin and fat from the back.

Further information beyond this brief introduction may be obtained by visiting the website of The Australian Society of Plastic Surgeons (ASPS) listed on the “Links” page.

Autologous or “Flap” reconstruction	Reconstruction with a Tissue Expander	Mastectomy

Breast Reduction/Augmentation/Lift

These adjunctive procedures, which alter the appearance of the breast, may help achieve symmetry in a number of different circumstances. Following a partial mastectomy for example, symmetry may be improved by either augmenting the remaining breast volume, or possibly reducing or lifting the other breast. Following complete mastectomy, a woman may choose to have a different sized or shaped breast reconstructed, where it is possible, and have the other breast modified accordingly. Clearly these procedures are available to women who have not had breast disease as well. Again more information is available from ASPS, or by consultation with your Plastic surgeon.

Nipple/Areola Reconstruction

Nipple and/or areola reconstruction is usually performed a number of months after breast reconstruction, to allow all swelling to have resolved, and to facilitate correct assessment of the position for the nipple.

A variety of techniques are available according to the shape and size of the normal nipple/areola, and will frequently employ a combination of surgery and medical tattoo. This surgery is usually performed on a day stay basis, under local anaesthetic.

Diagramatic Representation of Reconstruction Using a Tissue Expander:

	A tissue expander is inserted following the mastectomy to prepare for reconstruction.
	The expander is gradually filled with saline through an integrated or separate tube to stretch the skin enough to accept an implant beneath the chest muscle.
	After surgery to position the implant, the breast mound is restored. Scars are permanent, but will fade with time. The nipple and areola are reconstructed at a later date
	With flap surgery, tissue is taken from the back and tunneled to the front of the chest wall to support the reconstructed breast.
	The transported tissue forms a flap for a breast implant, or it may provide enough bulk to form the breast mound without an implant.
	Tissue may be taken from the abdomen and tunneled to the breast or surgically transplanted to form a new breast mound.