BOOK CONTENT

Contents

Contributors

Professor Andrew Baildam BSc Hons MBChB MD FRCS FEBS

Consultant Oncoplastic Breast Surgeon, King Edward VII’s Hospital, Beaumont Street, London W1G 6AA, UK.

Mrs Natalie Chand MBBS FRCS

Consultant Breast Surgeon, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Winchester SO22 5DG, UK.

Mrs Clare Clayden-Lewis RN Dip H.E Nursing Studies

Macmillan Senior Clinical Nurse Specialist, Hampshire Hospitals NHS Foundation Trust, Winchester SO22 5DG, UK.

Miss Lorna Cook BA (Hons) MBBS FRCS

Consultant Breast Surgeon, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing BN11 2DH, UK.

Professor Michael Douek MD FRCS

Rosetrees RCS Director of the Surgical Interventional Trials Unit; Professor of Surgical Sciences and Breast Cancer, Nuffield Department of Surgical Sciences, University of Oxford; Honorary Consultant Surgeon Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK.

Professor Diana M. Eccles MD FRCP

Dean of the Faculty of Medicine, University of Southampton, Level B, South Academic Block, Tremona Road, Southampton SO16 6YD, UK.

Mrs Catriona Futter BSc MPhil MCSP

Senior Physiotherapist, Physiotherapy Department, Canniesburn Plastic Surgery Unit, Jubilee Building, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK.

Professor Diana Harcourt BSc MSc PhD CPsychol

Professor of Appearance & Health Psychology, Centre for Appearance Research, University of the West of England, Bristol BS16 1QY, UK.

Associate Professor Susanna Kauhanen MD PhD

Chief Physician, Senior Consultant, Helsinki University Hospital, Department of Plastic Surgery, Jorvi Hospital, POB 800, SF-00029 HUS, Finland.

Ms Siobhan Laws MBBS FRCS DM

Consultant Breast Surgeon, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Winchester SO22 5DG, UK.

Miss Mary Morgan BSc MBBS FRCS Plast

Consultant Plastic and Reconstructive Surgeon, St Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, UK.

Ms Barbara Parry MSc

Senior Research Dietitian, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Romsey Road, Winchester SO22 5DG, UK.

Ms Sophia Pope-Jones BA (Hons) MBBS MRCS FRCS Plast

Consultant Burns and Plastic Reconstructive Surgeon, Morriston Hospital, Swansea SA6 6NL, UK.

Mr Dick Rainsbury MBBS BSc MS FRCS

Consultant Breast Surgeon, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Winchester SO22 5DG, UK.

Professor Venkat Ramakrishnan MS FRCS

Consultant Plastic and Reconstructive Surgeon, St Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, UK.

Miss Pankaj G. Roy MBBS FRCS MS MD

Consultant Oncoplastic Breast Surgeon, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford OX3 7LF, UK.

Mrs Diana Slade-Sharman BSc (Hons) MBBS FRCS Eng MSc

Surgical Sciences FRCS Plast, Consultant Plastic and Reconstructive Surgeon, Department of Plastic Surgery, Salisbury NHS Foundation Trust, Salisbury District Hospital, Salisbury SP2 8BJ, UK.

Mrs Rosie Stanton MA Cantab, MBBS FRCS Eng

Consultant Breast Cancer and Breast Reconstruction Surgeon, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Winchester SO22 5DG, UK and Basingstoke and North Hampshire Hospital, Basingstoke RG24 9NA, UK.

Dr Philippa Tollow BSc MSc PhD CPsychol

Research Fellow, Centre for Appearance Research, University of the West of England, Bristol BS16 1QY, UK.

Dr Raghavan Vidya MBBS MD MS FRCS

Honorary Senior Lecturer, Birmingham University, Consultant Oncoplastic Breast Surgeon, Royal Wolverhampton NHS Trust, Wolverhampton WV10 OQP, UK.

Acknowledgements

We would like to thank many people for their encouragement and support throughout the production of the second edition. Our special thanks go to Virginia Straker, our Breast Care Nurses, and all those patients who have been prepared to share their very personal experiences to help others facing similar life-changing decisions. Also to Eva Weiler-Mithoff for her contribution to Chapters 6 and 7. Finally, the whole project including free online access would not have been possible without the very generous sponsorship of The Winchester Cancer Research Trust (Registered Charity 1003252).

Chapter 1

Breast Reconstruction: Your Choice

Dick Rainsbury

  • Today if you need a mastectomy, your breast can be rebuilt to make it look just like the one you’ve lost.
  • Having your breast reconstructed at the same time as your mastectomy is often the best option.
  • With some types of breast cancer, it’s better to delay reconstruction until all your treatment is finished.
  • This book is based around the experiences of more than 60 women who made their own choice about breast reconstruction.

Hundreds of women in the UK are told every week that they need a mastectomy. They are faced with a scary and unfamiliar world, filled with doubts and uncertainties and a fear of the unknown. Scores of questions rush to mind. How bad is the cancer? Will I live? Will it be painful? Will I need chemotherapy? What about my family and my children? Have I passed it on? What about my other breast? How long will I have to wait? Why me?

And then as the word ‘mastectomy’ sinks in, other thoughts start flooding in. Is it that bad? Must I really lose my breast? How will it feel? Will people know? Will I ever look the same again?

This book is based around the very personal experiences of more than sixty women, from five major centres in the UK. They faced mastectomy and chose to have a breast reconstruction – an operation to rebuild the breast and replace what disease and surgery have taken away. Their own words are used to track a journey starting from the moment of diagnosis through to surgery and finally on to full recovery. It is hoped that by following their journey the reader will be helped to understand the steps along the way and to ask the most important questions at each stage of their treatment. We’ve recently interviewed some of our patients almost ten years after their surgery to get an idea about the longer-term effects of reconstruction.

What is breast reconstruction?

What does breast reconstruction mean? How can an organ as complicated as the breast be recreated and when can this be done? These are key questions that often go unasked and unanswered because those looking after you may think you know the answers already – but very often you don’t. Put simply, breast reconstruction is an operation in which the breast that has been taken away is replaced with something that looks like the real thing. With modern techniques surgeons can make a new breast that looks extremely lifelike – so much so that you may have to look very hard indeed to spot the difference. This is because some patients have their whole breast removed through such a small cut around the nipple that the surgeon can rebuild the new breast inside the natural skin pocket. This can leave just a tiny and almost invisible scar around the edge of the nipple (Figure 1.1).

But not every patient is suitable for this approach. The final appearance of the new breast will depend on many factors, including the type of mastectomy, the length of the scars, the type of reconstruction, the skill of the surgeon and whether your reconstruction is done at the same time as your mastectomy. And even though the breast may look normal, it won’t feel like a normal breast, it won’t work like a normal breast and it won’t even move like a normal breast. Depending on what kind of reconstruction you chose, the new breast will usually feel numb in the middle. This feeling is most intense in the early weeks after surgery, but gradually some of the sensation returns as the nerves grow back, starting around the edges of your new breast. Your new breast may also feel colder than the other side, particularly after a swim in cold water.

Figure 1.1 – Right mastectomy and reconstruction with tummy tissue leaving invisible scars.

Often the nipple will be removed and although it can be reconstructed, it won’t have any sensation and won’t respond to stimulation. Because all the glandular tissue has been removed, it won’t change with the menstrual cycle, it can’t make milk, and it may not change shape in the same way as your remaining breast as you get older. But your new breast will look normal to those around you. If the very latest techniques are used you’ll be able to feel confident wearing a low neckline, a swimsuit or even when topless. For many women, this is a big improvement to the alternative – a mastectomy scar and an external prosthesis. For others, the extra surgery, longer recovery and the higher risk of complications are too great a price to pay. They may decide that reconstruction is not for them.

One of the most important unasked questions about breast reconstruction is ‘When can it be done?’ All too often you don’t think about asking or don’t know about the possibility, and there are so many other important things going through your mind before you have to come in for surgery. It’s just one question too many. But if you’re interested in reconstruction, the time to ask your surgeon and your team is before you have your mastectomy. This is because it may be possible to rebuild your breast at the same time as your cancer surgery is carried out. This will depend on so many things – your choice, your health, your tumour, your surgeon and the type of treatment planned after your operation. But if you don’t ask the question, you may simply miss a big opportunity to have this type of surgery. And by having your breast reconstructed during your mastectomy operation (immediate breast reconstruction), you’ll cut down on the number of operations, the length of your convalescence and time off work. And you’ll also avoid much of the distress experienced by women who lose a breast without reconstruction (Figure 1.2).

But not every patient is suitable for immediate breast reconstruction. Even those who are may find it difficult to make a decision in the few days between hearing the diagnosis and their admission to hospital for surgery. Other patients may be referred to units that are not able to perform immediate breast reconstruction – as a result, they may choose to put off a decision until their treatment has been completed (Figure 1.3).

This book has been written with one aim in mind – to explain your options and to provide accurate, up-to-date information and advice to steer you through the increasingly bewildering world of breast reconstruction. The time, effort and personal accounts provided freely by so many women in the following pages are a testimony to the increasing importance of breast reconstruction to women in the UK today. The editors would like to thank all of these women, and also those who have given permission to have their photographs included throughout the book.

Figure 1.2 – Left mastectomy and immediate reconstruction with tissue from the back. Patient deciding whether to have her nipple reconstructed.

Figure 1.3 – Right mastectomy and delayed reconstruction with tissue from the back together with an implant. The left breast has been reduced, giving a balanced result.

Chapter 2

Mastectomy without Reconstruction

Natalie Chand

  • Many women opt not to have their breast reconstructed after mastectomy, for a number of reasons.
  • Your breast care nurse will be able to provide practical advice to help you feel more confident after your operation, as well as information about bras, prostheses, clothing, exercises and recovery.
  • You may find it helpful to get first-hand information from other women who have had a mastectomy.

Breast reconstruction isn’t right for everyone, and this chapter will discuss mastectomy without reconstruction – often called a ‘simple mastectomy’. We’ll also cover what to expect when choosing this type of surgery and your recovery.

About mastectomy

The aim of a mastectomy is to remove all of your breast tissue, together with some of the skin covering your breast, as well as your nipple. A simple mastectomy may be recommended to treat your cancer for a number of reasons – here are a few:

  • If your cancer lies behind your nipple, it may be affected and safer to remove it
  • If you have very small breasts, where a ‘lumpectomy’ would not leave an acceptable shape or size
  • If your cancer occupies a considerable amount of your breast
  • If cancer has developed in more than one area of your breast
  • If you’ve had a cancer in the same breast before, and have developed a recurrence
  • If you’ve decided that a mastectomy is the best option for you, after discussion with your surgeon and breast care nurse
  • When ‘lumpectomy’ and radiotherapy isn’t the best option for you because you are physically disabled or have a medical condition making radiotherapy difficult or risky.

What are the benefits?

  • A mastectomy removes as much of the breast tissue as possible and reduces the risk of cancer coming back in the same area
  • In most cases, having a mastectomy means that radiotherapy (x-ray treatment) after surgery isn’t necessary. The need for radiotherapy can only be confirmed with the detailed results of your tissue analysis, at your post-operative clinic visit.

   I was 50 when I chose to have a mastectomy, rather than a lumpectomy and radiotherapy. I did not know anyone who had had breast cancer before, so I had no pre-conceived ideas. My decision was made partly because I did not want to have radiotherapy but also because I thought I didn’t have the need for the breast anymore. I just wanted to get rid of it and get on with life. Breast reconstruction was mentioned to me but I was quite happy not to have it. The loss of a breast did not concern me…my husband was very happy to go along with this decision.   

The surgery

The operation is performed under general anaesthetic, and usually lasts 1–2 hours. Sometimes, a drain (plastic tubing) is placed during surgery, which comes out below the wound (Figure 2.1). You can usually go home with your drain in place, and you’ll be given advice about when it‘s removed.

Figure 2.1 – A right mastectomy scar.

Problems that can occur after mastectomy

All operations involve risks, and knowing about these can help you to make informed decisions about your surgery.

  • Healing: The edges of your mastectomy wound may not heal properly because of problems with the blood supply. If this happens the edges may become inflamed, forming a scab which often needs to be dressed for a few weeks.
  • Cosmetic result: At the end of the operation, a straight or slightly curved scar is left on your chest. The exact direction of this scar may depend on where the tumour is, but the most common scars are horizontal or diagonal (Figure 2.1). They are usually placed within the bra line so they’re not visible when you’re wearing clothes. If you want to see some other pictures or photos of mastectomy scars before your operation, do ask your breast care nurse or surgeon to show you some. Scars may be raised, red or swollen at first, but should gradually settle and will fade over time. Many women need to pluck up courage to look at the scar. Take your time – wait until you feel ready to do so. Sometimes you’ll find some fullness or lumpiness at the outer edge of the scar under the armpit. This may settle over time, but occasionally this ‘dog-ear’ of extra tissue may need a minor operation to remove it at a later date.
  • Infection: Any operation site can become infected and this uncommon problem usually becomes evident about a week after mastectomy. The wound becomes red, swollen and tender. Treatment is often just with antibiotics, but occasionally the infection needs to be drained in the operating theatre.
  • Bleeding: Your surgeon always makes sure that bleeding has stopped during the operation, but occasionally it starts afterwards, causing blood to collect in the wound. This is called a ‘haematoma’, and usually develops within a few hours. If it builds up it may need to be drained by a second procedure.
  • Pain: When you wake up your chest may be pain-free because local anaesthetic is often used during the operation. When this wears off, you’ll need painkillers both in hospital and at home. Later, you might have tingly feelings or shooting sensations where the breast was removed. This can last for six months or longer, and the skin next to the scar usually feels somewhat numb.
  • Seroma: It’s not unusual for fluid (clear or pink-stained) to collect underneath the mastectomy scar and produce a swelling called a seroma. This usually doesn’t cause too much discomfort, but if it does, it may need to be drained using a needle and syringe in the clinic or with the breast care nurse.

The other breast

Some women who are having a mastectomy wonder whether they should have their unaffected breast removed as well. This isn’t usually necessary or recommended, unless there’s a higher risk of developing breast cancer on the other side – for example if you’ve got an altered gene or a very strong family history of breast cancer. It’s important to discuss your individual risk with your surgeon.

Recovery

It’s becoming increasingly common to go home later the same day after mastectomy, but a few patients need to stay longer on the advice of the medical team. The day after your operation, you’ll be more or less independent and able to get out of bed, but it will take approximately 4–6 weeks for you to recover fully.

   I went home five days after the operation with the drain still in. Once the drain was removed, I did have some serous fluid collecting under the scar but after having it drained once, it dried up. I could do quite a lot when I got home.   

   I wasn’t in a lot of pain after the operation, although the drain was a bit sore. I went home after two days with a drain in and it was a relief when that was taken out. I felt a bit wobbly when I first got home.   

   I went home the day after the operation with a drain in and it does take a while to recover physically. We went on holiday in France after a couple of weeks and I spent that time recuperating. I was going through the psychological aspects of it and it was lovely to have the family to support me. Having children to distract me was probably the key to getting back to normal.   

You’ll be shown some arm exercises to help your recovery and prevent your shoulder from getting stiff. It’s important to do these regularly, and it’s helpful to carry on doing them long after the wound has healed and you’ve finished all your treatment. This gives you the best chance of full recovery of arm strength and movement.

   My arm was easy to move at the beginning but as the tissues healed, it tightened up and I had to do the exercises. Sometimes you wonder whether it will ever move properly. The numbness around the scar and back doesn’t actually go. It can just feel odd and uncomfortable.   

Returning to work

Everyone needs time off to recover after an operation, but getting back to your normal routine when you’re physically and emotionally ready for it can actually help you recover more quickly. There aren’t any rules – every person recovers differently and has different needs.

How quickly you return to work very much depends on a number of things:

  • Whether you need further surgery or other treatment such as chemotherapy or radiotherapy
  • How you heal
  • How you respond to surgery
  • The type of job you do
  • Whether you are psychologically ready to go back to work.

You’ll return to the clinic to see the surgeon and breast care nurse for your histology (cancer) results. Any further treatment recommended may influence how quickly you can return to work. Some women decide to remain off work for the full duration of treatment. Others try to do some work between treatments, or to visit work and keep in touch with work friends and colleagues. This may help to maintain your confidence and make returning to work easier. Ultimately, it’s your decision when you decide to go back, but listen to the advice offered to you.

   I went back to work after five months and worked part-time for the first two months. At first I felt as though I wasn’t up to speed with the work. It is a year since the operation and I am happy and comfortable with it. It is part of how things are and that is it. I have achieved my aim of going back to work and getting on with life. I do have times when I feel down about it but would not want reconstruction now because I would rather avoid operations if possible.   

   My work involves looking after horses and I went back to riding after five weeks. I felt as though I had freedom again. It is now three years since the surgery and I can do everything.   

Things that will help you recover more quickly

  • Eat healthily: A healthy balanced diet will help to ensure that your body has all of the nutrients it needs to heal.
  • Stop smoking: By not smoking you immediately start to improve your circulation and your breathing.
  • Family and friends: Family and friends can give you help with things you might temporarily be unable to do while you recover – such as driving, cleaning, the weekly shop or lifting heavier items. They are also there for emotional support. Sharing your concerns with close friends and family can help your recovery.
  • Exercises: You’ll be given information about shoulder exercises before your operation – these will stop your shoulder getting stiff. It’s important to continue these at home until your mobility is back to normal.
  • Build up gradually: Have a go at doing some of the things you’d normally do, but build up gradually. Everyone recovers at a different pace, so listen to what your body is telling you. As you build up your activities, you may feel more tired than normal. If so, stop and rest until your strength returns. If you feel pain, you have probably just overdone it a little. Ease back and then gradually increase again.
  • Driving: Let your insurance company know about your operation. There are no hard and fast legal rules about when you can drive after a mastectomy, and some patients may be fit to drive earlier than others. It’s important to follow your doctor’s advice, and the views of your insurance provider. Before driving, you should be comfortable in the driving position and able to control your car safely. You’ll need to be fully recovered from your operation, and able to concentrate free from the distracting effects of pain and the sedative effects of pain-relieving medication.

Breast prostheses

There are several practical ways to help you feel more confident with your new appearance. These include having a suitable, well-fitted and pretty bra, having a well-fitted prosthesis, and making adjustments to your clothes if necessary.

A prosthesis is a synthetic breast form that will fit into your bra cup to replace either the whole breast or part of it. They’re mostly made from silicone gel, which has an outer film cover, and come in different weights, sizes, shapes and skin tones. When you go home, you will be given a temporary light-weight breast shape – an external prosthesis (a ‘softie’ or ‘comfy’) to wear in your bra. This is very light so will not put pressure on your wounds, but don’t worry if you’d prefer not to wear a bra at this stage; do this when you feel comfortable and ready.

You’ll be offered a longer-term prosthesis about 6–8 weeks following surgery, once your mastectomy wounds are fully healed (Figure 2.2), This will usually be fitted by one of your breast care nurses.

Figure 2.2 – Examples of commercially available breast prostheses.

Making some adjustments to the type of clothes you choose can help your confidence early on:

   I work in a university and have to give presentations. I remember giving the first one after going back to work and being very aware of myself. I was standing up in front of a group of people when I was just getting used to wearing a prosthesis and wondered whether it looked right. I was not worried if somebody asked me about the mastectomy but did not want to draw attention to myself. I bought a lot of jackets in the first year because I was always worrying about whether the prosthesis would slip down or somebody would notice if there was a problem. The jackets helped my confidence and as I got more comfortable, I changed the type of prosthesis. It takes time to get used to it and find what is right.   

Getting the right bra

You may be asked to bring a soft non-wired bra to hospital for use after your operation. One of the ways women tell us they feel more confident after mastectomy is wearing a bra that feel comfortable and fits well with a prosthesis, making your chest look symmetrical when dressed (Figures 2.3 and 2.4).

Your bras may already be suitable – the best way to check is to show one to your breast care nurse when discussing the operation.

It’s quite possible to wear bras and swimwear bought from high street shops, looking out for these features in particular:

  • A full cup, which will cover the prosthesis
  • A firm or elasticated top edge to the cup to hold the prosthesis in place
  • Making sure the side of the bra under your arm is deep enough
  • At least two hooks to fasten the bra, with more for larger sizes
  • Straps that aren’t too thin
  • A bra that separates your breasts between the cups.

Figure 2.3 – Appearance undressed after a mastectomy.

Figure 2.4 – Appearance of a prosthesis in a correctly fitting bra and clothes.

You should always ask to be measured before buying a bra. Assistants in lingerie departments or specialist underwear shops have often been trained to measure for bras after mastectomy, and will understand your concerns. Ask your breast care nurse to recommend the best shops in your area.

Some women prefer to buy specially designed mastectomy bras, swimwear and accessories. These can be purchased online from mail-order companies or by visiting their shops. The main advantage of these is that they already have pockets sewn into the bra cup that hold the prosthesis securely.

   I bought mastectomy bras through mail order and had no problem wearing the comfy initially. It looked very similar to the other breast. I felt pleased when I first put the heavy prosthesis on because I felt normal again. I have pockets in my bra and have no problems with any activity, including riding. Communal changing rooms do not concern me at all. To my mind, that is somebody else’s problem. I wear a mastectomy swimming costume, which is fine.   

   I wear mastectomy bras with pockets. This year, for the first time, I feel quite confident and do not really think about it anymore. When I go running, I wear a loose T-shirt and a sports bra without a prosthesis. Prostheses get a bit hot and sweaty when you run. I don’t swim a huge amount but, after talking to a friend who also had a mastectomy, I don’t wear a prosthesis. Because I am small, if I wear a swimming costume with an insert bra which is quite stiff, I can get away with nothing inside it. My fear is that I don’t want to embarrass anyone else.   

Some women choose to sew pockets into their bras themselves. If you want to try this, choose a stretchable material to sew across the back of the cup, allowing a gap at the side to insert the prosthesis. Make sure the bra cup is not pulled too tightly, because this might distort the shape of the bra.

Psychological recovery and feelings about your appearance

We all feel differently about our bodies and what they look like after an operation. There is no right or wrong way to feel after a mastectomy, as everyone is an individual. Talk about your feelings to your friends, family or partner so they can support you. Psychological help is also available from the breast care nursing team.

   Your own feelings about body image are important. I am lucky enough to be quite confident about my body image. Having a big bust is not going to change my life. I have had a very good life and my partner is happy. I know that people have partners for whom this is very important and then it would have to be taken into account.   

   I wasn’t too worried about the appearance of a mastectomy because I have always been fairly flat-chested and worn padded bras. My husband wouldn’t have married me if he had wanted someone with big breasts. The fact that I had seen my colleague coping with a prosthesis also helped me to decide. I was told that I could always have a reconstruction later if I wanted one.   

Before your operation, do take the time to talk through your operation with your breast care nurse. She’ll be able to give you a realistic idea of what to expect in terms of length of time in hospital, scarring, and how long you’ll need to recover afterwards depending on your lifestyle. She’ll also be able to show you photographs of someone who’s had a mastectomy, advise you about suitable bras and show you a prosthesis if you’d like to see one.

Another way of gaining first-hand information, support and tips, is to ask your breast care nurse to introduce you to someone else who’s already had this operation. Although no two experiences will be exactly the same, someone who’s been through this already will understand how you may be feeling. They can help talk through your concerns as well as tell you how they coped, showing you that it’s possible to recover very well afterwards. Of course, it’s also fine if you’d prefer not to talk to others.

   I am the fifth teacher in my school to have been diagnosed with breast cancer in the past four years. We have all had different treatments and when I was told that I needed a mastectomy, I knew about my colleagues’ experiences. You never think that it will happen to you. I was told that I could have a breast reconstruction if I wanted. The fact that I had seen my colleague cope with a prosthesis also helped me.   

   I did not meet anyone who had a mastectomy before the operation because I didn’t want anyone else’s experiences. I could then cope with it my way.   

One of the most daunting things to face is looking at your new appearance and coping with your reaction. It’s often helpful to do this for the first time while you’re still in hospital. That way, if you want to, you’ll have the help and support of the breast care nurses and the nurses on the ward.

   I remember, in the days leading up to the mastectomy, treasuring my left breast a little bit. I thought that I should make the most of it because it was going.

I had to be brave to look in the mirror for the first time after the operation, but I made myself do that quite early on. I tried to feel interested in the operation scientifically to distract myself from self-pity. I thought that it was amazing that they had stitched me up like that and thought that it was OK. I showed my husband straight away and we got over that hurdle.

Over the subsequent three years, I still catch myself in the mirror and I am quite surprised. I am not sure you really get used to it. If I walk down the street, I see people with a lot worse wrong that is obvious, so I can’t really complain about it.   

Whether you choose not to have a breast reconstruction or are advised against it, it’s possible to live successfully with a mastectomy. Your breast team are there to support you, both practically and psychologically. Please remember, each woman’s recovery will be different. Here are some final thoughts about having a mastectomy:

   I think that it is very important to be open and talk about the mastectomy. I talked with my husband a lot. I did joke with very close friends and a sense of humour helps. It’s good to take each day as it comes, be positive and do the exercises. It is important to get on with it because you have been given another chance.   

   Having got myself so that I am comfortable, I don’t particularly want the body change that a reconstruction would bring. I am also scared of playing about with what I have got. I have got one breast that is fine and I would not want to end up looking at it and thinking that actually I prefer what I had before.

Some good things have come out of having a mastectomy. It has made me very aware and empathetic. The really nice thing that I have learned is that I thought when you have something bad happen to you, you would probably never feel like a nice young carefree person again. You can come out of it and begin to feel your old bubbly self again. It takes time, but as long as you let yourself go with the flow, things improve. Don’t expect too much too soon.   

Chapter 3

What is Breast Reconstruction?

Dick Rainsbury

  • Choosing breast reconstruction is a very important decision to make.
  • It can be done straight away or later if you can’t decide.
  • Get all the advice you can before making up your mind.
  • Don’t go ahead if you’re not certain.
  • A reconstructed breast matures over months and sometimes years.
  • Reconstruction often requires more than one operation.

People talk about breast reconstruction, but how on earth can you rebuild such a complicated part of your body? Today there are many different techniques to rebuild a breast that is soft, that moves and looks like the real thing. But it’s usually quite numb, especially around the nipple and the middle part of the breast. So it may look almost exactly like your other breast, but it’s only a replica – it’s not the real thing. Nevertheless, most women with a reconstruction enjoy normal lives without having to restrict what they wear, the sports they enjoy, or their personal relationships. This is because their new breast becomes accepted as part of their own body, just like the breast that was taken away.

Choosing whether you’re going to have a breast reconstruction is an important decision. You’ve already just been told you need a mastectomy, and maybe a range of other treatments such as chemotherapy, hormone therapy, and radiotherapy. In almost the same sentence, the surgeon talks about breast reconstruction and rattles off a variety of options, using words you’ve never heard of before. You’re anxious and confused. Too much information, too many decisions, too little time. You forget to ask the important questions and before you have time to think, you’re sent off to see the breast care nurse. She gives you all the information all over again, and lots of leaflets and booklets to take away.

When you get home, you realise you’ve forgotten almost everything they said to you. You need answers to important questions. When can it be done? What will it be like? Am I the right person for reconstruction? Will it affect my cancer? Is this a once and for all operation? What are my options? What about the other breast? Is my surgeon experienced?

Let’s stand back and take a good long look at these very important questions and concerns to try to help you to understand more about breast reconstruction. Then you’ll be in a better position to make a decision that is right for you and for those close to you.

When can it be done?

There are two main choices when deciding about the timing of your breast reconstruction. You can have it done at the same time as your mastectomy or partial mastectomy – this is called ‘immediate’ breast reconstruction. Or you can have your breast rebuilt months or years after your mastectomy – called ‘delayed’ breast reconstruction. If your surgeon recommends that only part of your breast is removed and that the gap left behind should be reconstructed, you may be told that it is better to wait for the pathologist to check your tumour before the gap is rebuilt a few days later. This is a type of immediate breast reconstruction that is becoming much more popular today.

So why don’t all women who want breast reconstruction decide to have this done at the same time as their mastectomy – surely this is better all round? This is a really key question, which leads to many other questions you’ll want to ask. But you won’t be able to make an informed decision until you’ve had a chance to look at all the arguments.

When you have a mastectomy, you have three choices to make about breast reconstruction – should you have it straight away, should it be delayed or should you have it at all? So let’s have a good look at the main advantages and disadvantages you need to know about to help you make your mind up.

Choosing immediate breast reconstruction

Advantages

  • Your breast is removed and reconstructed all at the same time, so you avoid the trauma of losing your breast.
  • You avoid having to have two major operations, as they are both carried out by one or two teams of surgeons under the same anaesthetic.
  • You have one visit to the hospital, one anaesthetic, one period of recovery and less time off work.
  • You avoid the anxiety and inconvenience, and the discomfort and disability of two operations.
  • Your scars are usually much smaller and can be hidden away more easily.
  • The appearance of your breast is more natural as nearly all of the skin that covers your breast can be saved. This helps the surgeon to shape your new breast, like ‘putting jelly back into a jelly mould’.
  • It’s much easier for your surgeon, who is able to plan and integrate the removal of your cancer and reconstruction of your breast at the same time, giving you the very best chance of a good cosmetic result.
  • It’s much easier for your partner, family and friends. They don’t have to worry about you having another operation hanging over your head as you would if you decided to have a delayed reconstruction.

Disadvantages

  • You have lots of other things on your mind and may find it very difficult to make such a big decision in a very short timeframe – often just a couple of weeks.
  • You’re naturally upset about your diagnosis and can’t think straight.
  • You don’t have a chance to experience what it’s like without a reconstruction, to help you decide if you really want to have this further surgery.
  • You’ll be having more major surgery, with a longer anaesthetic and the risk of more complications.
  • Your recovery will also take longer than after a straightforward mastectomy.
  • If you develop complications, any chemotherapy or radiotherapy treatment that your doctors may recommend may be delayed – although the chances of this happening are very small.
  • If your doctor decides you need radiotherapy treatment, this can affect the softness and shape of your new breast. One of the problems is that it isn’t always possible for your team to know if you are going to need to have radiotherapy until after you’ve had your mastectomy and they’ve had a chance to examine all your tissues.
  • Unless you’re having a mastectomy for ‘pre-cancer’ (ductal carcinoma in situ, or DCIS), there is always a slight chance you’ll need radiotherapy. More often than not, your team will have a good idea if radiotherapy is going to be needed after your surgery. If so, they are likely to advise you that having a delayed reconstruction after you’ve finished all your treatment would be a more sensible choice.

If you really can’t make up your mind about whether to go ahead with immediate reconstruction, don’t feel cornered into making a snap decision. Ask for more information from your breast care nurse and speak to your own doctor. There are lots of useful sources of information (see Chapter 20) and speaking to other patients who’ve had to make the same decisions is often really helpful. They’ll tell you about their own experiences and reactions, their recovery, and lots of other things that doctors and nurses won’t have thought about or experienced themselves.

If you still feel unable to make up your mind, then it’s probably wisest not to go ahead with a reconstruction. If you feel pressurised to go ahead and things go wrong, you’ll wish you’d never had it done. You can always have a new breast at a later date, once you have had a chance to get over your treatment and return to normal. The timing of breast reconstruction is a very individual choice and there are many different factors in deciding which choice is best for you and your own particular circumstances. These two patients opted for immediate breast reconstruction:

   I am slim and very conscious of my body and wanted to get the best result if I was going to have a mastectomy and breast reconstruction done. I lead a really young lifestyle, going clubbing and dancing, and my body is important to me.   

   I would urge women to go for immediate breast reconstruction if it is offered, because to go back for a reconstruction after mastectomy would be daunting. If you are able to come out of surgery feeling feminine, able to wear nice swimsuits and go into a public changing room without worrying, this is great. Also, I wanted to be able to cuddle my grandchildren and didn’t want to be a different shape for them.   

Another two patients chose delayed reconstruction as they felt it was the right thing for them:

   I coped very well with the mastectomy. What I didn’t like was having to keep putting the plastic thing on every morning and washing it at night. It emphasised the deformity. I thought that there was no way that I could go through life like that. I wanted to have a breast back. I realised how much I had been pushing those feelings back, in order to cope with the diagnosis.   

   I feel that I made the right decision about delaying reconstruction. Things happened so quickly and I don’t think I could have made a decision about reconstruction as well at the time. I knew that the opportunity would still be there for me in the future. It was important for me that I wasn’t shutting the door on it.   

Finally, if you need another week or two to make up your mind, don’t be afraid to ask for more time. It’s not going to make the slightest difference to your chances of recovery or the success of your treatment, and may just be the time you need to be sure you’ve made the best decision for you.

What will it be like?

   I was just 50 when I was told I needed a mastectomy, but could have a breast reconstruction as well. As I had no previous experience of it, I just could not possibly imagine what a mastectomy or reconstruction would look like.   

Most people have no idea what a reconstructed breast will look like and how it will feel. It’s partly because up until fairly recently, fewer than one in ten women underwent breast reconstruction, so there aren’t that many women around who have had this done. It’s also because it’s only recently that new techniques have been developed to help the surgeon to hide the scars of surgery so they become almost invisible (Figure 3.1). These new techniques can make women much more confident about their shape and appearance. Different kinds of breast reconstruction produce different results. We will talk about these later in this chapter.

Figure 3.1 – Bilateral mastectomies and immediate reconstruction (nipple reconstruction and tattoo hides the scars).

Let’s have a look at some things that you’ll probably notice soon after your operation, whatever kind of reconstruction you’ve had. When you wake up from the anaesthetic and take a look at your reconstructed breast, don’t be surprised to find some of these things:

  • Your new breast is a different size to your other breast: It may be larger because of swelling and bruising, which will gradually settle down. Some kinds of reconstruction may take up to a year before they reach their final size, so you may need to be patient while these changes are going on. Or your new breast may be smaller if you have chosen to have a reconstruction with a ‘tissue expander’. This will be used to enlarge your breast during the early weeks after your operation.
  • It’s a different shape compared with your other breast: Sometimes your new breast will look fuller and rounder near the top, but flatter and emptier near the bottom – the reverse of the normal shape. Don’t worry about this. It happens because your surgeon has reconstructed your new breast to look like a younger breast to begin with, knowing that it will gradually move downwards with the effect of gravity. By doing this, it will end up with a much more natural shape in the long run. It happens most often when an implant has been used for the reconstruction, but the recent development of ‘meshes’ helps to give a more natural shape as soon as you wake up (see Chapter 4 and Chapter 5).
  • It feels very firm and unnatural, and doesn’t move about like a normal breast: This again is completely normal in the early months after your surgery. Once healing and any adjustments are completed, your breast will become softer and will begin to move about like the other side. Major surgery produces a lot of swelling; if an implant or tissue expander was used for your operation, this will increase the swelling further still. You can imagine that if all this swelling is going on in the space that is left behind after removing your breast, your new breast gets really distended and can become quite hard. The swelling gradually drains away and settles down, but you have to be patient while your body adjusts to these changes.
  • The skin of the new breast will feel very numb: This is because nearly all of the small nerves to the skin have been cut to remove your breast. You may not notice this until you get home. Some of the feeling will gradually return as the nerves grow back around the edge of your new breast. This can feel very strange while it’s going on, and may take 12–24 months, but the middle of your new breast will always feel numb. And if you’ve had an operation which uses a ‘flap’ for the reconstruction, the flap itself, and the skin near where the flap was taken from, will also feel completely numb. So you have to be careful with sunbathing and hot water bottles, which can burn these areas of skin without you feeling anything at all.
  • Your scars will depend on what kind of reconstruction you’ve had: If your reconstruction is done at the same time as your mastectomy, the scars are often in the middle of your new breast and usually very small. If on the other hand you have a delayed reconstruction, the surgeon will often use your mastectomy scar, so the scar will be about the same length as before.
  • If you’ve had a flap operation, you will notice an ‘island’ of new skin somewhere in the middle or lower part of your breast: This will be surrounded by a scar, and the island will usually have a slightly different colour and texture from the skin of your breast. This is because it’s been removed from another part of your body, such as your back or your tummy. This so-called ‘patch’ effect will usually become less obvious as time goes by. The scars around the new skin island usually become thin, white lines over the next year or two. In a small number of people they become red and thickened in the early months. If this happens, the scars will nearly always settle down within a couple of years. The same thing may happen to the scars on your back or your tummy if you’ve had a flap operation.

And finally, it’s important to know what you are going to feel like when you come round from your operation.

  • Remember you’re going to have quite a big operation, depending on the type of reconstruction you’ve chosen. The surgery may take as little as two hours if it is going to be done using an implant or a tissue expander. A flap operation is more complicated, because tissue has to be moved very carefully from one part of your body to another. This often takes between 4–6 hours to do and sometimes as long as 8 hours.
  • When you come round, you’ll find you’re back on the ward. You may even be on a special ward if you’ve had a flap operation. This is so that the nurses can check and monitor the blood supply to your flap more closely for the first 12–24 hours. It shouldn’t be painful because the anaesthetist often uses a ‘block’ to deaden the nerves around the operation. You may also have a button to press that will deliver medications to help to keep any pain at bay.
  • Don’t be surprised if you’re attached to lots of drips and drains, and a urinary catheter, when you wake up. They are there to replace and measure any fluids lost during or after your surgery, and they’ll be removed as soon as your doctors are happy that they aren’t needed any more.
  • You’ll be sitting up and out of bed the day after your operation, and your breast team and physiotherapist will help you to get back on your feet as soon as possible. You may even be back home the next day after an implant operation, or 3–5 days later if you’ve chosen a flap.

Am I the right person to have reconstruction?

Almost anyone can have a breast reconstruction, but you need to decide if this is the right thing for you. Your surgeon and your breast team should be able to help you answer part of this question. They will be able to tell you if you’re physically fit for the operation and also whether it’s going to be affected by the treatment that’s planned for you after your surgery. In fact, they won’t suggest reconstruction unless they think you are fit enough to have this type of surgery in the first place.

Whether reconstruction is the right thing for you is a much more personal question, which only you can answer. You may be the kind of person who finds it’s easy to make a quick decision as soon as you’re offered the choice:

   I was 66 when I was told that I had breast cancer and needed a mastectomy. I was shattered. All my life I had thought that breast cancer was about the worst thing that could happen to me because I would be disfigured. Anything to keep my femininity and be able to present myself to the world as the same person was important.   

But it’s important not to make a snap decision. Although your first reaction is often your final decision, you really need to think about your options and ask lots of questions. Then if things don’t turn out the way you wanted, at least you’ll know you made an informed choice.

It’s easier in a way if you’ve already had a mastectomy and are thinking about delayed reconstruction, because you know what it’s like and you’ve got plenty of time to think and to do your own research. And age in itself is no barrier – it’s your health and self-motivation that really matters the most.

   I had worn two prostheses for some time and found them pretty awful. I got the leaflets about reconstruction out again. I thought that reconstruction would be better than working with two prostheses. It didn’t even dawn on me that I might not consider reconstruction at 62.   

Will it affect my cancer?

When breast reconstruction was introduced more than 40 years ago, no one knew if it was safe, from the breast cancer point of view. So back then, women had to wait for at least two years after their mastectomy before reconstruction was done. Now things are completely different. Many studies have shown this type of surgery doesn’t stimulate the cancer to grow back, it doesn’t make it spread, and it doesn’t make cancer any more difficult to detect in the few women who develop a recurrence after surgery. Nowadays, if you decide to have immediate breast reconstruction, you can be confident that it won’t affect your cancer in any way. On the other hand, if the treatment of your cancer includes radiotherapy, this can affect the appearance of your reconstruction. So you and your surgeon should discuss this together before you decide whether to go ahead with an immediate procedure.

Is this a once and for all operation?

The simple answer to this question for most people is ‘no’ – for two main reasons:

  • It’s very difficult to match your remaining breast in one operation. You’ll almost certainly need some further adjustment to your reconstruction or to your opposite breast if you want a balanced, natural-looking result. These are usually small operations that may be done as a day case and from which you’ll have a quick recovery. You may need to have a reduction or an enlargement of your remaining breast, a nipple reconstruction and a tattoo, or an exchange of your implant to get a better shape.
  • Later on, as you grow older, your reconstructed breast may not age in appearance as quickly as your own breast. Further adjustments may be needed to bring both breasts into line. And if it’s been rebuilt using an implant, this may need to be checked and changed as the years go by. So like any ‘spare part’ surgery, further operations may be needed to adjust your reconstruction, particularly if implants or expanders were used.

What are my options?

There are three very different techniques that your surgeon can use to reconstruct your breast.

  • An implant or tissue expander (an adjustable type of implant): This is either slipped into the space that lies between your ribs and your pectoralis muscle (subpectoral reconstruction), or into a space under the skin and on top of your pectoralis muscle (prepectoral reconstruction). By using these techniques, your surgeon doesn’t have to create a flap, and so avoids more major surgery. It also means that most of your breast is made from the implant or expander, and contains little of your own tissue (see Chapter 4 and Chapter 5).
  • Combination of an implant or tissue expander together with a muscle flap: This technique makes a new breast by using an implant together with one of the muscles from your back. It’s called a latissimus dorsi (LD) reconstruction – an approach used for more than 40 years because it’s so reliable. After this operation, between a third and a half of your breast is made from your own tissue, and the rest is made from the implant or tissue expander (see Chapter 6).
  • Building your new breast using all your own tissue without the need for an implant or a tissue expander: This approach is called autologous reconstruction, which normally uses tissue from the lower part of your tummy – the TRAM flap or DIEP flap. New techniques are helping surgeons to use other flaps, such as flaps from the buttock or the inside of the thigh, as well as using a much bigger part of latissimus dorsi (LD) – your back muscle. This is called an autologous latissimus dorsi reconstruction (see Chapter 6 and Chapter 7).

Your surgeon will make an assessment of your physique, together with your likely treatment when discussing your reconstruction options with you. On the one hand, your shape, size, expectations, and general health will need to be considered. On the other, your chances of needing radiotherapy after reconstruction will also influence the surgical options. It’s important that you ask as many questions as possible at this stage about your different choices – for example, about your hospital stay, your recovery, your scars and the effect of surgery on day-to-day activities and sports. It’s also important to find out how the operation will affect you in years to come.

   I think it would have been helpful if I’d asked a bit more about the long-term effects of reconstruction without an implant, and talked to someone who had had a similar operation. When you are discussing options with the doctor, you need to make it very clear what sort of activities you do and that you wish to be able to carry on with them afterwards. It is important to be able to pick up your life afterwards and carry on.   

You will need to give the doctors and the nurses as much information about yourself as you possibly can. Ask your team if it would be possible to speak to other women who have faced similar choices and have made different decisions about their surgery.

   I was offered either latissimus dorsi or a DIEP flap for the breast reconstruction. I made up my mind in two weeks, although I could have had longer. I didn’t want to keep putting off the inevitable. It is hard, because you try to cope with the diagnosis of cancer and all the worries that brings, and at the same time try to decide between two different procedures. It is impossible to know what the outcome is going to be. I read as much information as I could get my hands on, and also discussed it with my family. I wondered how on earth I was going to make a decision. I was lucky enough to speak to two women who had the breast reconstruction I was considering. That was very helpful.   

The trouble is that you’ll be given an awful lot of information, which you have to try to take on board all at once. So the important advantages and disadvantages of the three main approaches are summarised in the tables below. It’s to help you see how they compare with each other, and to help you ask some key questions.

Implant only reconstruction

Advantages

  • The simplest approach
  • The shortest operation
  • The quickest recovery
  • Scars on your breast only
  • No scars elsewhere on your body.

Disadvantages

  • Complications may cause implant loss and poor cosmesis
  • Tissue expansion needs repeated outpatient visits
  • A mature shape and feel are difficult to achieve
  • Your breast is made mainly from the implant
  • It won’t age like a normal breast
  • It won’t be as soft and warm as your normal breast
  • Scar tissue around the implant may make the breast feel hard
  • Further operations are more likely than after other techniques.

Latissimus dorsi reconstruction using implant or expander

Advantages

  • Your new breast will have a natural shape and movement
  • Feels soft and warm and fleshy
  • Feels more normal and may change with your body weight
  • Matures like your other breast as you grow older
  • Scar tissue isn’t easy to feel, because it’s hidden behind your flap
  • Further operations are less likely than techniques without a flap.

Disadvantages

  • Major surgery (4–6 hours) with longer hospital stay and recovery
  • Slightly more risky, with flap blood supply problems and fluid collections
  • Scars on your back and your breast but these can be hidden under your bra
  • May feel chest tightness for a few months after your surgery
  • Slight weakness of your shoulder that shouldn’t affect your normal activities.

Autologous reconstruction

Advantages

  • Your new breast will be much more natural – because it’s all you
  • It will change weight with you, and will feel just like your other breast
  • Once your surgery is finished, you shouldn’t need any more operations
  • After a DIEP flap, your tummy will be flatter – often seen as an added bonus.

Disadvantages

  • The most complex of all reconstructions – taking up to eight hours to do
  • The flap’s blood supply can get blocked which may need further surgery
  • Occasionally the blockage can’t be cleared, and the flap has to be taken away
  • You’ll have quite a long scar, either on your tummy or on your back
  • Tummy muscle weakness recovers, but there’s a small risk of a hernia later on.

Remember that it’s important to ask your surgeon to run through your own choices for reconstruction. Make sure that each of these options has been considered and whether or not they’re all carried out by the team that’s treating you. If they’re not, then you can ask to be referred on to a team that does the operation you want. Once you’ve had the operation, it’s very difficult to go back and do something different.

   I was only given the option of having a Becker tissue expander, but probably could have had a choice of different reconstructions if I had asked more questions. In an ideal world, people should have the chance to consider all the options, as well as seeing people who have had them by the same surgeon. Tissue expansion is a relatively simple process compared with other methods. With hindsight, I did not have enough information to make a balanced judgement. The issues that I did not know about were how much additional surgery I would have, and how long the whole expansion process took. People need to have realistic expectations and understand that the reconstructive process may be a good imitation, but not exactly the same. What is good for one person may not be good for another.   

What about the other breast?

There are two important questions that are often asked by women choosing reconstruction:

  • What if there is cancer in the other breast – wouldn’t I be better off having both removed and reconstructed? This is a very common and understandable reaction to the bad news you’ve just heard. The chances of you having cancer in your other breast are extremely small. Only 1 out of 200 women who have had breast cancer will develop a new cancer in each subsequent year, and your mammogram will nearly always find it. So unless you have other reasons which build up the risk to your other breast in the future (such as a very strong family history), having a double mastectomy is a very big thing to go through without an enormous amount of benefit to you. There’s nothing to suggest that it improves your chances of complete recovery from breast cancer, but it may reduce anxiety and increase confidence.
  • What size do you want to be? It’s important to think about what size you want to be before your operation. Now’s the time to talk to your surgeon about making a change – and it may make the results of your surgery much better in the long term. If you are very large with heavy droopy breasts, it can be difficult and sometimes impossible to reconstruct a new breast to match the other side. So it’s often a good idea to reconstruct a smaller breast, and then reduce your other side to match. This is usually done a few months later when your reconstruction has settled down. On the other hand, if you have a small or very small breast, then it’s really quite difficult to reconstruct a very small new breast to replace it. The surgeon can often get a much better result by rebuilding a new breast that is bigger than before. This means that the size of your other breast has to be increased to match – and this is often done at the same time. Both of these approaches – building a smaller or larger breast – mean having surgery on both sides. This shouldn’t affect the examination of your remaining breast, but it does mean more surgery. It can also give you better results in the long run.

Is my surgeon experienced?

This is a really important question and often the most difficult one to ask. After all, you’re relying on your surgeon to look after you, and to give you support and advice. And then you find yourself questioning his or her experience at a time when you feel you really need support and advice from the whole breast team. Don’t worry about asking this question. Any experienced surgeon won’t mind – they’ll be happy to tell you. If they are not experienced, now is the time to find out and to seek advice and treatment elsewhere.

Here’s a short list of questions to help you find out more about the experience of your team in breast reconstruction:

  • Ask how many reconstructions the team does every year. They should carry out at least 20–25 cases to give them enough experience.
  • Does the team do all kinds of reconstruction – implant only, latissimus dorsi and autologous reconstruction?
  • If not, will they refer you to a unit that does?
  • Ask to see all the publications and articles on reconstruction produced by the unit.
  • Ask if it is possible to speak to patients treated by the unit and look at written information and pictures of patients.
  • Look your surgeon up on the internet. This will tell you about his or her area of experience, as well as whether they have kept up-to-date.
  • Talk to your GP about the kind of services offered by the breast unit.

Modern training programmes for breast surgery now include training in breast reconstruction. So there is an increasing chance there will be a surgeon on your team who will be able to carry out your reconstruction and give you all the choices that you need. If not, remember you should ask to be referred elsewhere for another opinion.

Finally, remember that the service is geared around you as a patient, and those treating you will respect your own views and choices. You owe it to yourself to examine all your options and to ask lots of questions. You won’t be ready to go ahead until you feel that all your questions have been answered and you’ve had a good chance to make up your mind.

Chapter 4

Implants, Expanders and Meshes

Michael Douek, Lorna Cook

  • Implant-based breast reconstruction is the most common and simple type of breast reconstruction after mastectomy.
  • Silicone breast implants are safe and used worldwide.
  • There are many different shapes and sizes of implants to choose from.
  • Implants may be ‘fixed’ or ‘adjustable’ in terms of their volume.
  • Special meshes are often used in implant-based breast reconstruction to provide additional support to your tissues.

If you chose to have a breast reconstruction after mastectomy, one of the options you may be offered is to have an implant-based reconstruction. An implant can be placed either under or on top of your chest muscles and sits under your skin, recreating the fullness and volume of the missing breast. It’s the most common and simple type of breast reconstruction because your surgeon doesn’t have to borrow tissue from another part of the body to rebuild your breast. Because of this, you’re more likely to have a shorter hospital stay and a quicker recovery, but a greater risk of complications. We’ll come back to the anatomy and surgical details later but perhaps we should start by talking about breast implants.

Cosmetic breast implants and reconstruction: what is the difference?

There have been so many programmes about cosmetic surgery on television recently that most women will already know about the use of breast implants to increase breast volume and enhance the bust. Celebrity magazines constantly speculate about who might have had a ‘boob job’ (which in surgical terms is called an augmentation mammoplasty).

The difference between a purely cosmetic augmentation and a breast reconstruction is that after a mastectomy or a major removal of breast tissue there may be nothing left of the original breast. Your surgeon has to recreate not only the volume of the missing tissue, but also has to make sure that there’s enough skin and soft tissue to cover the new breast so that it has a natural contour and appearance.

The aim of all breast reconstructions is to create a new breast that looks and feels as normal as possible, and matches your remaining natural breast. After all, your new breast is one of a pair, but as with all reconstructive techniques sometimes it’s also necessary to also work on the opposite side to get the very best symmetry.

Breast implant materials

Any material that is implanted into living tissue has to be well tolerated. Early attempts to increase breast size surgically used a variety of substances with relatively little long-term success. In 1963, two American surgeons introduced the silicone gel implant, which was followed in 1964 by a saline-filled implant. These have been the basis of all breast implants since then, with constant technological developments to improve long-term durability and to make the implants better tolerated in living tissue. All current breast implants are based on the same basic design and use silicone components.

Silicone versus silicon

‘Silicone’ shouldn’t be confused with ‘silicon’, which is a chemical element. Silicon is the second most common material in the earth’s crust and is a component of glass, cement and ceramics. Silicones are synthetic materials, built around a frame of silicon and oxygen atoms. The more the chemical groups are cross-connected (polymerisation), the firmer the consistency of the material. The basic component of breast implant materials is PDMS, or polydimethylsiloxane. This varies in consistency from its softest liquid form, through to gel, then to a firm rubber-like texture, and eventually to a hard material similar to plastic.

Liquid silicones are used as medical lubricants; they are the clear material used to ‘grease’ the inside of syringes to allow the plungers to move smoothly, and to coat needles so that they can glide into tissue without friction. The ‘inertness’ of silicones has led to their widespread use for medical applications, and particularly for implanted devices, such as tubing in neurosurgery for draining ‘water on the brain’, and in cardiac surgery to insulate pacemaker wires. Silicones are also used for artificial joints in the hands and for a whole range of implants including, of course, cosmetic and reconstructive breast implants.

Are silicones safe?

Silicones are very much a part of everyday life. They’re added to infant feeding formulas to counteract burping. Babies’ dummies are coated with silicone, and it’s found naturally in cows’ milk. Silicones are also used in the kitchen to coat baking paper to make it non-stick. They’re present in processed and manufactured foods, and medicines, such as preparations for infantile colic. Silicone sealants have widespread uses in the kitchen and bathroom. So even though we may not be aware of their presence, we regularly ingest silicones and come into close contact with them every day in our homes.

The development of silicone implants

All implants are made up of an outer shell made of silicone and a filler substance composed of either saline or silicone gel. However the design of breast implants has undergone significant and incremental developments over time. As each new generation of implant is introduced their design has undergone major improvements. First generation implants had a thick smooth-walled silicone shell and were filled with silicone gel. In the mid-1970s, second generation implants were brought in with thin outer shells and more liquid silicone fillers. However these devices were fragile and had a high rupture rate so were discontinued. From the late 1980s third generation implants were produced with thicker double or triple layered shells to reduce silicone leakage as well as a thicker, more cohesive gel filler.

Modern silicone gel implants are either fourth or fifth generation and are manufactured under much stricter conditions. Fourth generation implants are stronger with a more durable shell and thicker silicone gel and are manufactured with a wide range of measurements so that they can be matched to individual patients. Fifth generation implants contain a gel called ‘form stable’ or ‘highly cohesive’ gel as it is able to hold its shape in any position and can bounce back into its original shape. These implants are also known as ‘gummy bear’ implants because they have the consistency of a gummy bear sweet.

Concerns about breast implants

Although numerous scientific studies have given strong reassurance that silicone breast implants are safe, some people still have concerns. It is important that if you’re considering a reconstruction technique using implants, you should be well informed so that you can make a comfortable decision.

The silicone controversy

In 1992, the United States Food and Drug Administration (FDA) imposed a virtual ban on the use of silicone gel-filled implants, which despite many years of use, were reclassified as experimental. They could only be used in clinical trials and for reconstruction after mastectomy. The use of saline-filled implants was not affected. There were suggestions that silicone gel-filled breast implants caused disease by stimulating tissue reactions and causing connective tissue diseases such as arthritis.

In the UK, a new body was established in 1993 to review the scientific literature. The Independent Expert Advisory group found no evidence of any link between silicone gel breast implants and diseases such as arthritis. In 1998, a new body, the UK Independent Review Group (IRG), carried out an extensive scientific review of all the available evidence. Once again, no conclusive evidence was found that breast implants cause abnormal tissue reactions or arthritis. The extensive scientific review included the results of investigation and monitoring in studies from the 1980s onwards. The IRG reviewed a very wide range of studies, concluding that silicones don’t have any long-term harmful effects on your body. No links were found with specific illnesses, joint diseases, diseases of the nervous system, breast-feeding or any toxic reactions. In fact, women with breast implants were found to have a lower incidence of breast cancer than the general population, and breast screening was possible following implants. Local effects, such as capsular contracture (scar tissue forming around the implant) were just like the body’s normal reaction to any implanted foreign material, rather than to any unusual toxic reaction. Implant durability, rupture and gel-bleeding (the leakage of silicone gel through an intact shell) were all highlighted.

Silicone gel breast implants continued to be used freely in the UK. The European Union carried out its own scientific studies, and in February 2003 voted to allow continued use of breast implants, but with specific measures in place to support patients, assure quality and encourage on-going research.

Eventually, the weight of the scientific evidence led the FDA to approve the use of gel-filled implants in the USA in 2005, and Canada followed suit. Remember however, that the use of breast implants for reconstruction after mastectomy has never been affected.

PIP implants

In 2009 concerns were raised about the type of silicone used to fill breast implants, when it was discovered that the French-made PIP implants contained industrial grade rather than medical grade silicone filler. This led to a mass recall of women who’d had these implants inserted for both cosmetic and reconstructive reasons, with many women choosing to have them removed. Whilst PIP implants are more likely to rupture than other implants, there’s no evidence to suggest that they cause harm to health. PIP implants have not been used in the UK since 2010 and most were removed and replaced.

Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

There’s a very rare type of blood cancer, or lymphoma, called Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL) which has recently been identified as being associated with breast implants. Currently it’s estimated that BIA-ALCL happens with 1 in every 24,000 implants inserted in the UK. This is therefore a very rare condition when it is considered that breast cancer (which is NOT related to implants) occurs in one in eight women. Only a very small proportion of women that have implants inserted, are affected. However, your surgeon will always discuss the potential risk of BIA-ALCL if you’re considering having an implant-based breast reconstruction. It’s thought that the risk of developing BIA-ALCL is mostly associated with implants that have a textured external covering, or shell.

The most common way in which BIA-ALCL shows itself is by the development of a seroma (fluid) around an implant, usually around 8–10 years after the implant was inserted. Less commonly it may present as a firm breast lump. In the majority of cases, BIA-ALCL can be completely treated by simply removing the implant and surrounding scar tissue. For this reason it’s important for doctors and their patients to be alert to the possible development of this condition.

Breast implant illness or Autoimmune Syndrome Induced by Adjuvants (BII/ASIA)

Despite the lack of concrete scientific evidence to confirm the existence of this syndrome, there is still concern that the use of implants may be linked to a set of symptoms known collectively as Breast Implant Illness or Autoimmune Syndrome Induced by Adjuvants (BII/ASIA). This is an umbrella term for a collection of symptoms reported by people who attribute them to their breast implants. These symptoms, which are relatively non-specific and are common in the general population who don’t have breast implants include fatigue, anxiety, joint pain and ‘brain fog’. Some people have reported that they have found their symptoms have improved once the implants are removed.

Whilst BII/ASIA is not currently recognised as a disease by the World Health Organization, data about potential cases is continually being collected and the scientific evidence is under constant review. For this reason your surgeon will mention this to you if you’re considering having implant-based breast reconstruction.

Implant rupture and ‘shelf life’

All implants carry with them the risk of rupture (Figure 4.1). With saline-filled implants the saline leaks out quickly and so the breast can soon look deflated. With silicone however, the gel leaks or bleeds out much more slowly. You may not realise it’s leaked out at all, or you may notice changes in breast shape and/or consistency. Your surgical team will explain that implants are likely need replacement at some point although it’s difficult to predict the time scale. The average life span of an implant is often quoted as approximately 10–15 years, but two large studies in the USA have shown that more than 90% implants are completely normal 10 years following surgery. If you don’t experience any problems, there’s no need for your implant to be exchanged.

Figure 4.1 – A ruptured implant, showing fractured outer shell.

The Breast and Cosmetic Implant Registry (BCIR)

To get a clear picture of implant use in the UK, the government set up a compulsory national registry in 2016, the Breast and Cosmetic Implant Registry (or the BCIR). This database also registers sling usage, and tracks the long-term outcomes of implant and sling-based reconstruction by using NHS numbers. It’s hoped that this large and comprehensive database will provide robust data on the safety of every implant and sling.

Specialised breast reconstruction implants

Implant types

There are three main implant types that are used in breast reconstruction to replace the volume of breast tissue removed at the time of mastectomy (Figure 4.2). The choice of which one to use depends on various different factors such as your personal choice, your natural breast size and your previous and ongoing cancer treatment. The different surgical techniques used for implant-based reconstruction will be described in further detail in a subsequent chapter.

Figure 4.2.1 – Fixed volume implants.

Figure 4.2.2 – A permanent expander implant.

The three implant types are:

  • Permanent or fixed volume silicone implants
  • Temporary expanders
  • Permanent expander implant.

Which implant type is used and when?

Fixed volume silicone implants

If you have an immediate reconstruction – at the same time as your mastectomy – then the overlying skin is preserved using a skin-sparing mastectomy (see Chapter 5). By preserving the skin over your original breast tissue, there’s sufficient space between the chest wall and the overlying skin to insert an implant straight away which matches the shape and size of your the other breast. This is also known as ‘direct to implant’ reconstruction (or DTI).

Permanent or fixed-volume implants have a defined, non-changeable size and shape and are entirely filled with silicone. They come in a wide variety of volumes and dimensions such that the implant selected for an individual patient can be matched closely to the desired size and shape of the reconstructed breast. They come in two main shapes: ‘round’ where the width and the height are the same; and ‘teardrop’ (or ‘anatomical’) where the shape has a more natural slope from the top to the bottom, so there’s more volume in the lower part. One of these shapes may be best suited to you depending on your body and breast contour. These implants are very much like the implants used in cosmetic breast enlargement surgery.

In contrast, if you have a delayed reconstruction after mastectomy, there’s no excess skin available to cover a fixed volume implant as it will have been removed at the time of mastectomy. Instead, the scarred skin lies immediately on top of the muscle. Your surgeon therefore needs to recreate not only the volume and fullness of your missing breast, but also has to make sure that there’s enough overlying skin to cover your reconstructed breast mound. Doing this ensures that it looks natural in terms of softness, with enough ‘ptosis’ (droop) to match the shape and contour of your remaining breast.

What are the cosmetic goals of breast reconstruction surgery? Try to imagine a typical female profile – what a woman with an average body build and proportionate breasts sees when she looks at herself sideways on in a mirror. She sees a natural profile and contour, and soft tissues that droop naturally under gravity and move on the chest as she turns. After a mastectomy in the absence of adequate skin, simply putting an implant under very tight, thin and scarred skin could look rather like a large apple stuffed into the breast pocket of a shirt; the tight fabric would hold the apple firmly, causing it to jut out and leading to a profile looking nothing like a normal female breast.

Tissue expanders and expander/implants

What is skin or muscle expansion?

If reconstruction is delayed until the mastectomy site has healed (delayed reconstruction), there won’t be enough skin left to cover the additional volume of a reconstructed breast. If the reconstructive surgery is carried out immediately after a mastectomy in which both breast and breast skin have been removed (in other words the skin has not been spared), the situation is the same. Even if the skin has been spared, there’s a large empty space that the removed breast occupied, and this needs to be filled.

In these situations, the implant is placed under your muscle (subpectoral reconstruction), and the thick layer of muscle needs to be stretched out to fill the empty pocket of skin, pushing your muscle out in a dome shape so that it becomes thin and supple and lies snugly in contact with your overlying skin. This moulding of the soft tissues to form the most naturally shaped breast is achieved by using an expander – an expandable bag that can be gradually increased in size to make the surrounding tissues stretch out (see Figure 4.3).

Figure 4.3 – Submuscular expansion stretches the muscle into a dome shape as the expander enlarges.

The surgical technique of ‘skin expansion’ takes advantage of the elasticity of living tissues. If they are gradually stretched, they can expand massively. Think of what happens when a woman becomes pregnant: towards the end of pregnancy her abdominal wall is stretched to accommodate the baby. Of course she probably hopes that as soon as the baby is born, her tissues will tighten again so that she has a taut and firm abdominal wall. If the period of stretching is relatively brief, and if the stretching has been moderate, there’s a much better chance that nature will restore a flat tummy. If, however, there has been a marked increase in weight, and if the baby has been very large (or perhaps there may have been twins or triplets), it’s less likely that her abdominal wall will go back to being exactly as it was before. The soft tissues may then be lax with some baggy skin being left.

Actually, this is what skin expansion in breast reconstruction tries to achieve: a permanent excess of tissue to contribute to an ordinary amount of drooping, with the breast implant lying comfortably in a large enough pocket of muscle and skin to move naturally with the body.

Temporary expanders

A temporary expander is an implant made of silicone and saline. Before expansion, it has an empty chamber that can be enlarged by filling it with increasing volumes of saline (a sterile salt solution, with the same sodium concentration as body fluids). The expander can be inserted at the same time as your mastectomy, or later, as a delayed reconstruction. There will normally be only one scar. Two separate surgical procedures are needed, each under general anaesthetic: the first to place your expander, and the second to remove it once there is a big enough pocket, and to replace it with an implant. Your recovery time after each procedure is about 2–3 days.

The expander is inserted underneath the soft tissues of your chest wall to create a space that was previously occupied by your breast. Depending on the design of the implant, a tiny valve may be placed in a separate pocket under your skin near to the expander, to which it’s connected by a tube. Saline is injected through your skin into the valve, and passes into the expander. With increasing volumes of saline within your expander, your soft tissues stretch out, and the expansion process continues until your newly created breast is slightly larger than the intended final size. There’s an uncomfortable feeling of pressure as the saline goes into the implant, which most women find they can cope with. When the tissues stretch, the feeling of tightness reduces, usually within 2–3 hours.

The expansion process can take a couple of months; at the end, your expander is removed and replaced with a silicone breast implant that will stay in place long-term, forming your definitive breast.

The permanent expander/implant

This design of device combines the two different stages of implant reconstruction described above (expander replaced by a permanent implant) into a single double-chambered implant. Permanent expanders are available in a range of sizes and shapes (Figure 4.4). The outer layer contains silicone gel, which gives the implant a more natural feel. The inner layer is an inflatable chamber, which functions as the expander, being stretched with saline injected through the valve (Figure 4.5).

Figure 4.4 – Different shapes of permanent expanders.

Figure 4.5 – Blue dye has been put into the inner chamber (the clear space around is the gel-filled out chamber).

Figure 4.6 – Expander insertion, overexpansion and deflation, and replacement with a permanent implant.

Some designs of permanent expander have a valve that’s incorporated into the wall of the device, being part of its permanent structure. Other permanent expanders have an ingenious pull-out system to allow the valve and tube assembly to be removed at the completion of the process, leaving the two-chambered implant in place as the permanent replacement for your breast, at the chosen final volume (Figure 4.6). This simple local anaesthetic procedure enables removal of the injection valve and tube when you and your surgeon are happy with the shape and size of the breast. An inner valve seals as the tubing slips out. With a permanent expander/implant, you only have to undergo one inpatient operation for the insertion of the implant, with the final valve removal often being a walk-in/walk-out outpatient procedure.

What is over-expansion?

Both temporary and permanent expanders can be filled gradually with saline, adding more volume as stretching occurs. However, many surgeons favour the technique of ‘immediate over-expansion’, which is suitable for some designs of implant, and is particularly appropriate for delayed reconstructions (Figure 4.7).

The breast implant is inflated immediately to 80–90% of its intended final, over-expanded volume. Of course this can be very uncomfortable, so pain control and sedation are important. However, the expansion process is shortened, and the need for many more injections for gradual stretching may be avoided.

The aim of over-expansion is to create additional skin to contribute to a normal contour, with the implant lying loosely within a mobile soft tissue envelope (Figure 4.8). However, some other designs of permanent expander incorporate a firmer, structured, anatomical implant which gives its shape to the overlying tissue, so that there is less need to over-expand in order to generate skin.

Figure 4.7 – Three early postoperative pictures showing a delayed reconstruction on the patient’s right side, and a subcutaneous (skin-sparing) mastectomy and immediate reconstruction on the left side, using a Becker™ permanent expander (there is a degree of immediate over-expansion).

Figure 4.8 – The patient in Figure 4.7 at the completion of implant/expander reconstruction: the over-expansion has been reduced, and final shape and volume have been achieved to patient’s satisfaction.

The use of meshes in implant-based reconstruction

Many surgeons use a mesh in conjunction with implant surgery. A mesh is a sheet of material that’s used to provide support to the breast implant and the tissues surrounding it. There are a variety of different meshes in use, however the most commonly types are known as ‘biological meshes’ because they originate from the skin or other tissues of animals (generally from cows or pigs), or from human skin. They are treated with a specialised method that removes all the living components of skin/tissue so there are no concerns about any infection risks with their use. They look and feel a bit like thin leather (Figure 4.9).

Figure 4.9 – A sheet of Meso Biomatrix® biological mesh manufactured from porcine tissue. This is cut to shape before use during a subpectoral reconstruction.

Advantages of using a mesh

The best way to describe how meshes are used in implant-based reconstruction is that they act like an internal bra or hammock to support the implant. By attaching the mesh to the lower border of the chest wall muscle (the ‘pec’ muscle), a pocket for the implant is formed (Figure 4.10). This has several advantages. Firstly, it means that procedures using a fixed volume implant (direct to implant reconstruction) are made easier as there’s a bigger space for the implant. Next, if an expander implant is used instead it may mean that the expansion process can happen faster, as less stretching of the muscles is needed. Other advantages of using a mesh are:

  • Less risk of implant rotation and movement
  • Improved cosmetic outcomes
  • Reduced pain following the operation
  • Reduced rates of scar tissue formation.

Figure 4.10 – Cross-section following implant reconstruction showing the position of a non-biological mesh (TiLOOP®), like a bra supporting the lower pole of the implant.

Figure 4.11 – An implant is placed in a pocket made from a non-biological mesh (TiLOOP®), before being positioned in the gap between the pectoralis muscle and the overlying skin after a mastectomy.

As well as the technique described above, another approach has been developed more recently where the implant is placed between the chest wall muscles and the overlying skin, rather than underneath the muscles. This type of reconstruction is called prepectoral reconstruction and is facilitated by covering the implant with a mesh (Figure 4.11). This mesh covers the whole implant, or just the area in contact with the skin, where it provides a supportive soft tissue layer (see Chapter 5).

Alternatives to biological meshes

There are other non-biological meshes that can be used for the same purpose in implant-based reconstruction, but they’re made of synthetic instead of animal material (Figure 4.10 and Figure 4.11). Selection of mesh type often depends on your surgeon’s choice but also on your preference, for example, if you don’t want a mesh that’s been derived from animals. For women with larger breasts, part of the skin from the lower half of the breast can be used to support the implant instead of a mesh. This is called a dermal sling.

Are there any risks associated with the use of mesh in breast reconstruction surgery?

The meshes used are not the same as the non-absorbable synthetic meshes that are used in the treatment of pelvic prolapse surgery. These have received a lot of adverse media attention because of lawsuits relating to associated complications and infections. The biological and synthetic meshes used in implant-based reconstruction have all been approved as ‘safe for use’, but outcomes are continually being reviewed.

Chapter 5

Implant Reconstruction: Subpectoral and Prepectoral Techniques

Siobhan Laws, Raghavan Vidya

  • Implant reconstruction is the simplest and most popular technique in the world.
  • The position of your implant will affect the shape and appearance of your new breast.
  • Implants are available in a big range of shapes and sizes, to help match your other breast.
  • Expanders are adjustable implants that may be exchanged once your cancer treatment is finished.
  • Complications are quite common and you may need further surgery to treat them.
  • Most techniques are ‘day case’ procedures, and full recovery takes about a month.

What is implant reconstruction?

As discussed in the previous chapter, implant-only reconstruction is a procedure which replaces the breast tissue removed during your mastectomy using an implant without moving any of your own tissue into the breast area. All implants and expanders are based on silicone. Implants have a fixed size and shape and may be firm or softer, depending on the consistency of the silicone used. Expanders are adjustable with an outer sleeve of silicone and an inner space which is filled with liquid (usually salty, ‘saline’) or occasionally and temporarily with air. The ‘ports’ which are used to change the volume of the expander are either integrated into the device, or lie under the skin and fill the expander remotely through a tube (see Chapter 4). Temporary expander ports are not compatible with MRI scans and will trigger metal alarms. Permanent expander ports are safe during MRI scans and will not trigger airport security.

Timing of reconstruction and type of mastectomy

Reconstruction can be performed at the same time as mastectomy (immediate reconstruction) or as a delayed procedure at a later date (delayed reconstruction). You can even use an implant or expander to preserve the breast skin while you undergo other treatments and then have a definitive reconstruction with your own tissues (immediate delayed reconstruction). Your mastectomy may remove most of the skin covering your breast including the nipple and areola, or this skin may be preserved in a ‘skin sparing’ or ‘skin and nipple sparing’ mastectomy. Sometimes the size and shape of the breast is changed with a ‘skin reducing’ mastectomy to form a reconstructed breast that resembles a breast reduction (reduction mammoplasty).

How is an implant used to reconstruct my breast?

The muscles on the front of our chest wall, and their relationship with each other is illustrated in Figure 5.1. Implant-only reconstruction is carried out by using an implant which is placed in one of three different positions. The implant can be located either behind the skin, entirely behind the muscles of the chest wall (pectoralis major, serratus anterior and rectus abdominis (Figure 5.2)) or only partly covered by the pectoralis major muscle which covers the upper pole of the implant (Figure 5.3.1 and Figure 5.3.2).

Figure 5.1 – The pectoralis major and some of the other muscles on the front of the chest.

Figure 5.2 – Subpectoral reconstruction with the whole implant lying under the muscle and fascia.

Figure 5.3.1 – Subpectoral reconstruction using a synthetic sling or mesh to cover the lower pole of the implant.

Figure 5.3.2 – Subpectoral reconstruction of right breast using mesh.

When partial cover is chosen, the lower pole of the implant is often covered by an overlying sling, or ‘hammock’, which gives the new breast a more rounded and natural shape. These slings can be fashioned from your own tissue if a skin-reducing mastectomy is being performed (a dermal sling), or from animal tissue or synthetic material.

The best type of mastectomy for you will depend on a number of things, including your natural breast shape and your surgeon’s preference. Choosing an incision which is safe whilst giving a good cosmetic result is important. Options include an incision which runs across the centre of the breast removing your nipple and areola (Figure 5.4, ‘circumareolar’), under the breast in the bra line (Figure 5.5, ‘inframammary’), around the nipple and areola, or extending from the areola towards the armpit (Figure 5.6, ‘radial’). A skin-reducing mastectomy produces scars similar to those following breast reduction surgery, which have a so-called ‘inverted-T’ shape (Figure 5.7, ‘Wise-pattern’).

Figure 5.4 – Circumareolar incision.

Figure 5.5 – Inframammary incision.

Figure 5.6 – Radial incision.

Figure 5.7 – Inverted-T incision (also called ‘Wise-pattern’).

So you can already see that there are many decisions to be made when using implants to reconstruct your breast. Choices about type of implants, their position, slings and incisions. The best option for you will depend on your body shape and size, the thickness of the fatty tissue under your skin, the size of the breast you are aiming to reconstruct, your overall fitness, your usual physical activities for work and play and of course your own preference. Your surgeon is likely be more comfortable recommending a technique they are familiar with and use frequently. As a rule of thumb, if your breast size is ‘C-cup’ or larger (more than 500 ml), it’s safer to avoid a reconstruction which uses an implant-only technique. This is because of the higher risk of complications when using implants alone to reconstruct the larger breast. Younger women, slim women with small breasts and those having bilateral mastectomy and immediate reconstruction tend to have the best cosmetic outcomes using implant-only techniques.

Table 5.1 – Different aspects of implant reconstruction and options available

Scar

Over centre of breast

Under bra line (inframammary)

Around areola (circumareolar)

Around areola and towards axilla (hockey stick)

From areola to armpit (radial)

Reduction pattern (T)

Shape

Round

Teardrop

Stages

One stage (fixed volume implant)

Two stages (temporary expander followed by fixed volume implant)

Permanent expander followed by removal of inflation port

Position

Under skin (prepectoral)

Under skin with sling (prepectoral)

Under pectoralis with sling (subpectoral)

Totally under muscle (total submuscular)

Type of sling

Dermal sling (your tissue).

Reduction pattern only

Animal (usually pig or cow with all allergens removed)

Synthetic

Extras

Make the other side bigger to match (augmentation mammoplasty)

Make the other side smaller to match (reduction mammoplasty)

Thicken the fat under the skin (fat transfer)

Nipple reconstruction or tattoo

There are also some technical aspects that surgeons need to consider when deciding whether to offer this type of reconstruction. For example if the skin covering your breast is relatively thin, the edge of an implant may be visible through your skin, and you may be offered fat transfer to hide the implant by thickening the fatty tissue under the skin (see Chapter 12). Some surgeons prefer to perform this type of reconstruction as a two-stage procedure. The first stage of the procedure places an expander under the tissues which is then inflated to produce the new breast mound. Once the desired volume is reached, the expander is replaced with a permanent fixed volume implant at a second operation. This approach has two advantages. It allows the skin to be stretched as part of a delayed reconstruction. After immediate reconstruction, the expander can be deflated to take the pressure off the skin to improve the blood supply and support healing. It also allows more choice about the final shape of the reconstructed breast whether round or teardrop shaped.

Topics you should discuss with your surgical team before choosing implant reconstruction

What is the best position for an implant?

When implants were first used for breast reconstruction in the 1970s, implants were placed directly under the skin (today called the prepectoral approach). Complications were very common, cosmetic outcomes were poor, and this approach was abandoned. The ‘total submuscular’ reconstruction followed, and although this technique was less prone to failure, it required slow enlargement of the expander to stretch the tight fibrous pocket between pectoralis major and rectus abdominis tummy muscle. This can also be quite a painful procedure, leading to deformity of the new breast mound in the short-term. It works best in slim women with small pert breasts. It’s also a good option as a delayed procedure after mastectomy, but doesn’t work so well when a longer skin envelope is preserved during immediate reconstruction.

   I chose to have a mastectomy, rather than lumpectomy and radiotherapy. Immediate breast reconstruction was not offered in 1988. My lifeline after the mastectomy was knowing that I was going to have a reconstruction. I had been widowed five years before that and there was a new male friend on the horizon. I thought that starting a new relationship might be the time to go for reconstruction. I have always been big-breasted and I wanted a big reconstruction. I wanted to look the same as I had done before.

The reconstruction was not as uncomfortable as I had thought it would be. The worst thing about it was the pressure on my chest, particularly at night. I felt as though I was struggling to breathe because of it. I was told that as time goes by, gravity helps and it is better to stand or sit up rather than lie down. I had to do quite a lot for myself when I got home but I did have some help.

The tissue expansion was done every two weeks. It took ten days after each expansion for the breast to feel reasonable again and then they would add more saline. It was a long and gradual process. The pressure on the chest was uncomfortable and it did help to see someone else who had had it. She was able to tell me that the pressure would pass. The process of expansion took nine months altogether. It is important to allow adequate time and then you can feel confident and put your life together again.   

In the 1980s, surgeons developed the subpectoral technique to reconstruct a breast with a more natural shape than can be achieved after the total submuscular approach. This approach places the top part of the implant or expander under the pectoralis muscle so that the edge of the implant is not seen in the cleavage area. More than 20 years later, a new approach was developed. This covered the lower and outer part of the implant with a sling to distribute the weight of the implant across the chest wall, relieving the pressure on the skin. The sling also gives the lower half of the reconstructed breast a more natural rounded shape, so it resembles a teardrop when seen from the side (Figure 5.8.1).

Figure 5.8.1 – Subpectoral approach seen from the side, showing mesh covering lower pole.

The main disadvantage of subpectoral reconstruction is that the muscle stays attached and active. This means that when you use your upper arm the muscle tightens and you can see it moving (‘animation’), which may be visible in a low-cut top. Over time, the muscle can push the implant downwards and outwards changing the position and look of your reconstruction. Some women also find that the pressure of the muscle on the implant can make them feel uncomfortable over their ribs and short of breath. This may be a particular problem if you use the pectoralis muscle frequently at work or during sports such as tennis and horse riding.

Figure 5.8.2 – Prepectoral approach seen from the side, showing mesh covering whole implant.

During the last 10 years, the prepectoral approach has been rediscovered, and is becoming increasingly popular. In the modern version of this operation, the implant is usually partly or totally covered by a sling. The weight of the implant is then supported by the sling rather than by the overlying skin, eliminating the problem of animation and discomfort. There is a downside to this approach – in some people, the edge of the implant may be visible under the skin particularly in the cleavage area.

Meshes or slings

These devices are a very important aspect of modern implant reconstruction because they’ve helped to improve the early physical and cosmetic results of this type of surgery since they were introduced more than 10 years ago. They’ve already been discussed in Chapter 4, but it’s worth taking a closer look at them to help you understand what happens if you choose this approach with your surgeon.

Slings made of your own tissue (dermal slings) are living tissue with their own blood and nerve supply, but your surgeon can only use this approach when there’s enough skin available, such as during a skin reducing mastectomy. Other slings are made from animal or artificial tissue, and need to be incorporated into your own tissue as quickly as possible. It’s important that they’re closely adherent to your own tissues and that no fluid collects between them and your skin. As touched upon in Chapter 4, fluid often collects after all types of surgery and is known as ‘seroma’ fluid. This seroma is made partly from lymph fluid trying to find new channels, and partly from inflammatory fluid produced by the trauma of surgery. Drains are used to ensure that this seroma fluid doesn’t stop these slings from being incorporated into your tissues.

Animal-derived slings are made predominantly from collagen, which is the material that makes skin strong and elastic. Once the slings have become incorporated into your body they’ll be completely replaced by your own tissue. Some of the artificial slings are made from material that becomes completely absorbed into your body, and others remain permanently. Those that are completely absorbed have the advantage that they don’t leave any foreign material behind as a hiding place for infection. Their strength will be lost as they dissolve, but new slings are being developed all the time that try to balance these two properties.

  • Dermal slings: These are made from your own skin. Breast reduction surgery normally removes the excess skin in the lower part of your breast so that it can be uplifted and made smaller. The tissue underneath the skin containing nerves blood vessels and collagen (the dermis) is left behind. When making a dermal sling, this tissue is separated from the skin above it and the underlying breast tissue, but it’s left attached to its blood supply from below the bra line. As it is a living sling, and your own tissue, it’s an excellent choice. But it can only be used if your breast skin is being reduced, so it’s not suitable for smaller breasts.
  • Animal-derived slings: These are also known as ‘acellular dermal matrices’ or ‘acellular collagen matrices’. They are also referred to as ‘biological’ matrices (see Chapter 4). The dermis is the layer immediately under the skin, which doesn’t contain hair or sweat glands. ‘Acellular’ means that all the cells that might cause rejection of the sling have been removed. A collagen matrix is made from tissue that isn’t under the skin — such as the pericardium tissue around the heart. Some of these matrices have been approved as kosher and halal. Surgeons often have a preference for a particular type of sling based on their experience or ease of handling the material. Some of the slings are freeze-dried while others contain preservatives that need to be washed out.
  • Synthetic slings: There are many different types of synthetic (or non-biological) slings available, and some are made from meshes similar to those used for hernia repair. Some are absorbable and some contain active ingredients such as titanium to prevent a reaction with the body. Synthetic slings are often less expensive than the animal-derived slings and are thinner. Their main disadvantage is that if your skin is particularly thin, your implant may be more visible and sometimes even the sling can be visible. A large-scale audit of implant-based reconstruction with and without slings has been conducted in the UK, and is known as iBRA. This has shown that many different slings are being used across the UK, but there’s no clear advantage of one sling over another. This is a rapidly evolving field of research that will give us much more information in the very near future.

If you have any concerns about the type of sling being used, in particular the slings derived from animals, please let your surgeon know so they can find an alternative. Slings derived from human tissue can be obtained. They are commonly used in the United States and are derived from freely donated skin from carefully screened volunteer individuals. This option is beginning to be available in Europe.

What are the early complications and side effects of implant reconstruction?

Implant loss, infection and skin necrosis

Losing your implant, or ‘reconstruction failure’ is one of the most serious complications that can happen after reconstruction, both for you and for your surgeon. The usual cause of implant loss especially in the early days after surgery is infection. This in turn is often secondary to skin breakdown caused by a poor blood supply (‘necrosis’). There are many other factors increasing the chance of implant loss. With the increasing popularity of this approach, new guidelines for surgeons and their teams have been introduced to reduce the risks of developing distressing complications which any patient can develop.

Some women have a greater risk of reconstruction failure, mainly because of a background of health and lifestyle factors. Women who smoke are at particularly high risk of developing problems because smoking narrows the small blood vessels that supply oxygen and nutrients to their skin, increasing the chances of the mastectomy skin dying off and becoming infected. Radiotherapy before or after a reconstruction can also narrow small blood vessels, increasing the chances of skin breakdown and infection. Other conditions such as connective tissue disease, diabetes or malnutrition can also increase the risk of implant loss.

Other technical and environmental factors can reduce the risk of reconstruction failure. These include the experience of the surgeon, the quality of the air conditioning in the operating theatres, careful aseptic precautions, meticulous operative technique and the use of antibiotics. There is as yet nothing to suggest that any one type of implant, sling, incision, implant placement or particular technique is more likely to have a better outcome than any other.

Pain

A number of women experience pain after a mastectomy. For some, this may persist, but doesn’t appear to be related to any particular type of reconstruction. The causes of long-lasting pain are unclear, but it’s more common in those women who are larger, or those with long-standing breast pain before their surgery or previously treated with radiotherapy.

Your specialists are very good at controlling pain around the time of surgery and will often use local anaesthetic blockade as well as painkilling drugs. Painkillers can be administered in tablet, liquid, injectable or suppository form. There will be plenty of pain relief available while you are in the ward after your surgery and to take home. Remember to alert your medical team if you develop severe pain as this may be the first warning of a complication.

Submuscular and subpectoral implant reconstruction may be quite painful immediately after surgery as the muscles are being stretched and feel quite tight. This usually settles quite quickly but the tightness can recur on physical exertion and if capsular tightening occurs.

   Because of the type of cancer that I had and the risk of recurrence in the other breast, I was offered the jackpot of double mastectomies and breast reconstruction. My treatment until then had been long-winded and I decided to have this to get it over and done with. Because I had lost a lot of weight after chemotherapy, they could not use the tummy muscle. I had no tummy and even less on my back. It was recommended that I had tissue expanders for the reconstruction.

I found the surgery very painful. The first set of implants was very painful, so they were swapped for something softer. I think that things might have felt tight because I am so slim.

As far as the shape of the reconstructions is concerned, if anything, there has been a slight drooping of the breasts. The tightness has always been there. The breasts match quite well because they were done at the same time.

The main thing that I would advise others is to get help for tightness, if it occurs, as soon as possible, rather than think that it will go away. My friends who have had breast reconstruction did not find it painful. They are all larger breasted and this makes quite a difference.

I am glad that I had the reconstructions because they have given me shape. I don’t have to worry or feel embarrassed in shops or on a hot day.   

Animation

Animation can happen if your implant is placed underneath your muscles. When you contract these muscles, the underlying implant is squeezed and upper part of your reconstruction becomes flattened. This deformity is visible above the bra line which is more of a problem in physically active women. As the muscle becomes stretched by repeated contraction, any deformity may become less obvious with time. It’s also possible that repeated contraction of the muscle over the top of the reconstruction will push the implant downwards and outwards with time. This can be uncomfortable, and may make some women feel short of breath.

The pectoralis is an important muscle that stabilises your shoulder and moves your arm. The muscle’s power will be weakened as it stretches across an implant so you may find some loss of strength, although the other muscles around the shoulder will normally compensate for this. It’s possible to reduce animation by cutting the nerve to the muscle, paralysing it with Botox, or detaching it from the breast bone. But doing this will weaken the muscle which may lose volume, making your implant more visible.

Implant visibility

Depending on where your implant is placed and the thickness of the fatty tissue under your skin will determine how easy it is to see the edge of an implant. This will be particularly important in your cleavage area. The thinnest part of the tissue covering the implant will be in the lower part of the reconstruction and sometimes it’s possible to see wrinkles and ripples in this area. Implants may be slightly rippled if they are soft or if the capsule is tightening around them. Expanders that are not fully inflated will also look rippled (Figure 5.9). This may not be a problem if the tissue overlying the implant is thick enough to hide irregularities, but you may be able to feel them as a ridge. A fat transfer is a simple way to thicken your own tissue, making your implant less visible.

Figure 5.9 – Patient with ‘wrinkles’ visible over the upper pole of the right breast.

Displacement and rotation

Sometimes your implant will change its position as time goes by. Teardrop-shaped implants can rotate within their pockets, moving into an ‘upside down’ position; when this happens, the upper part of the implant lies at the side or the bottom of the breast rather than at the top. This is most common after reducing the size of the implant and is relatively easy to correct with further surgery. Some subpectoral reconstructions are followed by a downward and outward displacement of the implant with time, due to contraction of the intact pectoral muscle. This is more difficult to treat and may require correction either by surgery to the muscle itself or to the implant cavity, or by replacing the implant in a different plane.

Upper pole fullness

When choosing an implant or expander your surgeon will need to know your preferred breast shape. Some women prefer to have more fullness in the upper part of the breast similar to that achieved by a balcony bra (Figure 5.10). The natural breast shape is like a teardrop, but this may be less popular with younger women. The aim of surgery is to achieve a good match between the breasts, but when surgery is to one side only, achieving symmetry out of a bra is more difficult than after bilateral reconstruction.

Figure 5.10 – Upper pole fullness after right implant reconstruction and augmentation of left breast.

Figure 5.11 – Red breast syndrome affecting both breasts after bilateral nipple-sparing mastectomy and prepectoral reconstruction.

Red breast syndrome

Occasionally, particularly after animal-derived sling reconstruction, the breasts may become red and sore (Figure 5.11). Your surgeon will be worried that you’ve developed an infection and you may need to be treated with antibiotics even without concrete evidence of the presence of bugs. It’s thought that this redness can occur when your body develops an immune reaction to either a component of the sling or to the preservatives that the surgeon tries to wash out. This red breast syndrome usually settles with painkillers and anti-inflammatories without any further treatment or long-term consequences.

What are the later complications and outcomes of implant reconstruction?

Capsular contracture and deformity

Whenever something is implanted into the body, it’s recognised as ‘foreign’ and a protective ‘capsule’ of scar tissue is formed around it, whether it’s a new joint, a thorn, or a silicone breast implant. The capsule may be thin and soft or thickened and tight. Over time a soft capsule may contract and become tight, changing the comfort and shape of your reconstructed breast, prompting you to consider further surgery. Capsular tightening (contracture) happens more frequently after breast reconstruction than augmentation, and after immediate rather than delayed procedures, particularly if radiotherapy has been given (Figure 5.12). Several factors may increase the risk, including a silent infection and the type of implant used. About 10% of women having breast augmentations will have further surgery within ten years for a range of reasons including capsular contraction. But the risk of capsular contraction needing surgery is much higher in women who have radiotherapy after implant-based reconstruction — about half will develop this problem by two years.

Figure 5.12 – Severe capsule contraction and distortion after reconstruction and radiotherapy to the right breast. Capsule removal and left breast reduction planned.

If you do develop painful capsular contraction, you may require further surgery for pain relief. Unfortunately surgery may also trigger further capsular tightening so it is important to avoid repeated surgery for relatively minor changes. The capsule may be completely removed or removed in part and the implant exchanged. This is performed under a general anaesthetic and most people will be comfortable within two weeks. NHS funding may be restricted for corrective surgery. Occasionally, it may be preferable to convert from an implant-based reconstruction to one that uses only your own tissue.

   I was 46 when it was recommended that I should have bilateral mastectomies. I did not have the option of immediate breast reconstruction, although it was being done at other hospitals.

I got through the mastectomies quite well physically and did the Run for Life five months afterwards. However, I hated the prostheses. I had been quite a large cup size before the surgery but because I had both breasts removed chose to have much smaller prostheses. I didn’t want to draw attention to myself any more. The crunch came when we were on holiday in Crete. It was hot and I got fed up with the prostheses, particularly in the swimming pool. It affected my confidence and I decided that I didn’t want to go through that again.

I saw a plastic surgeon about breast reconstruction and agonised about the choices but didn’t really have a lot of information. He only suggested that I should have a Becker tissue expander. I felt that I wanted to keep the surgery to a minimum, so came to terms with his suggestion   

All patients who have implant-based breast reconstruction or breast augmentation in England have had their details recorded by a National Registry since 2016. This means that is any implants need to be recalled or removed, or if there’s a safety concern, it’s easy to contact those patients who may be affected (see The Breast and Cosmetic Implant Registry section, Chapter 4).

Developing and correcting asymmetry

A reconstructed breast will never be completely the same as your natural breast. Not only will the sensation in your new breast be changed after a mastectomy, but it will look and move differently as well. It will normally be firmer and colder, and won’t ‘bounce’ or ‘squash’ like the breast it’s replaced. When reconstructing one breast it’s more difficult to achieve a well-balanced match with an implant, so your surgeon may offer to uplift, augment of reduce your opposite breast to get a balanced result. It’s also easier to achieve a good match if both breasts are removed and reconstructed at the same time. This is a much bigger operation which isn’t funded by the NHS, except in women at high risk of developing breast cancer (see Chapter 14).

   I was 62 and it was nearly 11 years since my mastectomy. I asked the Breast Care Sister whether it was too late to have reconstruction and she thought not. I saw the surgeon and he asked me why I wanted reconstruction. It was really the fact that I had gone from an ordinary prosthesis to a self-adhesive one, which had made me feel much more whole and natural. Having had to give that up, reconstruction presented itself to me as a good option. As I was small, it was suggested that I should have just a tissue expander, rather than anything more major. I was pleased about that.

Preparation for the operation was easy because it was my choice and there was none of the worry of the mastectomy or whether the cancer had spread. I felt more buoyant to cope with it than people who were having first time round operations.

After the operation, it was a bit sore but I only had the painkillers for a couple of days. After that, it was only uncomfortable if I moved. I got up and around the day after the operation and was in hospital for four days. The breast was covered and quite bruised. I looked at it when the dressings were taken off and was very pleased with it because it had been done through the same scar. I had been told what it would look like and that it would take two or more months to settle down, so I wasn’t anxiously expecting results at that time.

Because I was 62 and the other breast had lost condition, the surgeon operated on it at the same time, lifting it to match the reconstructed one. It did mean that I had twinges in both breasts at once but that was quite acceptable and also saved another operation.   

What if I want to be smaller?

It’s more difficult and risky to reconstruct a large breast using implant-only techniques, and it’s often safer to carry out a smaller more comfortable reconstruction. Discuss your preferred breast size with your surgeon before your operation to see what’s feasible and what’s most likely to match your body shape. You’re likely to lose your nipple and areola on the mastectomy side during a skin-reducing mastectomy, but your nipple is likely to be preserved on the opposite side if you decide to have this reduced as well. As long as your breasts aren’t excessively large or droopy, the nipple sensation on your remaining breast is unlikely to be affected very much.

What if I want to be bigger?

If your breasts are very small or empty it’s difficult to match this shape with an implant-only reconstruction. One solution to this is to make both sides larger by filling the skin envelope with a bigger implant. Sometimes your surgeon will be confident that your skin is healthy and loose enough to enlarge the breasts with a fixed volume implant at a single operation. In other patients, it may be safer to use an expander on the mastectomy side to make sure that the skin remains healthy as the breast enlarges.

Longer-term outlook

Information about the long-term results of implant-only reconstruction is limited, as the more modern techniques have not been widely used until relatively recently. As time goes by, your body shape changes, and your implant reconstruction may no longer be a good match for size or shape. Your natural breast tends to get bigger and droopier, while problems with your reconstructed breast including capsular tightening, implant displacement, wrinkling and visibility through the skin become more common over time.

The different techniques of implant-only reconstruction have not been compared for long-term satisfaction with each other, as it’s quite difficult to study long-term outcomes. Photographs are the most widely used technique for studying cosmetic outcomes, and tools to measure satisfaction are also used. This is a complex area of research. How you feel about your reconstructed breast may be tied up with your emotions about the initial cancer diagnosis and treatment, the effect on your relationships, and your body image and self-esteem. Clinicians have not yet developed a reliable measure of ‘squish’, ‘bounce’, or animation and how that affects women. We’re getting closer to developing reliable ways of measuring the outcomes of reconstruction that matter most to women. New approaches looking at physical, emotional and cosmetic outcomes reported by patients are increasing our understanding of the pros and cons of different techniques.

Chapter 6

Reconstruction with Latissimus Dorsi and Tummy Flaps

Dick Rainsbury

  • Latissimus dorsi (LD) reconstruction is a reliable technique, that takes tissue from your back.
  • It can sometimes be done without using an implant or expander.
  • It’s used for both immediate and for delayed breast reconstruction.
  • Tissue can be taken from your tummy instead of your back, using a similar approach.
  • Your reconstructed breast will look and feel very natural.
  • Both techniques require major surgery.
  • Recovery takes around 6–8 weeks.

Using live tissue from another part of your body to reconstruct your breast has been a big new development in breast reconstruction over the last 40 years. In fact, it’s quite remarkable that tissue will heal into place when it’s been moved from one part of your body to another. Most tissue that can be moved like this is made from muscle, fatty tissue, and skin, and these fleshy structures are called myocutaneous flaps. The use of living tissue to reconstruct a lost breast is a major advancement. Your new breast is made of soft, warm, living tissue, which can be trimmed and shaped to look like your original breast.

Two different approaches are used by surgeons to make sure a myocutaneous flap has a good enough blood supply to remain healthy and to heal into place once it’s been moved. The first approach is to leave the flap attached to its blood supply, or ‘pedicle’. The pedicle is rather like an umbilical cord, with the ‘mother’s end’ of the pedicle remaining attached to the place where the flap tissue was taken from – the donor site. The second approach is to divide the pedicle or umbilical cord before removing the flap to its new position. This is called a free flap, because it’s been freed from its own blood supply. The surgeon then has to use a highly specialised technique to join the blood vessels in the pedicle to the blood vessels in the region of the mastectomy site. The vessels are so small that this needs to be done using a microscope, so the other name for this procedure is a ‘free tissue transfer’, or a microvascular flap (see Chapter 7).

The best donor site is one where the loss of donor tissue doesn’t disfigure the area where the tissue is taken from. The two commonest donor sites are on the back and on the abdomen. The LD flap is taken from the back and is discussed below. The transverse rectus abdominus myocutaneous (TRAM) flap is taken from the abdomen. It’s discussed briefly at the end of this section, but in most situations today, a Deep Inferior Epigastric Perforator (or DIEP) flap is a more popular choice (see Chapter 7).

Implant-based LD reconstruction

The LD flap is often used with an implant or expander. It’s a reliable and adaptable technique that results in consistently good outcomes for a wide range of women. Some aspects of implant-based LD reconstruction are very similar to autologous LD flap reconstruction (when implants are avoided), but there are some important differences. The information in this section will help you to understand the differences so that you and your surgeon can decide which is the best operation for you.

The main difference between the two techniques is that following autologous LD flap reconstruction the whole of your reconstructed breast is made from your own tissues. But after implant-based LD reconstruction, a little less than half of your new breast is made from your own tissues and the rest is made from an implant. So less tissue needs to be taken from your back to do the reconstruction, but you’ll have an implant in your new breast. This often gives your reconstructed breast a very good shape and appearance, which can be adjusted after your operation. But there are some implant-related complications that you can avoid with autologous LD flap reconstruction – an operation that is associated with different complications (see below).

Deciding if implant-based LD reconstruction is an option for you

Implant-based LD reconstruction is suitable for a wide range of women. This is because the combination of an adjustable expander and a fleshy flap gives your surgeon the opportunity to rebuild a life-like breast of almost any shape or size. Because it’s a combination of two different approaches – an implant and a flap – it’s got some of the advantages as well as some of the disadvantages of each approach.

   Having a breast reconstruction at the same time as the mastectomy mattered to me. I am a singer and performer and need to wear suitable clothes. I need to wear low-cut tops and the first gig that I sang in again was two months after the operation. I wasn’t worried about my breast, but only that the scar on my back didn’t show. I found that the operation had not affected my voice or my confidence at all.

I didn’t know anything about breast reconstruction before it was recommended. I was given a lot of information in the clinic and later by the breast care nurse. I found that reading the information was the most helpful. I didn’t particularly want to talk to anyone else who had had reconstruction. I knew what the diagnosis was and just wanted to get the operation done.

I was expecting to be in a lot of pain after the operation. In fact, there was a lot of numbness but I have had worse toothache. The only thing that was difficult was sleeping in a comfortable position.

I didn’t see my new breast until about six days after the operation, when I was able to have a shower. I looked in a big mirror and it looked great. My partner was amazed at how good it looked and my friends thought that it was fantastic.

By the time that I got home, after ten days, I wasn’t restricted very much. Some things were difficult to stretch for initially.   

So when can it be used to reconstruct your breast? Because it’s a combined technique, it can be used in almost all of the situations when either an autologous LD flap or an implant can be used. This means that like autologous LD flaps, it’s a good technique for immediate and delayed reconstruction – for women who have their breasts reconstructed either during or after their mastectomy (Figure 6.1 and Figure 6.2).

   I knew that I was going to need a mastectomy because the breast cancer involved the nipple. I just thought that the breast had better go, and the sooner the better. My priority was to remove the cancer, get the chemotherapy and radiotherapy out of the way and then when everything was just right, have the reconstruction.

I did not like the real prosthesis after the mastectomy, so wore a softie, which was not sweaty. I did not want to wear the bras that the shop advised, so I wore what I wanted to wear, to be as normal as I could. I went on holiday three weeks after the mastectomy and the swimming helped my arm. I got a suntan and came back feeling good. My children were eight and fifteen at the time and they coped because I was positive. I went back to work during the chemotherapy because it stopped me from sitting at home.

When discussing reconstruction choices, I was attracted to the latissimus dorsi with an implant because I had seen people who had had them before and knew that it would look right for me. It is always worth talking to people who have had reconstruction, to see the finished breast when making up your mind. When I was making the decision, I was on my own. I am now back with my daughter’s father.

I had the reconstruction eight months after the last chemotherapy, with radiotherapy in between. The skin had settled down from the radiotherapy by the time that I had the operation. I felt fantastic after the operation and looked at the reconstructed breast straight away. I showed lots of people and was glad that I didn’t have to think about a prosthesis again. I threw it away. My arm was fine this time and I didn’t need physiotherapy afterwards.   

Figure 6.1 – Left mastectomy and immediate implant-based LD flap reconstruction, followed by nipple reconstruction.

Figure 6.2 – Delayed implant-based LD flap reconstruction of the right breast.

   I was offered a mastectomy and immediate reconstruction but I decided to delay the reconstruction because I felt that if I had to have any treatment afterwards, there was a chance that the new breast might be damaged. I think that I made the right decision.

I went into the choices for reconstruction very thoroughly. I read a bit about it in a book I was given and looked at the websites. I also talked to the breast care nurse in great detail. I was able to see what an implant looked like, as well as being shown photographs. I met someone locally who had reconstruction and couldn’t believe it when I saw it. I knew that my reconstruction would not be as good as that because she had hers done at the same time as the mastectomy. I spent a long time weighing up the advantages and disadvantages before I finally said that I would go ahead.

There was only one reconstruction available to me because I had had so many operations on my tummy in the past. Originally, I said that I did not want an implant. I later realised that if I didn’t, there was no way that I could have it done. Having taken facts about implants into account, I thought that perhaps it was not such a bad thing after all. It was my decision and no one has tried to influence me. I felt that is right because I didn’t want people telling me what I should do. Since the reconstruction, everybody has said that I did the right thing. My husband has been brilliant and has supported me all the time.   

Figure 6.3 – Implant-based LD flap reconstruction of the right breast can match the ptosis of the left breast.

Like autologous LD flap reconstruction, implant-based LD reconstruction is very useful for women who have badly scarred, thinned or irregular skin around their mastectomy after previous surgery, radiotherapy or complications from previous treatment. This is because it ‘puts back’ the tissue which has been lost or damaged, and replaces it with healthy, normal, soft living tissue from your back. It’s also very suitable if you’re a woman with a more mature breast shape, where most of the volume of your breast lies in the lower part of your breast (or lower ‘pole’), below your nipple (Figure 6.3).

   When being told by the surgeon that I needed a mastectomy, I was asked whether I had thought about breast reconstruction. I discussed the practical aspects and was shown some photographs but didn’t ask enough questions, for example how long the operation and recovery would last and how painful it would be. I just assumed that he would reconstruct and that would be that. I was quite naïve. I don’t think that anything would have put me off because to me having a reconstruction meant that everything would be as normal as possible. Once I had made my decision, I did not sit and worry about it.

I was given the option of speaking to another patient but didn’t do it because I had made up my mind. If I had been in two minds, seeing somebody else would have been extremely helpful.

I wasn’t expecting the operation to be as painful as it was. Again, it was probably a bit of naivety because I knew that it was a big operation. Also, I had never had serious surgery before. I got up the next day. I needed help and was really surprised how weak I felt. The drips and drains were no problem.   

Because it’s a good option after previous radiotherapy treatment, implant-based LD reconstruction is a good choice if you need a mastectomy for a recurrent cancer that was previously treated by lumpectomy and radiotherapy. And finally, it may be recommended for women who decide to have both breasts removed (bilateral risk-reducing mastectomy) and reconstructed at the same time. This is a major operation that can take 4–6 hours, even when two teams of surgeons are operating alongside each other. The cosmetic results of this type of surgery are often extremely good because the breasts can be reconstructed to match each other.

   Three years after I had a lumpectomy, chemotherapy and radiotherapy for breast cancer, I was told that they had found changes on the mammogram and I needed a mastectomy. I was 40 and I was devastated. Life had gone back to normal for me after the lumpectomy.

I did not know anything about mastectomy or reconstruction. I would have walked away from the surgery if I hadn’t been convinced that the cancer wouldn’t go away on its own. When you are so fit and well, it is hard to believe that you have cancer. Although the reconstruction was only cosmetic, I don’t think that I would have been happy without a breast. When I had the lumpectomy, it was just a very small scar. I did have scars from the radiotherapy on my breast. Considering reconstruction on top of that was difficult. I made the decision to have the surgery because of my children, who were 9 and 12 years old at the time. You have to do the positive thing and get on with it.

When I first woke up from the operation, I felt that it was behind me and I was on the road to recovery. I had lots of reservations before I looked at the reconstructed breast but I knew that it was going to be all right because I had every confidence in the surgeon.

I could do everything when I went home but it took quite a while to get my strength back. I wouldn’t say that it is an easy operation because it was six months before I could sleep on my side. That was a minor thing, though. I had nearly six weeks off work.

I had a nipple reconstructed six months later. I did lead life as normally as possible but nothing was just right until the surgery was finished.

It is four years since the reconstruction and the appearance has changed over the time. The shape has got better, the breast feels softer and it has dropped. The scars on my back are well healed and my breasts match well. There is nothing that I can’t do with my arm.   

When should this technique be avoided? There are some definite Nos and some Maybe Nots. It definitely shouldn’t be used in women who don’t want an implant. And like autologous LD flaps, it can’t be used if the blood supply to the muscle has been lost or the muscle itself has been divided and damaged. It’s also best to avoid it if you have a medical condition that increases the risks of major surgery. These include things like heart failure, circulatory problems, lung disease or stroke, or if you’re really overweight. It’s also important that you’re aware if you need radiotherapy after your mastectomy, there’s a 50/50 chance that your new breast will become firm, distorted or uncomfortable.

So if you’re likely to need radiotherapy, it may be better for you to choose an autologous LD flap or TRAM flap reconstruction. Or better still, think about delaying your reconstruction until you’ve had your radiotherapy. Doing a sentinel node biopsy before your mastectomy may help your surgeon to decide if you’re going to need to have radiotherapy, so that together you can decide which is the best operation for you.

There is one situation where using LD and an implant is one of the only options. This is in slim women with medium- to large-sized, mature-shaped breasts who want a reconstruction that doesn’t reduce the size of their new breast, and that looks like their other breast. Because they are slim they don’t have enough of their own tissue on their back, on their tummy or even on their buttocks to reconstruct their breast. In this situation, using an implant combined with an LD flap is an ideal solution. This approach is especially suitable if someone like this is requesting reconstruction some time after mastectomy and radiotherapy.

Surgical technique

On your back there are two large triangular muscles – the LD muscles – one on each side. They extend from the tip of your shoulder blade to your spine and down to your hip bone or pelvis (Figure 6.4). The muscles are attached by a tendon to your upper arm. The blood supply and nerve supply come from the blood vessels in your armpit (axilla) and are usually healthy and working well, even if all the lymph glands in the axilla have been removed. Although the LD muscle lies on your back, it’s actually a shoulder muscle and is used to push yourself or pull yourself up when you’re involved in activities such as mountain climbing, rowing, shovelling, cross-country skiing and butterfly-style swimming. Only competitive athletes or golfers will miss the extra strength of this muscle, which is why it’s used quite commonly for reconstruction of other defects, such as broken limbs, reanimation of paralysed faces and so on, without interfering with normal day-to-day activities. Other muscles around your shoulder girdle are able to take over the function of the LD and most patients return to their usual work, sporting or leisure activities within 3–6 months after surgery.

Figure 6.4 – Anatomy of the LD muscle, showing the different positions that can be chosen for the skin island.

Before your operation, your surgeon will normally ask you what size you’d like your reconstructed breast to be – bigger, smaller or the same? If this isn’t mentioned, you should bring it up because now is the time to have this discussion. This will decide what size implant or expander will be used. Also ask your surgeon whether the implant or expander will be shaped like a teardrop, or whether it will be a rounder type. The teardrop type is generally more suitable for a more mature breast shape, and the rounder type for a younger-looking, more prominent breast.

Your surgeon should explain to you that with an expander, the injection port – the small chamber that is used for injection of salt water (saline) into your expander after the operation – may be felt under the skin. It’s usually felt as a lump, either below the breast or behind the breast, near where the cup of your bra meets your bra strap. Some expanders have ports that are built into the shell, and are located using a magnetic device.

Just before your operation, your surgeon will visit you and draw some lines on your breast or mastectomy region (Figure 6.5.1). This is like a road map to make sure that your new breast is in the best possible position. Some lines will also be drawn on your back to help to show exactly how much muscle needs to be ‘harvested’ for your reconstruction (Figure 6.5.2). Your surgeon may also ask you to put on your bra so that your scar can be positioned accurately so it’s hidden by your bra strap or bikini strap (Figure 6.6).

Figure 6.5.1 – Mark-up before implant-based LD reconstruction showing where the new breast will sit on the chest wall.

The actual operation is very like the operation for autologous LD flap reconstruction. There are a few differences because you’re having an expander put in and the flap itself isn’t so large and bulky. This means the incision on your back is usually smaller than the one used for autologous LD flap reconstruction (Figure 6.7). Also, the donor site, or space left behind once your muscle has been removed, is smaller. Because of this, the drainage of fluid coming out of a small tube in this space is usually less.

Sometimes, if your mastectomy scar is low down on your chest wall, your surgeon may decide to make a longer incision on your back. This means that the skin island of your flap can be be hidden away in the lower part of your reconstructed breast, making it less visible, and giving the breast a more natural shape (Figure 6.8).

Figure 6.5.2 – Mark-up before implant-based LD reconstruction showing the skin and muscle outline on the back.

Figure 6.6 – Scar under bra-line after implanted-based LD flap reconstruction.

Figure 6.7 – Small scar on the back after implant-based LD reconstruction.

Figure 6.8 – LD flap lying in lower part of breast, covering the expander, giving a more full and natural shape to breast.

   I was 66 when I was told that I had breast cancer and needed a mastectomy. I was shattered. All my life I had thought that breast cancer was about the worst thing that could happen to me because I would be disfigured. The week before the diagnosis, I saw a film showing breast reconstruction. So my response was ‘Please do a reconstruction at the same time.’ Anything to help me keep my femininity and be able to present myself to the world as the same person was important.

I was then given plenty of detailed information which only confirmed my decision. It was three weeks before Christmas, so engagements were cancelled and I asked for the operation as soon as possible. The breast care nurse was very helpful and she introduced me to another patient with a similar breast reconstruction. She was lovely and had a list of things that were unexpected when she had her operation. We worked our way through it with a cup of coffee. I would say that people should certainly consider talking to other patients because it is often easier talking to them rather than those close to you. I couldn’t talk that way to my daughter because I didn’t want to burden her.

I went home with the drain in and it was manageable. It is easy to catch it on door handles, though. I could do everything. It would not be difficult for someone who lived on their own. I did have to go back as an outpatient and have fluid drained from my back four times but didn’t mind because I couldn’t feel it. I went to the gym two weeks after the reconstruction and just did leg exercises to begin with. It was several weeks before I did arm exercises.   

When your flap has been freed up from the surrounding tissues, it’s passed around the outside of your chest, through your armpit and into the mastectomy ‘pocket’ that your surgeon has prepared for it. Up until this point, the operation performed by your surgeon is much the same as the operation for an autologous LD flap. The only difference is that the amount of tissue taken from your back is less. From here the operation’s a bit different; instead of modelling the flap by folding it to make the shape of your new breast, the flap is sewn into the edges of the space that was left behind after your mastectomy. This makes a kind of ‘sandwich’ of muscles – your LD muscle in front, and your pectoral muscle behind. Your surgeon completes the reconstruction by sliding an expander or an implant in between these two muscles, so that it becomes the ‘filler’ lying between the two muscles of the sandwich (Figure 6.9).

If an expander is used, it’s now inflated with a solution of saline, so that the size of the new breast is as close as possible to your natural breast.

Symmetry surgery

Because expanders enable your team to adjust the size of your breast after the operation, fewer women need surgery to adjust the size and shape of their natural breast than after using non-adjustable implants, or after autologous LD reconstruction. If there’s still some ‘lopsided-ness’ once expansion has been completed, then a small number of women will opt to have a breast reduction or a mastopexy (see Chapter 11) to produce a more symmetrical result. It’s better to do this after your reconstruction has settled down, rather than at the time of your reconstructive surgery (Figure 6.10).

Figure 6.9 – Inserting the expander under the LD flap.

Figure 6.10 – Implant-based LD flap reconstruction of the right breast and reduction of the left breast for symmetry.

   I had surgery on my other breast to make it match the reconstruction four months after the mastectomy. The breast care nurse assured me that although it looked very square, the shape would improve in time, and it has. My appearance would have been very odd if I had not had this second operation. The breasts match fairly well. I wear off-the-peg bras but not underwired ones. It is better to have a reconstruction than no breast. I can wear normal clothes and feel normal. I just forget about it.   

The scale of the operation, success rates and complications

The scale of the operation is very similar to having an autologous LD reconstruction. Although there is a little less surgery to harvest the flap, this is counterbalanced by the extra surgery needed to prepare and position the expander in your new breast. As with the autologous LD, it’s a highly reliable flap and it’s very rare to have problems with the blood supply. The problems with healing of your mastectomy skin are also much the same, with a higher risk of skin death (known as necrosis) and skin loss in smokers. The problems caused by loss of fatty tissue on the surface of your flap are avoided, because much less fatty tissue is attached to your flap. The wound on your back tends to heal quickly because it’s smaller, and there’s less extensive surgery underneath it.

The main difference in complications are linked to the use of implants or expanders. These are avoided with autologous LD flap reconstructions. They aren’t very common, and can either happen soon after surgery or later on. Complications soon after surgery include infection and a collection of blood, called a haematoma. If you get an infection around your implant or expander, it usually means your surgeon will have to remove it. You’ll then have to wait for your infection to settle down before it’s possible to put it back in again. If you develop bleeding and a haematoma around your implant, this may settle by itself. If it continues, your surgeon will have to drain the blood and stop the bleeding, but it’s not usually necessary to remove the implant in this situation.

Later on, you may develop some thickened scar tissue around your implant or expander, which can make your reconstructed breast look distorted, and feel hard and painful. When this happens, it’s possible to cut away the scar tissue, which can cure the problem, but it sometimes returns. In a small number of women, their expanders will rupture, often ten or more years after the initial surgery. If that happens, your surgeon will need to replace it with a new one.

   I was 67 when I had breast reconstruction. Once the operation was over, I didn’t feel too bad. I was walking around the next day and went home after a week. I could do most things at home but tired easily. I couldn’t reach high things for the first three weeks. I drove again after six weeks. I don’t think that the strength in my arm was affected.

I had to have the fluid drained from my back, where the muscle was moved, for nine weeks as an outpatient. Once that stopped, it was easier to get back to a normal lifestyle.

The reconstructed breast is slightly smaller than my other breast but it doesn’t really bother me. I don’t think that anybody would notice. I don’t have to wear special bras and you don’t really see it under clothes.

I am all for going for it anyway. It is a very personal thing. Some people do have complications and there is always the risk. It was very helpful having the contact with the breast care nurses and knowing that I could phone them if I was worried about anything. I felt I was normal again after having the reconstruction, it helped psychologically.   

Advantages of implant-based LD flap reconstruction

This approach is safe, reliable, adaptable, and generally available. It’s suitable for a wide range of women with a big range of breast shapes and sizes. It usually results in smaller scars on the back, that are less visible. As the size of the reconstructed breast can be changed after the operation, fewer women need to change the normal breast to make it match the reconstructed side.

Disadvantages of implant-based LD flap reconstruction

The main disadvantages with this technique are related to the use of implants or expanders. The complications are uncommon, and affect less than 5% of women. If they do happen to you, it may mean that your implant of expander will have to be removed and replaced at a later date. If you develop problems with scar tissue, this can usually be corrected by fairly minor further surgery. In the long run, your implant may need to be exchanged for a new one if it shows signs of leakage or rupture. Perhaps the most important disadvantage is the fact that radiotherapy can undo the good results from this approach. Even autologous LD flap reconstruction can be adversely affected by radiotherapy, but these effects are greater when implants or expanders are used. Implants are very rarely associated with Anaplastic Large Cell Lymphoma (ALCL), which is covered in Chapter 4.

   I looked at the breast the first morning because the nurse looked at it and said that it looked really good. After that, I showed everyone who came that I knew well. My husband had a quick glance the first day and his reaction was ‘Oh, that’s all right isn’t it?’ He wouldn’t express himself more fully than that. The fact that I was so positive helped him.

Getting home was difficult. I couldn’t get comfortable without the triangular pillow that I had in hospital. Other than that, I was fairly OK. I couldn’t do very much in the first few days. I just came downstairs and the cat sat on me. I did go with my neighbour to the local shop but I didn’t do anything energetic.

Fluid collected on my back where the muscle had been moved for four weeks. It was only a problem in as much as I kept on thinking that it wasn’t getting better. I felt better after it had been drained and then it filled up again. I was able to go abroad after four weeks, taking care.

I only had the tissue expansion done a couple of times and it wasn’t painful.   

Autologous LD flap reconstruction

Another popular method has been developed to reconstruct part of a breast or the whole breast using nothing but your own tissues. It’s called autologous LD flap reconstruction because it’s based on making use of the LD muscle, skin and fatty tissue from the back to rebuild the breast without using an implant.

Deciding if autologous LD flap reconstruction is one of your options

This is a particularly good option for women who want a reconstruction at the time of the mastectomy (immediate reconstruction) and may need radiotherapy after surgery. The autologous LD flap can also be used to rebuild your breast, sometimes months or years after your mastectomy (delayed breast reconstruction), but the amount of spare skin on your back will decide how droopy your new breast will be. An uplift of your opposite breast is required more often than in immediate breast reconstruction, when a much smaller area of breast skin is excised and the original skin ‘envelope’ is filled with the flap tissues. This technique is also a good alternative for patients who require reconstruction of both breasts either at the same time – in women with cancers in both breasts, or for risk-reducing mastectomy – or as a staged procedure should a second cancer appear in the remaining breast at any time.

   I was really determined that I didn’t want to have an implant, so breast reconstruction was narrowed down to two options. The reconstruction using my tummy might have had complications later, so I didn’t want that. I am quite active, particularly with gardening. I decided to have an immediate latissimus dorsi reconstruction, using just the back muscle to make the breast.   

Surgical techniques

The LD flap is particularly suited for breast reconstruction because the muscle lies directly underneath your skin. This allows a skin patch (also called a skin island) of almost any size and shape to be moved safely together with your muscle and with a layer of fatty tissue on the surface of your muscle to wherever the muscle will reach, while it is still attached to its blood supply from your armpit (Figure 6.4). By taking extra layers of fatty tissue on top, below, above and in the front of the muscle, it’s possible to double the volume of the flap and avoid the use of an additional implant when reconstructing small to moderate-sized breasts.

The LD muscle, together with the fat and the skin island, are moved through a tunnel under the skin of your armpit, which may have already been created by removal of the glands in this area, to the front of your chest. During your mastectomy, some breast skin, including the skin of the nipple, together with any skin that may be scarred or involved in the cancer and the breast itself will be removed. The skin island from your back can be inserted like a dart into the space surrounded by your remaining breast skin and the muscle and fat can be folded underneath to fill up the space created by your removed breast (Figure 6.11). This builds up a breast with your own tissues, avoiding the use of a breast implant.

Figure 6.11 – Autologous LD flap reconstruction.

The operation will leave a slightly curved scar on your back, usually at the level of the bra strap and therefore hidden as much as possible. The amount of back skin showing on your reconstructed breast depends on the amount of breast skin that needs to be removed. If you have a delayed breast reconstruction, your surgeon will usually need to take a larger amount of skin from your back (Figure 6.12.1 and Figure 6.12.2) than during immediate reconstruction (Figure 6.13). A reconstruction using LD isn’t possible if you’ve had previous surgery with a scar on the ribcage such as a lung or heart operation. This is because it may have divided the muscle or the blood vessels that keep this muscle alive (called the ‘vascular pedicle’).

Figure 6.12.1 – Marking the patient’s skin before delayed autologous LD flap reconstruction.

Figure 6.12.2 – Post-operative pictures following delayed autologous LD flap reconstruction.

Figure 6.13 – Post-operative pictures following immediate autologous LD flap reconstruction, showing smaller scars compared with delayed reconstruction.

Symmetry surgery

As with all types of breast reconstruction that use a woman’s own tissue, there’s a limit on how big a breast can be reconstructed. Surgeons can only take as much tissue that’s available on the back, but most women have enough tissue to reconstruct a breast of average size (B to C cup). If your other breast is very large or very droopy, then there are two options. Your larger breast can be reduced and uplifted to match your reconstructed breast (Figure 6.14). This would result in two smaller breasts with a more uplifted appearance and may be the preferred option for most women with very large and very droopy breasts. Alternatively, it’s possible to increase the size of the smaller, reconstructed breast with a traditional implant or ‘lipofilling’. This form of ‘fat transfer’ moves fatty tissue from other areas of your body into the reconstructed breast to increase the size, or to even out any irregularities (see Chapter 12). Breast implants should be avoided in immediate LD reconstruction if there’s any real chance that your team will advise you to have postoperative radiotherapy. This is because the chance of hardening of the implant after radiotherapy (called ‘capsular contracture’) is high.

Figure 6.14 – Reconstruction with left autologous LD flap and reduction of the opposite breast to achieve symmetry.

   I had chemotherapy and radiotherapy after the reconstruction and worked during the treatments. My breast doesn’t seem to be any different after the radiotherapy.

I went back to wearing underwired bras quickly after the reconstruction.

I would say to someone considering reconstruction to do it. It makes you continue to feel like a woman and you also only have to go through it once. The whole experience has made me think that I should stop and live for today. Obviously we all hope that we won’t have to face it but having done so, you have to be as positive as possible. There were days when I thought that it was horrible and didn’t know how to go on but I talked myself through it and got on again. You should take the opportunities that you are given so that you come out feeling as complete a woman as you can.   

The scale of the operation, success rates and complications

The LD reconstruction is performed under general anaesthetic and will take your surgeons about four hours for a delayed reconstruction, when the breast has been removed already. An immediate reconstruction will take four hours if there are two teams of surgeons performing the mastectomy and the reconstruction at the same time. When one team of surgeons is performing the whole operation, it takes about 5–6 hours, as your breast has to be removed first before doing your reconstruction. You’ll stay in hospital for 3–4 days, depending on how much fluid is draining from your wound. Your recovery from surgery will take about six weeks. During this time you’ll need to have regular physiotherapy to make sure that your shoulder function returns to normal as quickly as possible.

   After the operation I got up as soon as I could. My back felt very numb. I really didn’t have a lot of pain. I just felt a bit wobbly. After about three days, I went for a walk around the hospital. That gave me confidence. I looked at the reconstruction after a couple of days and it wasn’t as bad as I thought that it was going to be. The breast was higher up than I had expected and it was bigger because it was swollen from the bruising after the operation. I was in hospital for one week. I didn’t do any housework for some time and lifting anything heavy was difficult.

I was given exercises by the physiotherapist in hospital to do at home. I did not realise how important that was. My back became stiff while I was having radiotherapy and I had some more physiotherapy. I wish that I had had more physiotherapy help earlier.   

   By about nine months, I still couldn’t do the things that I loved like swimming and gardening. I found that I couldn’t push a full-sized shopping trolley and staying in one position for too long was difficult. Some days I felt quite frustrated and had to be very patient, particularly with the gardening season.

It is now over two years since the reconstruction and I still have some stiffness in my back but it is much improved. I continue with the exercises and the swimming. I can now do most things in the garden but for shorter periods. I have to change position frequently. I cannot carry as much as I used to but I don’t really feel restricted. When it is cold, my back muscles do stiffen up.   

   I felt a lot better than I thought I was going to after the operation. I was not in pain as such, it was discomfort. The drains were a little bit daunting and awkward but you adjust and cope with them. I got up and around the next day, as well as starting exercises gradually. My arm was quite stiff but the movement came back fairly quickly.

The scars were very neat and I kept my own skin. I was only missing the nipple.

When I got home, I could do all the normal things but I wasn’t allowed to do any heavy lifting for six weeks. My mum came to stay but I did all the washing and things like that. I did my exercises regularly and my arm movement got better.

Some fluid did collect on my back after the drains were taken out. It was drained once, some more collected but it just dissolved back into my body itself.

I drove again after five weeks. I went gently to start with. I had been concerned about having to make any quick movements but that was all right.   

LD flap breast reconstruction is a very versatile, safe, and reliable technique. The overall success rate of the LD flap is very high, with the operation producing a healthy flap in more than 99% of patients. Serious damage to the blood vessels in the armpit that keep the muscle alive is rare, and causes the flap to die off and fail. Some fatty parts of the flap die off in about 15% of women. This happens most commonly in overweight patients undergoing reconstruction of a large breast.

Loss of some of the breast skin that has been saved during mastectomy or delayed healing of the back wound happens in 10–15% of cases and it’s much more likely in smokers. The most common problem with the back wound is a collection of fluid under the skin, a seroma. Your surgeon may need to draw off this fluid with a needle and a syringe if it becomes troublesome – sometimes on several occasions until it settles down. The injection of a weak steroid at the first time the fluid is drawn off or the use of special sutures to close off the space during the initial operation helps to reduce the chances of seroma formation.

Advantages of autologous LD flap reconstruction

The LD flap breast reconstruction is a very adaptable and predictable technique. As with reconstruction using abdominal tissue, it’s able to provide a completely natural reconstruction with your own tissues, but it avoids having to take muscle from your abdominal wall. It also avoids the complications of free tissue transfers. The technique is therefore suitable even for patients who have other health problems and may be too high risk for free tissue transfer.

The biggest advantage of the autologous LD flap is that only your own tissues are used to rebuild your breast. This avoids all the potential complications of breast implants or tissue expanders – including infection, loss of the implant, capsular contracture and the need for replacement of the implant at a later stage.

This type of reconstruction will also withstand postoperative radiotherapy much better than most other types of breast reconstruction. Because of this, it’s well suited for immediate breast reconstruction when it may not be possible for your team to predict whether radiotherapy is going to be required. It’s also suitable for women who have large, advanced cancers, when radiotherapy is planned from the outset. Radiotherapy after autologous LD reconstruction will lead to some shrinkage of your reconstructed breast. This shrinkage is often most obvious in the upper part your breast (the cleavage area), but can be corrected by lipofilling.

Disadvantages of the autologous LD flap reconstruction

Disadvantages of the autologous LD flap include a large donor scar on your back, which can sometimes be avoided by use of keyhole techniques (Figure 6.7). There may also be a difference between the colour of the skin island (taken from your back) and the remaining skin of your breast. When this patch effect happens, your reconstructed breast will have a patch of paler skin in the centre, surrounded by a rim of darker skin (Figure 6.2 and Figure 6.15). There may also be a limit to the amount of skin and soft tissue that can be transferred, so that your reconstructed breast may be quite a lot smaller than your other side. The patch effect can be avoided by designing your flap to sit in the lower part of your new breast.

Figure 6.15 – Patch effect of the LD skin island.

Scars on your back following autologous LD flaps are sometimes slow to heal, and the quality of the scar cannot always be predicted. Even so, these problems compare favourably with some of the abdominal problems experienced by patients after reconstruction with pedicled or free TRAM flaps (see Chapter 7).

   I work in a male environment and the guys on the shop floor were a bit dubious about me going to see them afterwards. I don’t know whether they thought that I was going to be physically different. As soon as I went in, they all wanted to know what had happened as long as I was happy to tell them. I think that it helped them and me to talk.

My back was a little bit numb where the muscle was moved and even after a year, I have not got full sensitivity, particularly in the front. It used to upset me but does not worry me now. I also used to be able to touch the muscle in my breast and feel the sensation in my back where the muscle had been. I was warned about this but it is strange. It is going away now.   

   I had my first mastectomy in 1985 and the second in 1999. I would not have even thought about breast reconstruction if the breast care nurse had not talked to me about it after the second mastectomy. I looked at the leaflets and thought I couldn’t possibly think about it at that stage. After I had worn two prostheses for some time and found them pretty awful, I got the leaflets about reconstruction out again. It didn’t even dawn on me that I might not consider reconstruction at 62.

I talked to my family doctor and came to the conclusion that I would have reconstruction done using the muscles from my back. My husband took part in the discussions and said that if I wanted reconstruction, I should go ahead. It was an easy decision to make.

I was advised to bring two good quality sports bras and back extensions into hospital with me. It was a wonderful operation and I was not aware of having pain at all. I was out of bed the next day and sat on a seat for a shower after two days. I looked after myself, with all the drains after three days on the ward and it was all manageable. My back was pretty numb, so lying down was no problem. My back is still numb now, three years later but I realise that is just part of the operation. People should be advised to rub cream into the back scars daily because I didn’t and it stiffened up a bit. Regular gentle exercises relieve the stiffness.

I went home after a week and could do most things apart from anything heavy. I did the exercises I had been taught regularly.

Once the drains had been removed, I did have fluid collecting on my back, where the muscles had been moved. This is normal and I had it drawn off regularly. This went on for some time. I drove after about three weeks.

It is three years since the reconstructions and there is nothing that I can’t do. I can even do curling. In curling, you use your right hand but you have to brush with both hands and it is good exercise to do the sweeping. Nothing is impossible.

I had assumed that having both breasts done, they would both be exactly the same. What I didn’t take into account was that the mastectomy scars were different ages and the skin coming in would be at different levels. They did their best with me but it was like working with two different things. I would say that expectations go with age. Even if you have a delayed reconstruction like I did and have a seam, it still looks good wearing a low neckline.

People should take each day as it comes because there will come a day when they forget that they had anything done. I preferred to know as little as possible. It was only the night before the operation when I wondered why I was putting myself through it. I considered going home but thought that everyone would think I was a coward if I walked out. I am glad that I decided to stay and have it done. I have never looked back.   

Table 6.1 – Comparing autologous and implant-based LD flap reconstruction at a glance

Autologous LD flap

Implant-based LD flap

Advantages
  • All your own tissue
  • Avoids implants or expanders
  • Ages very well
  • Tolerates radiotherapy
  • Feels warm and lifelike
  • Good for small or medium sized breasts.
  • Less surgery on back
  • Smaller scars on back
  • Better healing of back
  • Adjustable breast size
  • Good breast shape
  • Suitable for any breast size.

Disadvantages
  • Can shrink
  • May need adjustment by lipomodelling
  • Larger back scar
  • Greater risk of back wound problems
  • More fluid collection and fat necrosis
  • Insufficient tissue for more than 30% of women.
  • Implant-associated problems: infection, implant loss, ‘capsule’ formation, implant rupture
  • Need for subsequent implant surveillance and exchange
  • Adverse effects of radiotherapy in up to 50% of women.

The transverse rectus abdominus myocutaneous (TRAM) flap is harvested from the lower part of the abdominal wall. It may be pedicled or free, and because it removes excess tissue from the lower part of the abdomen, it produces a ‘tummy tuck’ effect.

Pedicled TRAM flap reconstruction

The pedicled TRAM flap moves the lower abdominal tissue into the breast area, still attached to the blood vessels coming from under the ribs before travelling along a strip of abdominal muscle – the rectus abdominus or rectus muscle – into the flap (Figure 6.16). The TRAM flap can produce a breast that has a very natural weight, feel and movement. But it’s a complicated and specialised operation that can take your surgical team anything from 4–6 hours to complete. Because of this, it should only be undertaken by surgeons who are fully trained and skilled in the technique.

Figure 6.16 – Anatomy and blood supply of a rectus muscle of the abdominal wall.

The TRAM flap is a major undertaking both for you and your surgeon, but it can result in a very lifelike breast with a natural softness, warmth and feel. If you decide to have your nipple reconstructed later, this is a finishing touch that often makes your breast look and feel even more natural. Many women find that the loss of their tummy is a bonus. The long scar is seen as an acceptable trade-off for a much flatter abdominal wall. You’ll also find that your reconstructed breast will gain or lose weight in step with the rest of your body. A natural droop, or ptosis, of your reconstruction will develop as time goes by. This helps to match your natural breast without having to undertake any further surgery to keep you looking balanced.

Deciding if pedicled TRAM flap reconstruction is one of your options

Whether or not a TRAM flap is the right operation for you is a matter for discussion between you and your surgeon. You’ll need to have enough fatty tissue on the lower part of your tummy wall to match the size of the breast that’s going to be rebuilt. A woman with a slim abdomen isn’t suitable for a TRAM flap, because there isn’t enough tissue, and there’s no point in carrying out this kind of major surgery only to have to use an implant as well. Some women have enough fatty tissue to be able to reconstruct both breasts, and this approach can be very useful if you’re facing bilateral mastectomy, maybe to reduce your risk of breast cancer. But your surgeon will have to be sure that you have enough tissue, and that you’re fit enough to withstand this type of surgery.

Figure 6.17 – Immediate reconstruction of the left breast with a TRAM flap.

The surgery is complex and specialised. The blood supply to the flap can be precarious, so a TRAM flap isn’t normally recommended for women who are otherwise in poor health. If you’re markedly overweight, suffer from high blood pressure or diabetes, or have certain types of abdominal scars, or smoke, then doing a TRAM flap may be too risky and another approach will be recommended by your team. If you’re a smoker, the arteries that supply your tissues can be narrowed and hardened, and this may result in your flap dying off soon after your operation because of a poor blood supply. So you can see that a TRAM flap isn’t a sensible choice for quite a lot of women.

   I was given the choice of three different types of reconstruction – one with an implant, one with the muscle from my back and a TRAM flap. I chose the TRAM flap because I did not want to have an implant.   

   The fact that I could have reconstruction done at the same time as the mastectomy was a bonus because I did not want to have any time when I was not complete.

I thought hard about the TRAM flap because it is a more complex operation with a longer recovery period. There are also more things that can go wrong. The latissimus dorsi operation would have involved an implant and when he said that they replace them every ten years, I thought ‘That is it. I’m not going through that again. If I have the TRAM flap, it is all my own body.’ Although I was going to lose stomach muscle, which is needed, I decided to make that choice. My work as a librarian wasn’t a consideration because I have a supportive employer and colleagues.

I did speak to another lady who had a TRAM flap and she was very helpful. She told me that she had no regrets. She was very fit and runs marathons and skis. She said that she would do it again. She told me what to take into hospital, what I would be able to do afterwards and that I should be aware of just how much energy I would lose after the operation. You have to accept that it will be some time before you are anything like back to normal. At least if you are not feeling too well, you know that is to be expected.   

   I opted to have a lumpectomy first for breast cancer and was devastated after that when I was told that I needed a mastectomy. I couldn’t entertain the idea of a breast reconstruction at that stage, although it was mentioned. I started to think about the options for reconstruction once the chemotherapy was out of the way. I didn’t like myself at all after the mastectomy and found the prosthesis heavy. I made myself go swimming but didn’t feel happy.

I didn’t know a lot about breast reconstruction but read the information I was given and found it really helpful talking to another person who had reconstruction. I would recommend that to others. I had the choice of reconstruction using a muscle from my back and an implant, or a TRAM flap. I was adamant that if I had reconstruction, I didn’t want anything foreign put back into me. I had a lot of discussion with the surgeon and the Breast Care Nurse and was told that the TRAM flap was the most serious operation that I could go for. I was told that the scar on my abdomen would go from hip to hip but it would be quite low down. It took at least twelve months to accept that I was going to have a reconstruction. I chose the TRAM flap.   

Surgical techniques

The TRAM flap can be used to reconstruct your breast either at the same time as your mastectomy (immediate reconstruction) or at a later date (delayed reconstruction). Not all women are suitable for immediate breast reconstruction, but when it can be done, the overall shape of your reconstructed breast and its sensation is often better than after delayed reconstruction (Figure 6.17). After a TRAM flap, there’s a large scar in the lower part of your tummy, shaped rather like a smile, which stretches from hip to hip below your tummy button. The lower the scar, the better the cosmetic result. There will also be a scar around your tummy button, as it needs to be moved into a new position during your surgery (Figure 6.18).

You’ll need to stay in hospital afterwards for anything between 4–6 days, depending on your recovery rate and any complications. It’s important to stay in hospital while the blood supply to your flap is fully established and until the first stages of healing have taken place. It may be possible to close the gap in your abdominal wall by pulling together the remaining muscles, or by bridging the gap where your rectus muscle has been removed using a sheet of artificial mesh.

Figure 6.18 – Abdominal scar after a TRAM flap operation.

A TRAM flap can also be carried out as a delayed reconstruction, many months after your mastectomy (Figure 6.19). Any poor quality skin from a previous mastectomy scar, or following radiotherapy, can be removed and replaced with healthy skin from your abdomen as part of the TRAM procedure. When you’re having one breast reconstructed, the TRAM flap can be developed either from the same side as the mastectomy, or from the other side. This is called a unipedicled TRAM flap, as it involves one of your two rectus muscles. The rectus muscle is one of several muscles that you use for sitting up – it forms a major part of the pedicle because it carries the blood vessels to the flap, in the flap’s ‘umbilical cord’ (Figure 6.20).

When it’s developed from the same side, there may be a small bulge underneath your breast where the rectus muscle is coming in to supply and nourish the flap. When it’s developed on the other side, the bulge may be across the midline in the lower part of your chest, between your breasts. This bulge often shrinks within the first 3–6 months after surgery, and it’s not usually very obvious.

Figure 6.19 – Delayed reconstruction of the left breast using a TRAM flap.

Figure 6.20 – Transposition of a TRAM flap.

The scale of your operation and recovery

Initially, your tummy will be tight, and your bed will be flexed at your hips to make you feel more comfortable. Drains will be used for the abdominal wound and also for the breast site. Your room will be kept warm and you’ll find it difficult to stand straight in the early days after surgery. You’ll begin to mobilise early on, and you may well experience abdominal tightness, but this will ease with time.

You’re likely to have a small catheter in your bladder to help you pass urine without having to get up to use the toilet. The catheter also allows very careful monitoring of your body fluids and kidney function, both of which are important for good recovery. Your surgeon may advise you to wear leg stockings or to have injections to thin your blood. This is because your surgery takes a long time, and you’re likely to spend some time in bed. During the early stages of your recovery, pain will be kept to a minimum using a number of techniques, including patient-controlled analgesia (PCA). It’s important that any pain is kept at bay to build up your confidence and to get you going as soon as possible after your surgery.

If you’re having both breasts reconstructed, then your surgeon may decide to use both rectus muscles, a so-called bipedicled TRAM flap. When your flap is harvested, it’s left attached to both muscles and then divided in half. So each half is supplied with blood from its own pedicle, and is used to reconstruct one of the missing breasts.

A TRAM flap is a long operation, and there will be some blood loss. This may make you feel tired for a few weeks after surgery while you restore your own levels. Blood transfusion is rarely required. If you’re undergoing any major surgery such as reconstruction of both of your breasts, it may be possible for you to donate some of your blood a few weeks in advance. This can then be stored and given back to you during your operation – a so-called ‘auto-transfusion’.

   I found it hard to move when I first woke up after the operation. There were drains, a drip and it felt sore rather than painful. I sat in the chair after three days and had to use every single muscle in my body just to stay upright. When I first started walking, I felt as though I had lead weights on the end of my legs. I found it shocking looking at the breast and tummy scar at first but now I don’t take any notice of it at all. The exercises were painful but it became easier. Doing a little bit at a time helps you to get a bit further.

The most difficult things to do at first were walking because the scar went from hip to hip and reaching for things. I couldn’t do an awful lot for the first month. I managed to walk around the house and up and down the stairs. Now and again I tried something more difficult. After that, I started looking after the house. I felt like a fraud and didn’t like accepting help because I was used to doing a busy cleaning job as well as doing everything for my family. Once the pulling sensation went, it was much easier. It took a good six months to get back to my usual activities but I did have chemotherapy in that time.

Sometimes, I just did not want the family to see me and I just didn’t feel like myself but I got over it in time. They were just feelings that you go through. I do go dancing again now and love that. Having my family around me helped me get through it and they need me now just as much as before, even my new grandchild does.   

   Because of the long anaesthetic, I wasn’t too with it for the rest of the day after the operation. All the things like oxygen, drainage bottles and a drip were manageable. It was four days before I got to the bathroom on my own. When you take your first steps, you feel the stitches pulling in your abdomen. It wasn’t painful, just very uncomfortable.

I looked at my new breast as soon as I was conscious enough. I was impressed with it and it was a relief to see it. My husband was also impressed when I showed him in hospital.

I blow-dried my hair with the affected arm and I could get washed and walk across the ward to talk to people after five days. I went home after a week.

I couldn’t do a lot when I first went home. My husband did the cooking and looked after me. One of the main things that strikes you is how tired you get. You very quickly find out that you can’t do what you thought you could. It is easy to become impatient. I found that I got used to it and settled into making the most of being at home.

I drove again after two months. That wasn’t purely because of the physical side. I felt that because I had been out of it for so long, I wasn’t sure that I was up to speed mentally.

I went back to work after ten months and had a staggered return. I have been back at work full-time for a year and I do get tired sometimes but I think that I would have done anyway. I have quite a demanding job. There are no practical things that I still find difficult.

The reconstruction has given me a very natural appearance. I am confident in my dress and day-to-day life. If I had to, I would do the same again.   

   I had to stay in bed for the first three days after the reconstruction and the worst thing was that they had to keep me really warm. I suffered from hot flushes because the chemotherapy had put me through an early menopause. I had no problems with my breast and didn’t have a lot of feeling in it. My tummy was the worst part to get over. It was painful for the first three weeks but improved after that. My first walk in hospital was awful because it was very painful but once I had done that, things got better.

It was hard initially at home. Walking up the stairs was difficult but the more I did it, the easier it became. My husband was at home to help me. I started to do more around the house after six weeks and the wound healed up really well. I did no heavy lifting for some time. I found that swimming was very helpful.

The breasts match pretty well and are excellent in a bra. The reconstructed breast is not quite as full as the other in one place and I am careful about some tops I wear. Everybody tells me that you can’t see it from the front. We did discuss having the other breast reduced, depending on how the new breast turned out but this has not been necessary. As far as my tummy is concerned, I have a flat tummy now and that is great. I can wear whatever clothes I like.

My husband has been very supportive and the mastectomy made no difference to him, although it did to me. Even now that I have had the reconstruction, it still makes a bit of difference to me because although I have the shape, there is very little feeling in the breast.

It is now 18 months since the reconstruction and I can still not stretch up too far. It feels as though there is a weakness in my tummy and my lower back feels as though it has not got the muscle support that it had before. These are not difficulties compared to the psychological benefits of the reconstruction.   

Complications following your surgery

Even with the highest standards of care and attention to detail, complications can and do sometimes occur. Difficulties may be encountered while the new tissues are healing into place. Very occasionally, the flap will fail totally, but this happens in fewer than 5% of women. Even so, it’s important that you realise it’s a rare possibility. Sometimes the blood supply to the flap may be just enough to keep it alive, but not good enough to keep the tissue soft and healthy. When this happens, hardness may develop in the fatty tissue, known as fat necrosis. This may feel quite like a tumour, but your surgeon will be able to reassure you and it will usually settle and soften with time. Liposuction can also help to treat it.

If bleeding continues after your operation into the spaces over your tummy or around your new breast, a haematoma, or collection of blood, can develop. This usually settles by itself, but occasionally your surgeon will need to take you back to theatre to stop the bleeding and to clear away the haematoma. In the long term, your abdomen may be weakened by the operation, and an abdominal hernia can occasionally result (Figure 6.21). In a significant proportion of women, full sensation in the lower part of the tummy may not recover completely. Because of this, you should be particularly careful to avoid undue heat to the skin of the lower part of your abdomen, such as a hot-water bottle or lying in very hot sun, as you can burn yourself without realising.

Figure 6.21 – Abdominal hernia after a pedicled TRAM flap reconstruction.

   During the first year, I began to feel as though there was a knot in my tummy sometimes. I mentioned it and was told at first that it would improve. I also had some bulging of the scar on the side where most of the operation had been. It got worse and worse and I went back to see the surgeon who told me he thought that I had a hernia and it would need repairing. In a strange way, I was relieved to be told that it was a complication of the surgery because it had been getting so uncomfortable and it was nice to know that something could be done to get rid of it.

I had the hernia repair 18 months after the breast reconstruction. It involved opening up my tummy scar again and they also moved my tummy button. It was not quite as big an operation as the reconstruction and my recovery was remarkably good. I was in hospital for a week. I could move about at home but I was a bit doubled up as before because of the pulling stitches. It wasn’t too bad. I just had to be careful about lifting again. I had about a month off work. When I went back, I could do everything apart from picking up huge boxes of brochures from the floor.

It took two years to fully recover from the reconstruction and the hernia repair. Nearly three years have passed since the reconstruction and I feel really good. I do feel that it has been worth having the reconstruction, despite the hernia. When the hernia got bad, I wondered why I had bothered with the reconstruction but now I would say that it was definitely the right way to go.   

Recovery from the TRAM flap operation is slower than other kinds of breast reconstruction. Most women find that they can stand upright by 10–12 days, and can gradually get back to normal activities after 4–6 weeks. But you’ll find it’s difficult to return to full time work in under 12 weeks. You should be able to do gentle sports once your breast and tummy have healed soundly. Your physiotherapist will give you good advice about the exercises you can do to build up your abdominal strength and confidence in the early days after your surgery (see Chapter 16).

TRAM flap or DIEP flap reconstruction?

There are two main techniques that can be used to reconstruct your breast using tummy tissue – TRAM flaps and DIEP flaps (see Chapter 7). Both can produce soft, warm, natural-looking and natural-feeling breasts, but they use quite different approaches. The TRAM flap remains attached to your body by one of your tummy muscles, as this carries a vital blood supply to the flap. This means that the wall of your tummy loses a muscle, and the ‘gap’ has to be repaired carefully at the end of the operation, to prevent subsequent weakness or a hernia developing. Most people don’t notice the loss of the muscle, as there are plenty of others that take over.

Unlike the TRAM flap, the DIEP flap is completely separated from its blood supply, and the divided blood vessels are joined to other vessels in the area of your mastectomy. This means that your surgical team has to use microscopic equipment to join up these very small blood vessels, and the operation takes longer. These tiny ‘join ups’ are a bit more likely to get blocked up in the early hours after the operation, and you may need to go back to theatre to have them unblocked. Because the DIEP flap has a more vulnerable blood supply, the risks of flap failure are a little higher after DIEP than after TRAM reconstructions. On the other hand, the DIEP technique has very little effect on your tummy muscles. So there’s slightly less weakness and fewer hernias, although overall, these problems are uncommon after both operations.

Chapter 7

Free TRAM Flap Reconstruction (DIEP Flap)

Mary Morgan, Venkat Ramakrishnan

  • The free DIEP flap uses tissue from your lower tummy to reconstruct the breast.
  • It’s best for healthy patients who’ve got enough tummy fat to reconstruct their breast.
  • It’s the most natural looking and feeling of all reconstructions.
  • It’s a technically complex procedure.
  • The function of your tummy wall is generally preserved.
  • There’s a 6–8 week recovery period.

The free DIEP flap is the gold standard of breast reconstruction. It involves transferring the tissue between the belly button (umbilicus) and the bikini line, with a blood vessel, to the breast to reconstruct it. This has the added effect of a ‘tummy tuck’ which many patients find attractive.

Using this tissue, a breast that has a very natural look, and feels soft and warm, can be created. It’s a technically demanding operation that requires specialist skill and equipment, so it should only be performed by surgeons with enough training and experience. It can take up to six hours, and the recovery takes around six weeks. This requires a commitment from you but many patients feel that the natural result and the improvement of the appearance of the tummy are worth it. Your reconstructed breast will gain and lose weight with your weight changes, and over time will droop like a real breast. This means that many patients don’t require any further surgery to achieve good symmetry. A nipple reconstruction and tattoo can be performed later to make the new breast look even more realistic.

Deciding if free TRAM flap reconstruction is one of your options

The decision to have a breast reconstruction is a something that you and your plastic surgeon will need to discuss in detail. You’ll need to have enough fat in your lower tummy to make a breast, and you will need to be healthy enough to undergo a major operation. If you don’t have enough tissue or you have certain scars on your tummy, other options may be more suitable for you. If you have other medical problems such as poorly controlled diabetes or are very overweight, it may not be safe to perform this surgery on you. If you smoke, you’ll need to stop for at least a few weeks before and after the surgery.

This type of abdominal tissue breast reconstruction is best for young and active women who want to maintain their sporting lifestyle, women who are planning to have children in the future and those women who require bilateral breast reconstruction. This is because it’s able to preserve the strength and function of the abdominal wall as the blood supply is divided completely. But it’s only suitable for fit and healthy patients without any additional health problems, because it’s a very complex procedure with prolonged recovery time.

Blood supply to the abdominal wall tissues

The skin and fat of your lower tummy receives it blood supply mainly from the ‘deep inferior epigastric’ vessels. These branch out from your groin and run behind the ‘six pack’ muscles – ‘rectus abdominus’ or ‘rectus’ muscles. Small ‘perforating branches’ – ‘deep inferior epigastric perforators’, or ‘DIEP’– pierce through the muscle to nourish the overlying fat and skin. Other smaller vessels called ‘superficial inferior epigastric’ vessels run from your upper thigh into the superficial fatty layer of your lower tummy. These are particularly important in the drainage of blood from this tissue. They are often injured after abdominal surgery such as a Caesarean section, hysterectomy and hernia repairs.

Surgical technique

A breast reconstruction can be carried out either at the same time as a mastectomy (immediate reconstruction) or some time after (delayed reconstruction). When possible, immediate reconstruction is far superior to a delayed for several reasons. Immediate reconstruction has the advantage of retaining most of the breast skin at the time of the mastectomy (skin sparing mastectomy) so that the reconstructed breast has a more natural shape and is covered mainly by the native breast skin. This gives the best aesthetic result and is considered the gold standard of breast reconstruction. In addition there is a psychological benefit to leaving hospital with a new breast.

The previous chapter described how the pedicled TRAM flap uses the skin and fatty tissue from your lower tummy attached to one or two of your rectus muscles. The pedicled flap is nourished through the superior epigastric vessels which come from your chest, but this weakens your tummy. This can sometimes interfere with lifting, housework, sports and even simple activities such as getting out of bed. Because the rectus muscles counterbalance your back muscles, back problems may also occur after the pedicled TRAM flap. It’s also been highlighted that muscle harvest can weaken your abdominal wall with bulging or even hernia formation. The vast majority of these problems can be avoided with the DIEP flap.

This type of reconstruction is called a ‘free tissue transfer’. Unlike the pedicled TRAM flap, all of the skin and fatty tissue on your lower tummy is disconnected completely and then reconnected to blood vessels in your mastectomy area. This clever technique allows your surgeon to take only what’s needed to make your new breast: skin, fat and blood vessels to keep the tissue alive. The small perforating blood vessels are traced through a split in your rectus muscle down to the larger blood vessels – the deep inferior epigastric vessels – in your groin. So the muscles and the strength of your abdominal wall are preserved more or less completely. The blood supply is then disconnected and your flap is then transferred to your chest where your breast is reconstructed. The blood supply to your new breast is re-established by connection of the small blood vessels which have been divided to blood vessels in your axilla (your armpit) or behind your breastbone. This is a very delicate procedure and the join-up has to be done using a microscope as the blood vessels are so small.

The scale of the operation and recovery

Although not major surgery, this is a complex procedure that must only be carried out by surgeons experienced in the technique. The blood vessels that supply the tissue from your lower tummy that will be transferred must be very carefully dissected out through the rectus muscle, to avoid damaging them. They then must be connected to a new blood supply in the breast using a microscope as they are tiny, only 1–2 mm in diameter. This can take 4–5 hours, and most patients will stay in hospital for 5–6 days. It’s necessary to monitor the blood supply to the flap closely over the first three days, so that any problems can be picked up quickly and resolved.

When you wake up from the surgery, you’ll have a catheter (small tube) in your bladder, a drip and a heated blanket. It’s also most likely that you’ll be kept ‘nil by mouth’ for the first night after the surgery. On the first post-operative day, you’ll be allowed to eat and drink and will be helped to sit in a chair. Your tummy will feel quite tight and you won’t be able to stand up straight immediately. Over the next couple of days you’ll become independent in getting in and out of bed, walking small distances and showering yourself. By the time you leave hospital you will be self-caring.

Typically most patients will return to normal activity within six weeks, however it can take up to three months for the full strength of your abdominal muscles to return.

The DIEP flap is suitable for most women wishing to have reconstruction, provided that they have a sufficient amount of tissue in the lower tummy and that they’re physically fit to undergo a long procedure. Women who have significant medical problems, such as poorly controlled diabetes or heart disease, or have had previous abdominal surgery may not be suitable.

Free tissue transfer is a complicated and technically demanding procedure. Great care has to be taken during the operation to avoid damaging the delicate structures of the perforating blood vessels. Equally great care has to be taken during the re-connection of your blood vessels under the microscope.

Figure 7.1 – Immediate reconstruction of the right breast with a DIEP flap.

The free DIEP flap is a much more involved procedure than the autologous LD flap. It may be a woman’s only option for breast reconstruction if there isn’t enough tissue on her back or if her LD muscle can’t be used because of previous surgery. Other women who are suitable for this type of breast reconstruction are those who need to have a large amount of breast skin removed and replaced because of a large breast cancer, or those who have developed a recurrence of breast cancer after previous lumpectomy and radiotherapy. The free DIEP flap is suitable for immediate or delayed reconstruction of a larger and droopier breast (Figure 7.1), and for women requesting bilateral breast reconstruction because of a high risk of familial breast cancer.

Complications following your surgery

Any surgery carries a risk of complications. When tissue is disconnected from its original blood supply and re-connected to a new blood supply, there is a risk of failure. If the vessels get clotted up, twisted or stretched, then this can cause the tissue to die. The most common problem with the blood supply is called ‘venous congestion’, where the blood is able to flow into the tissue but not out again. This causes blood to collect and pool in the tissue and if left long enough, the pressure can build up enough to stop the blood flowing in. If this problem is picked up early, your surgeon will return you to the operating theatre to try to re-establish the blood flow. Fortunately this is usually successful. In a unit where these operations are performed regularly, the success rate should be around 98–99%.

Another complication that can occur during the first few days is a ‘haematoma’, where there is bleeding around the new breast or into the space in the tummy between the skin and muscles. This is rarely life-threatening, but it does mean you’ll need another small operation to wash the blood away and stop the bleeding. The wounds will then heal quickly without further problems.

After you’re discharged, the most common complications are problems with wound healing and wound infections. Later on, you may develop ‘fat necrosis’, where some of the fat transferred doesn’t have a good blood supply and dies off, forming a hard lump. The free DIEP aims to preserve muscle and the nerves to the muscle, so unlike a pedicled TRAM, a hernia is very rare.

The need for symmetry surgery and the effects of radiotherapy

It may not be possible to match the size of your remaining breast with your reconstructed breast, and some patients decide to have a breast reduction to restore symmetry. If your breast’s very droopy, then you may decide to have an uplift (or ‘mastopexy’) to match the reconstructed breast (see Chapter 11). Sometimes there can be areas where there has not been enough tummy tissue to fill the upper part of the breast, and fat can be injected (lipofilling) to improve the contour of these areas (see Chapter 12). If desired, a new nipple can be reconstructed by lifting small flaps of the DIEP skin to make a little nub, which can then be tattooed to match the areola of the other breast (see Chapter 10 and Figure 7.2). From now on, you’ll be very unlikely to need any further surgery. Both of your breasts are made entirely from your own living tissue, and behave and react to changes in body weight and gravity just like a natural breast.

If you do need to have radiotherapy after your reconstruction, changes will occur. All tissues react to radiotherapy just like a real breast does after ‘lumpectomy’. These effects can be unpredictable, but at best, the reconstruction will feel firmer. In a few cases, the radiotherapy can significantly damage the tissue, causing shrinkage and hard lumps (‘fat necrosis’).

Women with larger, more fatty breasts are more likely to develop a bigger reaction and in the same way, women with large breasts who’ve had a reconstruction with quite a lot of fatty tissue from the abdomen may also be at higher risk of hardening and shrinkage following treatment. Radiotherapy will also make it impossible for the breast to increase and decrease in size with changes in body weight, and to develop a natural droop over time. Because of these side effects of radiotherapy, it’s more than likely that a difference in size and shape of the reconstructed breast will develop over time, so more of these patients need to have symmetry surgery to the other breast as time goes by.

Figure 7.2 – Bilateral DIEP flap and nipple reconstructions after radiotherapy.

It isn’t possible to predict how an individual patient is going to react to radiotherapy. Because of this, some surgeons won’t agree to perform this type of surgery at the same time as mastectomy, when the need for radiotherapy can’t be judged with certainty, so they may recommend that the reconstruction is delayed until all treatment is finished. What’s interesting is that most women are equally happy with their reconstruction in the long term, whether they’ve had radiotherapy or not. So it’s very important to discuss these issues thoroughly with your surgeon before surgery.

   The second surgeon who I saw agreed with me that because of my large droopy breasts, the DIEP flap would give me a more realistic reconstruction. He said that if I did want to have that, he would refer me to a plastic surgeon who specialised in this. By the time that I saw the plastic surgeon, my mind was made up about the DIEP flap. I realised that mastectomy alone was not for me and I wanted to feel that I was back to being as normal as I could be.

I didn’t like the idea of having tissue tunnelled up through my flesh because that makes the muscles not quite as good as they were. I really liked the idea of having the blood supply disconnected and reconnected so that I was left as normal as possible. I didn’t like the idea of implants, however safe anybody tells me they are. Somebody else might be quite happy with that.

I was 66 when I had the DIEP flap. When I came round, they said that I was chirpier than people usually are. However, I did feel very knocked out. I was monitored every hour for several days. I remember thinking that I didn’t want anyone to do anything to me again. I didn’t even want a nipple!

I got up after three days. I was quite constrained by the drips and drains but could do most things with my arm on the reconstructed side. Because the nurses had to keep the reconstructed breast warm, they would check it regularly. That was when I looked at the breast. What I hadn’t realised, although it is quite logical, was that I kept my own skin on the breast. It made me feel as if I had not lost anything.

I went home after nine days. I live on my own and looked after myself. Before going into hospital, I made lots of pre-prepared meals so that I just had to take something out of the freezer and cook a few vegetables to get a meal. You just have to recognise that you do things slowly. I didn’t want to be looked after. I had a sleep every day after lunch and a friend shopped for me. I wasn’t as fit as I usually am before the operation because it was only about two months after I had finished chemotherapy and that was very depleting. I think that I would have found it more difficult to cope if I had never had an operation before.

My tummy wound took about four weeks to heal because I had a collection of fluid under the scar which needed to be removed. Although the scar is a very long one, I could wear a bikini now. My tummy button has been moved sideways slightly and although I would prefer it to be in the middle, it doesn’t seem to be a big issue.

I restarted driving after nearly five weeks. Although my tummy felt numb to touch, when I went over bumps in the road, it felt incredibly sensitive. My arm was not a problem.

I had two and a half months off work. I was held up by the slow healing of my tummy scar. By the time that I was back at work, I was doing normal things around the house. I do still get tired and hope this will improve.

I go to the gym and do as much of my exercise programme as I feel able at the time.

I have had to have another small operation to take a tuck in the reconstructed breast to make the shape match better. I may need to have this done again. I don’t mind about having these procedures done because it only involves having a local anaesthetic.

It is now seven months since the reconstruction and my new breast doesn’t droop quite as much as the other one. I have got used to that and it is near enough the same. I would not want to have any adjustments made to the other breast. It doesn’t look any different in a bra because I use a silk scarf to pad the bra out. I knew that I would be pleased that I had the reconstruction, even immediately after the operation. I made a clear decision about what kind of operation I wanted. It was the right thing for me to do.   

   I found it very hard after the operation because I was in a room on my own and had to lie flat on my back. I am not a person who likes to sit still. There were lots of drips and drains and I controlled the painkillers, which was all right. You have to be very careful with the affected arm in case you damage the blood vessels. I got out of bed after three or four days and because the arm was weak, it was helpful to have things where I could reach them. I went home after two weeks.

I found it very difficult to do much at home. This was partly because of the tummy scar which ran from side to side. I had already had two caesarean sections, so it meant just making the scar bigger. I found walking hard and getting to the shops at the top of the road after two weeks at home was an achievement. I always had someone with me who could carry the shopping. If I had little goals, it made me do a bit more each time.

I went back to work after six months part-time to begin with and gradually built it up until I did a full day’s work. You want to get back to a normal routine and in reality there is no way that you can do this straightaway. It is tiring and I was frightened that people would knock me. We were asked to wear a sports bra from the first day, to support the reconstructed breast and I have found it more comfortable to continue doing that since.

Initially, the reconstructed breast was much bigger than the other one, partly due to the swelling. After that settled, it was still larger than the other breast. The surgeon told me that the size of the reconstructed breast could be reduced when I had the nipple reconstruction. It is a good idea to talk to the surgeon about the expected size of the breast before the operation.   

   I was given a choice of three different breast reconstructions which I could have at the same time as the mastectomy. My partner was involved from day one and that was very helpful for both of us. I liked the idea of having something that was made from me and was as natural as it could be, so I chose to have the DIEP flap.

For the first couple of days after the reconstruction I felt as though I had been hit by several buses. I also felt relieved and exhausted. I was mentally exhausted because there is a big run up to something major like that. I watched the other girls who had the same operation as me and they looked as wrecked as I did for the first couple of days. I was moving into my chair by the third day and the big milestone was having the urinary catheter taken out and going to the bathroom. The physiotherapy helped with my arm movements and I was able to stretch my arm out properly after some time.

I developed an MRSA infection in my wound and that delayed my recovery. I had to go back into hospital for treatment twice and that was distressing. If it hadn’t been for that, the whole procedure would have been so smooth and I would have been back at work quite quickly.

I have a numb sensation under my arm on the side that was reconstructed. I am getting used to it: it feels odd putting on deodorant and sometimes you scratch your arm in one place and get a funny sensation in another part of the arm. It feels odd but not horrible.

I wish that I had had the tummy scar put in a different place.

When I spoke to the surgeon before the operation, she told me to wear a pair of knickers that I like to wear and then we could work out how high or low to put the scar. I didn’t listen to her properly and wore the wrong pair and wish that I had thought more about it. I could have had the scar a bit lower. It is totally up to you and you know what you like to wear. After she had done all the drawings on me, I wondered whether I could say anything and I wish now that I had. It makes no odds to the surgeons and they want you to be happy with the result of the surgery. It would have been a simple thing to do.

My whole shape has changed since having a DIEP flap made. I used to have a small waist and big hips. Now, my waist size has gone up a bit but I have a flat tummy, which I like.

My partner is fine with the reconstruction. It doesn’t bother him at all. He is not worried about touching or caressing it the way he does with the other one. At first, he was worried about touching me in general, in case it was a bit sore but now, it is no problem. I feel great about the future now and am glad that the breast problem was caught early. I feel that I am healthier now than I was in the first place.   

   I was told that a DIEP flap tends to give a more realistic looking breast. When you are dealing with body fat as opposed to an implant, you have more leeway to mould it and make it look more natural. That was a priority for me. I decided to go for the more natural look and have the DIEP flap, although it was a bigger operation.

I was fine immediately after the operation. There was no pain in the breast region, it was totally numb. The pain in my abdominal scar was just like a really bad period pain. I could have had morphine for pain control but I did not have any. I felt fine emotionally.

I think that I had to stay in bed for five days. I had to keep still for the first two days, which was hard. The blanket to keep the breast reconstruction warm was uncomfortably hot. The heat made me itchy and it is helpful to use some baby powder. It is a good idea to put long hair up before the operation because you get hot lying for so long. I used a V-shaped pillow under my arms and one under my legs to stop the tummy scar pulling when I was resting.

By the time that I went home after a week, I was feeding myself with the other hand. I started walking about after four days and it felt quite strange. I tended to want to shuffle, as opposed to walking properly. The surgeon was very strict about how much I should do with the arm on the reconstructed side, in case I damaged the blood vessels which had been joined under my arm.

I think that I could do most things at home. I made sure that I could put my make-up on with my left hand. I started to use the arm more after the first week. My husband has always been the homemaker but nobody did any more for me than they would normally have done. I was determined to get up and about. Because I wore an abdomen binder for some time after the operation, I was unable to fit into normal skirts. Elasticated waistbands are helpful. I drove after four weeks because I was keen to do so. My family were amazed.

I had chemotherapy after the operation and it is now a year since the reconstruction. I started going to the gym a few months ago and I do rowing and things like that. Exercise doesn’t feel any different than it did before. The arm on the reconstructed side feels as strong as the other one.

I have a totally flat stomach below the navel and a thin white line where my briefs go. I wore a bikini in the summer and haven’t done that for years.

The reconstruction itself looks brilliant and that is a combination of the surgeon’s skill and the fact that I kept my own skin and nipple. I am really proud of it and don’t think that I shall ever take my body for granted. I don’t feel any less confident than I was before. If anything, more so.   

   Ten months after having a DIEP flap, the reconstruction started to go wrong. It appears to have sunk inwards on the lower part and felt hard, although the cleavage was still fine. I was told that I had fat necrosis and needed to have the lower part of the breast refashioned. To begin with, it didn’t bother me and I was in two minds about whether to have this done because I had gone back to work, been promoted and it felt like a step backwards. The plastic surgeon said that because I was young and have all those years ahead of me, I wouldn’t be happy later if it was not done, and that it might be better to get it done in case it got any worse.

I had a second operation which removed all the hard fat and was supposed to pull up some surplus fat from beneath my reconstructed breast to fill in the area. This was not at all successful and left me with a strange lumpy mound which wouldn’t hold a bra in place and was uncomfortable. It was then recommended that I had a further reconstruction with a silicone implant and I decided to go ahead with this.   

Table 7.1 – Comparing pedicled and free TRAM flap reconstructions at a glance

Pedicled TRAM flap

Free DIEP flap

Advantages
  • All your own tissue
  • Soft, warm, natural breast
  • Breast matures with age
  • Breast mirrors your weight
  • Gives you a ‘tummy tuck’.
  • All your own tissue
  • Soft, warm, natural breast
  • Breast matures with age
  • Breast mirrors your weight
  • Gives you a ‘tummy tuck’
  • Doesn’t weaken your abdomen
  • Doesn’t affect your back
  • Avoids hernias.

Disadvantages
  • Health problems prevent
  • Four to six hours surgery
  • Specialist skill required
  • Blood supply problems in 4%
  • Long scar on tummy
  • Three months off work
  • Hernias and ‘bulging’
  • Back problems
  • Variable radiotherapy tolerance.
  • Health problems prevent
  • Four to eight hours surgery
  • Microvascular skill required
  • Blood supply problems in 5%
  • Long scar on tummy
  • Two to three months off work
  • Variable radiotherapy tolerance.

Alternative types of free flaps

Some women are not suitable for a DIEP, either because they’re very slim and have no spare tissue at all on their tummy or they have significant scarring. If they need or request a breast reconstruction with their own tissue, this can be taken from other sites, such as their buttocks, hips or thighs.

In most units the preferred alternative to a DIEP is the ‘transverse upper gracilis flap’ (TUG flap) that uses the skin and fat in the upper inner thigh. The blood supply to this area of tissue first passes through the ‘gracilis’ muscle on the inside of your thigh. Here it divides into many small branches before supplying the skin and fat overlying the muscle. For this reason, it’s necessary to take a section of the muscle with the overlying skin and fat. The ‘feeding’ blood vessel is called the ‘medial circumflex femoral artery’ and is then traced back to its origin deep between your inner thigh muscles. These vessels are then divided and connected to blood vessels behind the ribs. The amount of tissue that can be transferred with these techniques is limited, but fortunately most very slim patients also have relatively small breasts. The scar runs just below your knicker line in the inner thigh and is visible in swimwear from the front, but it’s usually well hidden in the buttock crease at the back. The surgery involves a 4–8 hour operation with a 4–5 day hospital stay and 6 weeks recovery. Long-term weakness or restriction to movement and exercise is very rare.

Other donor sites for free flap breast reconstruction include (i) your buttock area – the ‘superior gluteal artery perforator flap’, or SGAP flap (Figure 7.3), and the ‘inferior gluteal artery perforator flap’, or IGAP flap, (ii) the saddlebag area of your thighs – the ‘lateral thigh perforator flap’, or LTP flap, and (iii) the ‘love handles’ over your hips – the ‘lumbar artery perforator flap’, or LAP flap.

Although there are many alternatives to the DIEP free flap, there aren’t very many surgeons in the UK who regularly perform these operations. So it’s wise to be referred to a surgeon with plenty of experience if you’re considering one of these procedures. The DIEP flap from the abdomen is routine for most reconstructive micro-surgeons with success rates of about 98%. Free tissue transfer from the buttocks or from the thighs is much less common and the success rates are lower. If you’re considering any of these alternatives, it is very important to have a thorough discussion with your surgeons about all specific risks and the success rate of the particular centre.

   I was just 50 when I was told I needed a mastectomy but could have a breast reconstruction as well. The plastic surgeon said that I didn’t have enough fat on my stomach to use that muscle, so the options were: a silicone implant, taking some muscle from my back or taking some of my buttock and using that. I was slim and very conscious of my body and wanted to get the best result if I was going to have a reconstruction done. I lead a really young lifestyle, going clubbing and dancing, and my body image is important to me.

Figure 7.3 – Right breast reconstruction using SGAP flap.

I wasn’t keen on silicone because I wanted something more natural. I was told that the most natural result would be from the reconstruction using part of my buttock. The thing against the SGAP reconstruction was that it would take eight hours. I was terrified of an operation that was that long. I was told that the scars from the SGAP would be inside my bikini line and that my buttock wouldn’t look that different, partly because I have a small bust and they would not have to take too much tissue. I spoke to someone who was able to reassure me about the long anaesthetic and then decided to have the SGAP reconstruction.

I had to lie flat for the first day after the operation. There were drains to the breast and my buttock. When I got up to the lavatory I had to manage with a drip stand, an arm that I couldn’t bend and take off really tight support pants. I was doing that from the second day after the operation.

I went home after five days. Although I couldn’t walk far by then, I was keen to get home. A friend looked after me to begin with. I had to wear a heavy-duty bra and support pants for six months, which I hated. The buttock was never much of a problem. It didn’t hurt much.

I am fit and supple from doing yoga but found not being able to do things like lift my arm far quite frustrating. Things like shopping on my own were difficult at first. Using a trolley or a suitcase on wheels was helpful. You need to be prepared for several months of recovery and do have to take it easy. It is helpful to have somebody supporting you at home in the first few weeks.

By five weeks after the operation, I went to a concert in the Students’ Union with my son which involved standing up all evening and I enjoyed it!

I went back to work part-time after three months and found that I was too tired to do much after work. I work in IT, so once I had got there, I just had to sit there and do the work. There was no problem with using my arm and the computer but I did notice that my arm was weak for some time. I got into the habit of using the other hand, where possible, for anything heavy. I worked full-time after four months and didn’t look back.

I think that I was pretty much back to normal by the time that I got together with my 26-year-old partner eight months after the operation. My confidence was helped by having the reconstruction, rather than a mastectomy.

The reconstructed breast is not the same as a real breast and never will be, but the fact that they used my skin helps. I can feel when something is touching the breast but have no more sensation than that.

We have a busy time and I still get pain under my arm after playing frisbee for a long time. Going to a really hectic ceilidh and being swung around by the arm hurts afterwards for a day or two. It also hurts after windsurfing, but is no worse than after doing exercises. I have also managed a backpacking holiday in Brazil.

I have got a big scar running across my buttock but it does fit inside my bikini line. It doesn’t really bother me much. The overall appearance of the reconstructed breast is pretty good. To me, it looks slightly lumpy and not like a normal breast. I don’t think that the shape has changed in the past two years.

If I had to have breast reconstruction again, I would probably go for the same thing. Life is great. It is not the end of the world and life should go on. You can still enjoy life afterwards.   

Chapter 8

Reconstruction after Partial Mastectomy using Volume Replacement

Dick Rainsbury, Pankaj G. Roy

  • Reconstruction after partial mastectomy is a new and increasingly popular option for patients that avoids a mastectomy and the use of implants.
  • This procedure isn’t suitable for everyone, but today it’s being used in more and more patients, avoiding more extensive surgery.
  • There are two different approaches that can be used depending on the size of your breast.
  • A partial reconstruction is a smaller operation than a full reconstruction.
  • Your reconstructed breast normally looks and feels like part of you.

Until recently, surgeons treating breast cancer were only able to offer their patients one or two choices – either breast-conserving surgery (lumpectomy) or mastectomy, with or without immediate reconstruction. This is because if much more than a fifth of your breast tissue needs to be removed to take away your tumour, then the ‘gap’ left behind is usually very obvious, making the breast distorted. So until recently, a mastectomy has been a much better option in this situation. The chances of lumpectomy causing deformity in your breast depends not only on the amount of the breast that needs to be removed, but also which part of the breast has to be taken away. The most obvious and distressing deformities are caused by removal of large amounts of tissue from your cleavage area, in the central and inner parts of your breast, as well as from the lower part of your breast. So when a lot of tissue needs to be removed to clear the tumour, your surgeon will normally advise you to have a mastectomy and to wear an external prosthesis, or a reconstruction of the whole breast at the same time. Reconstruction is a good solution in this situation, but does require more major surgery, which in turn increases your chances of complications.

Development of a new approach

A new approach has been developed that offers a third choice to women who until recently would be advised to have a mastectomy because of the amount of tissue they would lose. These patients often have larger tumours, or tumours which affect more than one part of the breast, so that they may need to have more than half of the breast taken away to remove the cancer completely. This new approach is becoming increasingly popular because it offers patients the opportunity to save as much of their own breast as possible, while having the gap in their breast reconstructed with their own tissue. Reconstruction is normally done at the same time as the surgery to remove the tumour, so that both the shape and the appearance of the breast are preserved.

Surgeons doing this innovative type of surgery need to be skilled in techniques for removing the cancer, as well as being skilled in the techniques for reconstructing the gap. Sometimes two surgeons – a breast surgeon and a plastic surgeon – will do the operation together, working as a team. But it can be difficult to organise this because surgeons often have different timetables, and getting them together at the same time in the same place can be challenging and costly. Fortunately, the UK has developed a unique training programme which has enabled the next generation of surgeons to develop these oncoplastic skills. As a result, many breast units today are supported by oncoplastic surgeons who have been trained to remove the cancer, and to rebuild the area at the same time.

This approach isn’t suitable for everyone, but it’s becoming an increasingly popular choice as it allows a greater number of women to avoid a full mastectomy. There are some other advantages too. Rebuilding part of the breast involves less extensive surgery than reconstructing the whole breast thus enhancing recovery, and many of the complications following reconstruction with breast implants can be avoided. These include infection which may lead to implant loss and pain, hardening and deformity caused by scarring around implants. The scarring around implant (called capsular contracture) can be a difficult problem to sort out, particularly if you’ve been treated with radiotherapy. If only the diseased part of your breast is removed and followed by partial breast reconstruction, the rest of the breast feels normal, looks normal and moves normally as well.

Oncoplastic surgeons are beginning to offer these techniques more and more frequently in preference to mastectomy because of their quicker recovery and favourable outcomes. The indications are being extended, as we begin to realise that it’s possible to achieve an excellent cosmetic result in spite of removing more than half of the breast – something that was unthinkable ten years ago! You should ask your surgical team about this approach, and if it isn’t available locally, you could ask to be referred to another unit that does this type of surgery.

As more surgeons develop these skills and breast cancer drugs get better, most women will be able to avoid a mastectomy altogether in the future. Patients will also avoid many of the complications, inconvenience and pain of repeated operations that are often required following implant-based reconstruction (see Chapter 4 and Chapter 5). We are at a very exciting time when these new surgical approaches are revolutionising the treatment of breast cancer. The traditional approach, which limited surgical options to mastectomy or lumpectomy is rapidly becoming a thing of the past. The new partial mastectomy techniques offer a safe, effective and increasingly popular third choice that’s driving down the need for mastectomy. Many of these operations can be performed as ‘day case’ procedures, unlike the more complex reconstructive techniques after total mastectomy that usually require a hospital stay.

   I am glad that I was able to keep some of the breast. I remember thinking before the operation that this was the last time that I was going to be normal. However, it is still me, my nipple, my breast and back. I am glad that I made that decision. I still would not want to wake up without the breast.   

Choice of technique

There are two different ways that a surgeon can reconstruct your breast after ‘partial mastectomy’ (the term used when a large amount of your breast tissue is removed).

  • Volume replacement: Breast tissue that’s been removed with your tumour may leave an unpleasant gap behind. This gap can be replaced with a flap of your own tissue, which is made up from skin, fat and sometimes muscle from nearby. This flap remains attached to its own blood supply to keep it alive, making sure that the gap is filled with healthy, living tissue. After this kind of surgery, the shape and size of your reconstructed breast should be much the same as before the operation. This is because all of the volume that was taken away has been restored by this ‘volume replacement’ approach. Volume replacement techniques are usually recommended for women with small to medium-sized breasts (A, B or C cup). This is because they don’t have enough of their own breast tissue to fill the tumour gap without making the treated breast much smaller, leaving them lopsided.
  • Volume displacement (referred to as therapeutic mammoplasty): With this approach, tissue from another part of your breast is moved (or ‘displaced’) into the gap left behind after removal of your tumour and the surrounding tissue. After this kind of surgery, your breast will have a good shape, and will often have a more youthful appearance than before the operation. But it will be smaller than the other side, because unlike the volume replacement approach, the tissue that’s been removed hasn’t been replaced by tissue from elsewhere. Instead, it’s been borrowed from the breast itself. Because of this, another operation to reduce the size of the other breast is often requested to avoid a lopsided appearance, and to achieve a symmetrical result. Full details of volume displacement techniques are discussed in the next chapter.

Volume replacement procedures

During volume replacement operations your surgeon will create flaps that are formed from the tissues next to your breast. Two different kinds of flaps are used for volume replacement:

LD miniflaps

These flaps include part of the muscle on your back (your latissimus dorsi or LD muscle, see Chapter 6), together with a layer of overlying fatty tissue (Figure 8.1). Sometimes a small island of skin attached to the muscle is taken as well if it’s been necessary to remove the skin or nipple alongside the tumour (Figure 8.2).

The amount of tissue needed to fill the gap in the breast is usually smaller than the amount of tissue needed to reconstruct the whole breast when a full mastectomy has been carried out. This is why this particular type of flap is called the ‘LD miniflap’. The flap is then swung through your armpit and is shaped and modelled to fit into the gap in your breast. The muscle is able to contract, and small movements can sometimes be seen under the skin where it lies in the breast. Most miniflap operations involve removal of the cancer and reconstruction of the ‘gap’ at the same time. Occasionally, it’s safer to delay the reconstruction until full removal is confirmed by the pathologist. In some breast units, this can be confirmed by ‘frozen section’ examination of the tumour edges in the laboratory during the operation, avoiding another procedure.

Figure 8.1 – LD miniflap without a skin island.

Figure 8.2 – LD miniflap with a skin island.

Usually your nipple won’t have to be removed, and a miniflap can be used to reconstruct defects in any part of your breast. You’ll normally spend 1–2 days in hospital, and a small drain is often left in the wound that’s usually removed 2–3 days later. Complications are uncommon, and include haematoma (a collection of blood), infection, wound breakdown, and loss of sensation. Very rarely, the miniflap dies because of a poor blood supply, and has to be removed. Some patients will experience stiffness and tightness around the shoulder and shoulder blade during recovery, but this can be overcome by an early return to exercises including using the cross-trainer, the rowing machine, and swimming.

Chest wall perforator flaps

The second place where your surgeon can borrow soft tissue is from the area of skin and fatty tissue lying behind the outer and lower border of your breast. This area may extend around the chest onto the back. Flaps from this area are called ‘perforator flaps’, as they get their blood supply from small vessels that pass through, or perforate, from other blood vessels inside the chest wall. Unlike miniflaps, they don’t usually include any muscle, so they have no visible movements.

Like miniflaps, perforator flaps are used when removing larger tumours relative to breast size, as they’re expected to leave a big defect after removing them. So this operation allows the surgeon to remove the tumour and still preserve the breast in a good shape. It’s most suitable if your breast cancer is in the outer or lower part of the breast. In a few cases, these flaps can also be used for tumours in the upper inner part of the breast.

Perforator flaps don’t involve removal of muscle, so these techniques do not affect your arm or chest wall function. The surgery will leave a long scar on the side of your chest wall, running towards your back. There are three different types of flap, which have names depending on their blood supply. They include the Lateral Intercostal Artery Perforator (LICAP) flap, the Lateral Thoracic Artery Perforator (LTAP) flap, and the Thoracodorsal Artery Perforator (TDAP) flap. Cancers in the lower inner part of the breast may be suitable for reconstruction using tissue from underneath the breast on the lower chest wall, using an Anterior Intercostal Artery Perforator (AICAP) or thoraco-epigastric flap. This leaves a scar running along the fold under your breast (Figure 8.3). Usually this will be the only scar, unless it is necessary to remove breast skin overlying the tumour when the tumour is very close to the skin.

Figure 8.3 – Typical scar after a perforator flap operation.

Like miniflaps, perforator flaps may be carried out as two-stage procedure, to ensure that the tumour is excised completely before undertaking the partial breast reconstruction. This approach may result in additional scar on your breast. Your surgeon will discuss the pros and cons of the approaches that would be suitable for you. Radiotherapy is nearly always needed after volume replacement operations. Both miniflaps and perforator flaps tolerate radiotherapy very well, but there’s a risk that your reconstructed breast will gradually shrink over the years. This may make you lopsided, and if this becomes distressing, further surgery can be offered to restore your symmetry.

Your surgery will take between 2–3 hours, and you may be treated as a day case or stay overnight in the hospital. You’re likely to have a drain placed during the surgery that’s normally removed the following day before discharge. Your recovery from surgery is quite quick, taking about 2–4 weeks. Wound healing depends on your general well-being and any other medical conditions. You’ll be advised about exercises that will help you to regain a complete range of shoulder movements.

Risks and complications of volume replacement procedures

As highlighted above, miniflaps carry a small risk of bleeding, infection, loss of sensation, and delayed wound healing. Each of these complications can develop after perforator flaps as well, and further surgery may be required if either technique hasn’t been successful in completely clearing the cancer. More specific complications of both approaches include flap loss that will require further surgery, and shoulder stiffness that responds to exercise and physiotherapy. Cases of chronic pain have been reported following these procedures, which can happen because of trapped nerves. This is rare and is usually resolved with release of scar tissue or steroid injections.

Scars in patients after volume replacement operations

LD Miniflap operations

Figure 8.4 – Lateral scar without skin from the back.

Figure 8.5 – Breast scar with skin from the back.

Perforator flap procedures

Figure 8.6 – Breast appearance three years after LICAP flap.

Figure 8.7 – Appearance of scar three years after LICAP flap.

Making your choice

One of the most difficult things about breast cancer is having to wait for the diagnosis to be confirmed, and then being asked to make decisions about your choice of surgery.

   I had to wait two weeks for the biopsy results and they were the worst two weeks out of the whole thing. I did get upset then. I already had a gut feeling that it was cancer because my mum’s sister was roughly my age when she was diagnosed and she died of it after it had come back in her bones. My dad’s sister died of breast cancer when I was very tiny. I have always known since I was a kid that I would get it. It wasn’t really a big shock when they told me. My friend who was with me was more shocked. As soon as I was told that it was cancer, I thought that I had to get on with it. There was no point in crying and being miserable.   

It’s often helpful to meet or talk to other women who have faced similar choices to you. Your breast team should explain your options, and help you with pictures and printed information about the different techniques. It’s important you ask about anything you don’t understand and if you’re unhappy about the advice you’ve received, you’re entitled to ask for a second opinion.

If your surgeon thinks you’ll need radiotherapy after the operation, you may be encouraged to consider delaying reconstruction altogether until after all your treatment has finished, or to think about having an autologous LD, TRAM flap or partial reconstruction, as none of these techniques involve the use of an implant.

   The surgeon then said I could either have a mastectomy and after the chemotherapy and radiotherapy was finished, I could have the breast reconstructed, or I could have a latissimus dorsi miniflap reconstruction. With this, sometimes after the radiotherapy the muscle shrinks and looks a bit odd. I was told that it was up to me. They are both long operations but the full reconstruction takes longer. I was offered a TRAM flap because I was advised not to have an implant and then have radiotherapy. However, I did meet other women who had implants at radiotherapy. I decided straight away which one I was going to have. I thought that a really long operation was silly and I couldn’t cope at the time with the thought of losing my whole breast. I thought that I would rather keep as much of me as possible. The possible risk of the shape changing after radiotherapy didn’t enter into it. I just didn’t want to wake up without a breast there. I had a partner at the time and he was very supportive and upset but didn’t take part in the decision making. What got me was how upset everyone else was. I felt fine but couldn’t handle everyone else. I talked about it with my partner, friends and my brother and sister-in-law. I just wanted to get it done as quickly as possible.

I saw the breast care nurse and she showed me pictures. They didn’t really make a difference because I had made my decision.

Don’t be stampeded, take your time when deciding what to have done. People get scared when they have cancer and think that it must be dealt with immediately. I thought that it had been going for some time, so I should see what the options were. Even if a partial reconstruction had not been an option, I would have probably tried the full reconstruction. I have no regrets at all. Even though my breasts were a better shape before the treatment, the main thing is that they are still there.   

What will it be like soon after the surgery?

Having a partial mastectomy and reconstruction is a smaller operation than a full mastectomy and reconstruction, but a bigger procedure than having a mastectomy without any reconstruction at all. Most patients are pleasantly surprised to find that it’s not very painful when they wake up. This is because powerful painkillers such as morphine are used as and when needed, and the amount can be decided by you by pressing a button. This delivers a small dose into your blood stream every time you need it. In many hospitals, the anaesthetist will use a technique to deaden the nerves around the reconstruction using local anaesthetic, which can last for 24–48 hours.

   I can’t remember pain when I woke up, although I was on morphine to control it. I had three quite large scars, one on my back, one in my armpit and one below the breast.

The one on my back was fine. I had no trouble from that. The one under my arm was the most painful. All the drips and drains made it harder to go the loo.

I looked at my breast while I was still in the hospital. I felt fine. I didn’t care after I knew that I had not lost the breast. I kept my nipple. I did show my partner and that was all right. He wasn’t offended by it.

I was in hospital for a week and by the time that I went home could do most things apart from lifting. I was washing and dressing. I went and stayed with my brother and was looked after.

My arm movement was all right straight away. I was given exercises by the physiotherapist and I did them. I go to the gym twice a week at least and if I miss it, for example because of going on holiday, it gets stiff and pulls under the arm. I went back to the gym throughout the radiotherapy four or five times a week. I was trying to lose weight before going on holiday. I just did a gentle programme that was devised by the trainer at the gym after I told him what I had done. It really helped. I was very unfit, having not been active during chemotherapy and radiotherapy.   

   I was in hospital for two nights. There were teething problems with the healing and at first I clutched myself when I turned over in bed and my breasts were a bit sore for a while. You mustn’t be too depressed when it doesn’t go right immediately because it will in the end. I found it helpful to be warned that it could take time to heal. I was very tired in the beginning but if you are sensible, you pace yourself.   

What about long-term recovery?

After volume replacement you may be aware of numbness over your back and experience some tightness around your chest. If you’ve had a miniflap operation, you may also notice some ‘jumping’ of the muscle in your breast, particularly if you move suddenly or sneeze – something that doesn’t happen after a perforator flap. You’ll find that within a few months of surgery most of these new sensations settle down.

   My armpit and the top of my arm are still numb. I can feel where the muscle was moved but not above it. I have sensation to the upper outer part of the breast. The sensation has slightly improved and my back is numb. It is annoying but that is all. Very occasionally, when I cough, the muscle in the reconstructed breast jumps slightly. It doesn’t really bother me.

It is a year since the operation and I can do anything. I do know that my left arm is weaker and I have not got quite the movement when raising my arm above my head, but I have got a full range of movement, apart from that. I don’t have central locking in my car and I would not now lean right across the car to use the arm on the reconstructed side to undo the door lock. I would walk round instead. That is the only thing that I have changed.

Initially, the reconstructed breast matched the other one well but I have lost two stone since then. That means that the reconstructed breast has stayed the same size and the other breast has shrunk a bit. The side of the breast under the arm, where the muscle has been brought through is fuller than the other side. I was warned that if I lost or put on weight, the breasts might not match.

I was told that with the TRAM flap, the reconstruction would lose or gain weight with me, whereas it wouldn’t with the miniflap. The difference is not that noticeable. Nobody else has noticed. I now wear non-wired bras, which are quite comfortable. I can’t run in the gym because the muscle in the breast is too heavy and painful. I was advised to wear a bra for support a lot of the time, which was helpful. It also helped in bed.

I finished the radiotherapy three months ago and I think that it is still slightly affecting the breast.   

One of the great benefits of partial mastectomy and reconstruction using volume replacement is that your breast feels pretty normal and looks pretty normal. And, unlike full mastectomy and reconstruction, your breast will very much feel like part of you, rather than something that’s been made to look like a breast but doesn’t feel like the real thing.

   At the beginning, the breast was a bit numb. The back of the arm and around the scar felt as though I had pins and needles. This probably went on for a year to 18 months. I could cope with that as my activities were not affected by it. It was just a strange feeling when I touched it. Even now, five years later, when I have done things which I shouldn’t have done, for example, heavy lifting, I feel the muscle tightening where the scar is in my armpit but it lasts for a couple of seconds and is gone. I don’t remember having much numbness in my back.   

Chapter 9

Reconstruction after Partial Mastectomy and Volume Displacement

Rosie Stanton

  • Volume displacement combines techniques used for breast reduction, a mammoplasty, with an operation to remove your cancer.
  • This approach allows your surgeon to displace your own healthy breast tissue into the gap left by your cancer surgery.
  • These techniques are very useful if you’ve got large or droopy breasts, but can be used if your breasts aren’t so large.
  • Afterwards, you breast and nipple may feel numb, and the tissue may become firmer than the other side after radiotherapy.
  • Most women experience little pain, and return home the same day.
  • Different techniques leave different scars, and healing is sometimes delayed.

What is mammoplasty surgery?

A therapeutic mammoplasty is an operation that uses the surgical techniques of a cosmetic breast reduction to remove your cancer. The breast is then re-shaped and the nipple is lifted to leave you with a nicely shaped, but smaller breast, without any dents (Figure 9.1). It can be performed as day case surgery. Very often the other breast is reduced to match. This can be done at the same time as your cancer surgery or later. This operation is most suitable if you’ve got larger or more droopy breasts, but a more subtle nipple lift or mastopexy technique can be useful to remove cancers with good cosmesis in some smaller breasts.

A breast reduction will change your body shape. It can take some getting used to.

   …it has taken me quite a while to get used to my girls, as I call them. Evidently, I was a lot larger…It’s also very reassuring, knowing the bad bit’s gone… and now I’ve got them, they’ve become part of me again. My husband says how wonderful they look and what a great job you’ve done.

I have to say, when you actually said we can keep them, I was quite surprised because I honestly thought they’d come straight off, and I had got that in my head, that they were going to come off and that was it. So yes, my girls are great.   

Figure 9.1 – Therapeutic mammoplasty showing removal of a tumour combined with reshaping of the breast.

Do ask lots of questions of your surgical team and breast care nurses. It can be helpful to have a second conversation about the specifics of your surgery at an appointment separate from your cancer diagnosis. It’s very normal to feel very uncertain about your surgical options and decisions.

   Well, I think you have to put your trust in the person that’s doing it for a start. You’ve got to have a trust between the people, and listen to what they are saying to you, what they advise you to do. And I think you’ll find the strength in that. I thought to myself when I had it done, ooh, I didn’t know if I was going to…I wanted to then I didn’t want it to…then I wanted to have the breast off and get rid of it. But, no, then I found that when I was spoken to, and I was told, and explained everything that was going to happen to me by yourself, then I found it was okay.   

After the surgery, you may find that parts of the skin of your breast and your nipple are numb. This numbness can feel a little odd if the breast is touched. Over time some sensation may return. If not, your brain will, in time, become more used to the new sensation, but this can take a couple of years. This numbness happens not only after breast reduction surgery but also after any surgery in any part of the body.

You’re likely to need radiotherapy on the side of your cancer. Your irradiated breast will feel more stiff than the other side, and over time, is likely to remain the same size and shape. Your other breast will lose and gain weight with you, which can lead to a difference in appearance.

Scar patterns

There are a variety of possible surgical techniques that can be used in breast reduction surgery and each one produces slightly different scars. Your surgeon will use the scar pattern they feel will give the best outcome for the shape of your breast.

The most commonly used technique is a Wise pattern which gives an anchor-shaped scar that runs around your nipple and down into the crease under your breast (Figure 9.2). This tends to be used if you have a larger breast or your breast has a lot of droop.

Figure 9.2 – Wise pattern scar after operations that reduce the breast size.

A vertical scar pattern will give a lollipop-shaped scar around the nipple and straight down only (Figure 9.3). This tends to be used in more moderate-sized breasts.

Figure 9.3 – Vertical scar pattern used in moderate–sized breast.

A melon slice breast reduction will leave a scar across the breast (Figure 9.4). This surgery can be helpful if you have large breasts and other medical problems such as diabetes or smoking as it tends to heal without problems and is a shorter operation.

Figure 9.4 – Melon slice scar used in larger breasts.

What will it be like soon after the surgery?

Having a therapeutic mammoplasty is a bigger operation than a lumpectomy, but it is still a day case operation. Most patients are pleasantly surprised to find that it’s not too painful when they wake up. A good fitting bra that keeps your breasts held still after the surgery helps with any pain. Your surgeon will normally use local anaesthetic during the surgery and will recommend that you take regular pain killers for a few days. It’s more effective to keep the pain away than to try and get rid of it once it comes.

   As for the surgery, I thought about it afterwards, I do think about it, of course I do. When you said, ‘Would a breast reduction be okay?’ I was quite happy with that. I was thinking, ooh, good, because they had always seemed too big for me, my bosoms, my breasts. And I thought, well, if it had to be, it had to be.

As for the treatment, I went through each stage, you know the appointments and things. I was upset to begin with, I wasn’t upset when I saw you [the surgeon] I was almost excited, I don’t know how that works, but then later, when I got the call, to come in for my chemo, that upset me, because I thought, you know, this is real.

The day before my surgery I was quite worried. I didn’t know what to expect, I didn’t know what would happen really. I can honestly say that the day of my surgery, I didn’t feel pressure, I just felt relaxed. I was taken through each step that I needed to do. I saw the surgeon who did all the markings, I went for the nuclear medicine injection.

They took me in to the theatre directly, everyone was talking to me, they were all doing what they needed to do and before you knew it, I was asleep. And it felt like the next minute and I was waking up in recovery thinking ‘It’s all done, I don’t feel any pain’.   

It’s not unusual to use a special, negative pressure dressing attached to a portable battery pack, called a PICO dressing, for seven days after the surgery (Figure 9.5). This helps with wound healing.

Despite this, it’s possible for your wound healing to be delayed. This may lead to repeat dressings or occasionally a second trip back to theatre. If this happens, it can impair the final cosmetic result, but it’s important to emphasise that most women heal without major problems, and are left with neat, fine scars.

Figure 9.5 – A large PICO dressing has been applied after mastectomy.

Chapter 10

Reconstruction of the Nipple and Areola

Sophia Pope-Jones, Diana Slade-Sharman

  • Nipple reconstruction can have a big effect on body image.
  • It can make a major difference to the appearance of your breast.
  • There are many different types of nipple reconstruction.
  • The choice is influenced by the amount of projection you require.
  • Most nipples are made longer than the opposite side, to allow for shrinkage.
  • Tattooing and micropigmentation are optional, and often need to be repeated after 12–24 months.

Your nipple, also known as the nipple–areola complex (NAC), includes both the nipple and the surrounding pigmented area of skin, called the areola. Nipples are usually projectile, although some can be inverted or flat, even with stimulation. The little bumps on your areola are called Montgomery’s tubercles – these extra-large ‘goose bumps’ are glands that secrete a waxy fluid to moisturise and protect your areola and nipple. Your areola also contains hair follicles, and hairs can be quite prominent in this area. There are about 15–25 lactiferous ducts that pass from the glandular breast tissue through your nipple. These ducts transport milk to your nipple, as well as providing projection (Figure 10.1). The colour, size and texture of the nipple is highly variable across ethnic groups and in different individuals, although the NAC is usually darker than the surrounding skin.

The NAC is integral to the overall appearance of your breast, and a feminine symbol of nurturing and eroticism. NAC reconstruction is usually the final step of breast reconstruction following mastectomy. Women with other conditions, such as congenital or developmental abnormalities of the nipple, burn deformities, and complications following surgery including breast reduction, can also benefit from NAC reconstruction.

   Although the reconstructed breast was a natural shape, I was left with a flat circle of skin where the nipple should have been. Whenever I looked at it, I was reminded of what I’d had. I thought that having had such a good reconstruction, it would be a shame not to complete the process.

Having been pleased with the breast reconstruction, I felt inclined to have the nipple reconstructed to rid myself of all the artificial attachments (adhesive silicone prosthesis).   

Reconstruction of the NAC can have a great effect on your body image and overall quality of life. Making a NAC that matches the position, size, shape, projection, and colour of the other side can make a big difference to the appearance of your reconstructed breast and to the overall result. These are currently achievable goals but creating a new nipple that can become erect and has full sensation are goals for the future. There are many different ways that your NAC can be reconstructed. We’ll take a look at the most commonly used techniques.

Figure 10.1 – The nipple areola complex (cross-section).

Principles and techniques

It’s normal to have your nipple reconstructed as a day case under local anaesthesia. There are some general principles that are common to all techniques:

  • NAC reconstruction is usually postponed until your breast reconstruction has settled down. This is usually about 3–6 months after your penultimate reconstruction procedure (main reconstruction plus possibly additional corrective procedures such as symmetrising surgery on other breast). A few surgeons will reconstruct your breast and your NAC at the same time.
  • When your new NAC is being reconstructed, your own NAC serves as a template. Both you and your surgeon should find time together to plan the position of your new NAC. Various techniques can be helpful when deciding on the best place, including using the sticky dot usually used for making heart traces, or a sticking plaster. You can stick the dot in the best position for you, while looking in the mirror.
  • If you’re having both sides reconstructed your surgeon will rely on certain well-known anatomical landmarks to choose the location of your NACs. In general, they will be located at the apex or most projecting point of your new breast mounds.
  • To begin with, your surgeon will aim to make your new nipple almost twice as long as the one you’ve lost. This will allow for the shrinkage, which is inevitable, particularly in the first three months.

       I had dressings on the nipple and it healed up in a few weeks. It did not affect my normal activities.

    In my case, it took almost six months to get the nipples right. At first the nipples looked a dreadful sight while they were healing. They were made long to allow for shrinkage. Most of the shrinkage takes place in the first few weeks and months. They are perfect now and look so real.   

It’s easier to understand NAC reconstruction if we look at the operation in two steps – first the nipple, and then the areola.

Nipple reconstruction

Over the last 40 years or so, many different techniques have been used for nipple reconstruction. These techniques include using the original nipple, using the nipple from the remaining breast, using grafts of skin and cartilage from the ear, as well as tattooing alone. Some of these techniques are no longer used.

Currently, local flaps provide the most reliable techniques. These use local tissue that is rearranged to create a bump. This local tissue may well be the skin island from your breast reconstruction, in other words the skin from your tummy or your back or your inner thighs. The skin over your reconstructed breast is quite numb and because of this, nipple reconstruction is usually a painless experience. There are many different ways of creating a bump and we will discuss the best current techniques, and most commonly used ones. The best techniques are simple, giving long-term projection, and provide a good blood supply. Healing is good and there is minimal scarring in the site from which the skin has been borrowed.

Your surgeon will often make your new nipple larger than the one on the other side because the new nipple will shrink in size over the first few months. Nipples made from skin borrowed from the back tend to be firmer than those made from tummy skin or inner thigh skin – reflecting the much thicker skin we have on our backs. Swelling and scabbing around a new nipple is very common in the early weeks, but this will settle down naturally as healing takes place.

The skate flap

The skate flap was introduced in 1984 and became the most popular technique for nipple reconstruction (Figure 10.2.1–2).

Figure 10.2.1 – Appearance of right skate flap nipple reconstruction following DIEP reconstruction of right breast.

Figure 10.2.2 – Close up of skate flap nipple reconstruction in Figure 10.2.1 without nipple areola tattoo.

Two thin skin flaps, shaped like the wings of a skate fish, wrap around the central fatty core and create a prominent nipple (Figure 10.3). This is a good choice if you want a large projectile nipple. The skate flap sometimes requires a skin graft to close the residual defect.

Figure 10.3 – The skate flap (top left: marking the flaps; top right: raising the flaps; bottom left: forming the nipple; bottom right: closing the defect and the final result).

If your surgeon decides to use a skin graft, this will also create a new areola around the nipple. The skin can be harvested from different parts of the body. Common areas include the groin, the inside of the thigh, or the end of the scar where your flap was taken from. It can even be taken from your other breast if you are having a reduction of your other breast to match at the same time.

The CV flap

The CV flap was introduced in 1998. It is made from a central core with a hat and two thinner arms that wrap around it, producing a less pointed shape than the skate flap (Figure 10.4).

This type of flap leaves a smaller gap in the surrounding skin than the skate flap. This means that it’s usually unnecessary to use a skin graft and a new areola can be made by tattooing the surrounding skin to hide the scar if required. Your surgeon will often advise waiting a few months before doing this to allow the scar to mature and settle down.

Figure 10.4 – The CV flap (top left: marking the flaps; top right: raising the flaps; bottom left: forming the nipple; bottom right: closing the defect and the final result).

The arrow flap

The arrow flap was introduced in 2003 and is a modification of the CV flap. Essentially it is very similar to the CV flap except that the two arms dovetail in the shape of an arrow rather than lying side-by-side, in the case of the CV flap (Figures 10.5.1–4).

Attempts have been made to provide long-term projection of the nipple by using firm material during the reconstruction of the nipple. Cartilage grafts can be used to augment the nipple reconstruction, and cartilage can be removed from your rib at the time of certain kinds of breast reconstruction, such as DIEP or TRAM flap reconstructions. It can then be ‘banked’ under the skin of your breast or your abdominal wall for use at a later date.

Figure 10.5.1 – The arrow flap, a modification of the CV flap (top left: marking the flaps; top right: raising the flaps; bottom left: forming the nipple; bottom right: closing the defect and the final result).

Figure 10.5.2 – Arrow flap drawn on the breast.

Figure 10.5.3 – Flaps raised and closed.

Figure 10.5.4 – Nipple height at the end of the procedure.

Areola reconstruction

Reconstruction of the areola can be achieved very successfully by micropigmentation alone or by skin grafting. ‘Nipple and areola sharing’ methods are rarely used today. In this method, the normal unaffected areola is reduced in order to create a new areola on the reconstructed breast. Donor site scarring and potential damage to milk ducts and breast-feeding, as well as to the erogenous structure, have made this technique unpopular. Skin grafting was a commonly used technique for areola reconstruction (Figure 10.6.1–2). The upper, inner thigh is a popular site for taking a full thickness skin graft, as skin from this area is more pigmented than breast skin. Other sites include skin from the labia and from behind the ear. These are not so popular as patients find them less acceptable.

NAC reconstruction using full thickness skin graft from the upper thigh

Medical Nipple Areola Micropigmentation

For the NAC to look as realistic as possible, it needs to match the colour, shape and size of your natural NAC. If you’ve had both nipples reconstructed, and you have two NACs to pigment, the colour and size of areola can be discussed to match your skin tone and your preferences. A good match can usually be achieved by a technique called ‘micropigmentation’. This is usually performed several months after the nipple reconstructions have had time to settle. The procedure takes about 30 minutes per nipple and doesn’t usually require local anaesthetic. Sometimes, if the area is sensitive, topical local anaesthetic cream can be applied beforehand. Rarely, a local anaesthetic injection is required for the procedure.

Figure 10.6.1 – Areola reconstruction using full thickness skin graft from the upper thick: preparation of area for skin graft.

Figure 10.6.2 – Full thickness skin grafts in place.

If you’ve had one nipple reconstructed, the skin needs to match the shade of your natural NAC so it looks as realistic as possible (Figures 10.7.1–2).

A reasonable match can usually be achieved by colouring the skin using the micropigmentation technique, which is similar to tattooing. This is usually done several months after the nipple reconstruction has had time to settle, and it may need to be repeated to give a better result or further depth of colour. The colour will fade over time but should last 3–5 years or more.

Micropigmentation is a procedure whereby pigment (colour) is implanted into the epidermis and superficial dermal layer of your skin. This is done using a machine designed specifically for the cosmetic and medical market. The machine and pigments are different to conventional tattoo inks used in tattoo parlours. Treatment lasts 3–5 years and is carried out in line with strict health and safety protocols. Colours are chosen to match your natural nipple and areola. Advanced micropigmentation techniques involved shadowing, highlighting, feathering and contouring. Colour selection and blending is vital for a natural result (Figures 10.8.1–4).

A trained and experienced practitioner will perform the procedure, usually during an outpatient clinic appointment. Traditionally, this was a plastic surgeon, but today this procedure is more commonly delivered by many highly skilled and fully trained Advanced Nurse Practitioners. They may perform a patch test prior to the procedure, and the pigment is applied using a pen-like device, which contains several small needles. The needles move up and down rapidly, penetrating the outer and inner layers (epidermis and superficial dermis) of your skin, and implanting the coloured pigment. This can feel like a scratching sensation. Following the procedure, you may have a light dressing and the area will crust and heal over the next week or so. You may have a light dressing for the first 24–48 hours.

‘3D’ micropigmentation can be performed by highly skilled practitioners. This can be undertaken if you don’t want or can’t have a nipple reconstruction. The techniques of shadowing, highlighting, contouring are used to recreate the impression of a protruding nipple. However, on closer inspection the nipple is actually flat. This technique can be performed with medical grade pigments using micropigmentation (Figures 10.9.1–2).

Figure 10.7.1 – Right breast and nipple reconstruction before micropigmentation.

Figure 10.7.2 – Patient in Figure 10.7.1 after micropigmentation of nipple and areola.1

Figure 10.8.1 – Marking the area of the new areola to be pigmented without using a skin graft after delayed DIEP reconstruction.

Figure 10.8.2 – Applying the pigment.

Figure 10.8.3 – Tattooing (no anaesthesia needed).

Figure 10.8.4 – Immediate result of tattooing, which will fade over the next year.

The advantages of medical micropigmentation are the lack of need for a donor site and extremely realistic results. It can be done on an outpatient basis, is quick to perform, and risks such as allergies are very low. The setting is usually a minor operating facility and the procedure will be performed with sterile needles and inks. The disadvantages of micropigmentation are that the pigments fade with time (due to the pigment molecule and more superficial needling) and therefore secondary touch-ups are not uncommon. The technique of micropigmentation requires training and experience to achieve good results. Rarely, overcorrection with the tattoo may persist.

Figure 10.9.1 – 3D micropigmentation after bilateral reconstruction, showing impression of nipple projection when viewed from the front.

Figure 10.9.2 – Patient in Figure 10.9.1 showing absence of nipple projection when viewed from the side.2

Remember however that micropigmentation is an invasive procedure and isn’t without risk. These risks include:

  • Not achieving an exact colour match
  • Fading of colour over time
  • Scarring
  • Pigment migration or spreading of the colour
  • Uneven pigment colour
  • Slight skin irritation
  • Risk of infection.

The results of micropigmentation can also vary according to your skin type. It can be affected by:

  • Oral medication (tablets or liquids)
  • Your natural skin tones
  • Sunlight
  • Your skin’s characteristics (dryness, oiliness, sun damage, thickness, colour)
  • The pH balance of your skin (how acid or alkaline your skin is)
  • Alcohol intake – alcohol dehydrates the body, causing drying and flaking of skin; this can cause the pigment to break down more quickly
  • Smoking – this also dehydrates the skin and can make the pigment break down more quickly
  • How well you normally heal
  • Illness – this can affect the pigment and cause it to be broken down more rapidly
  • Swimming (chlorine can bleach the colour) or jacuzzi use.

Micropigmentation cannot be undertaken if you have recently tanned skin (including fake tan), as this makes it very difficult to match the colours of your areola.

3D nipple tattoo

This is performed by artistic and skilled commercial tattoo artists and results in a more permanent tattoo with often excellent results. Thus, less touching up is required in the following years. They can also perform tattooing following nipple reconstruction. The main difference between traditional tattoos and medical micropigmentation is both the depth of pigment placement (deeper dermis in tattooing and more superficial dermis in micropigmentation) and the dyes used. Most tattoo inks are composed of heavy metal compounds in one or more solvents. There are no clearly defined regulations on the use of inks in the tattoo industry in most countries, resulting in high variability in composition of tattoo inks on the market. Some red inks used for permanent tattoos contain mercury sulphide, while other reds may contain different heavy metals like cadmium (more of a yellow colour) or iron oxide (more of a black colour). These metals, which give the tattoo its permanence in skin, can cause allergic reactions, eczema and scarring in small proportions of cases. It has been reported in the medical literature that tattoo pigment can be taken up by lymph nodes. The lymph nodes can appear calcified on mammograms and may require a biopsy for confirmation. Certain tattoo inks may cause issues with PET scans or even MRI scans. It’s a good idea to ask what type of ink has been selected and also which of the two techniques are being used.

   I was not so happy with the match of the new nipple but after having the colour tattooed on, I felt much happier.   

   The reconstructed nipple did have some colour but as it settled down over a period of time, it became patchy. I had it tattooed to make it a better colour match. I think that it was worth it. You can live without it but it is important for the sake of your appearance.   

   Although I was very pleased with the nipple reconstruction as it was, I decided to have the nipple colour tattooed on as well. I had been completely undressed once or twice in the female showers at the swimming pool and just felt slightly conscious that one side was coloured and the other was not. The colour was not uniform all over. I have been told that it will fade. I shall leave it and see how it goes but know that I can have it coloured again in the future.   

   I did have a nipple reconstruction, which initially was thoroughly disappointing because it was not a good shape and it turned white when it healed. However, it was still better than having no nipple. I took the breast care nurse’s advice and had the nipple tattooed and it looks much better now. The size and colour of the area matches the other breast and I am glad that it has been done.   

Complications

Serious complications of NAC reconstruction are rare, but they need to be discussed when you’re deciding whether to go ahead. They include wound infection and wound breakdown, and there may be partial or complete nipple loss if the blood supply to your nipple is poor. This may be due to the design of the flaps, or sometimes where radiotherapy or smoking has affected the blood supply of the skin. A common complication is loss in the projection of your nipple. This is usually acceptable, but correction can be attempted using local tissue, cartilage or commercial fillers if required. Complications of areola reconstruction include fading of the tattoo and, rarely, a tattoo that is too dark. Top-up tattooing to correct fading is a simple procedure. Complications of areola reconstruction when your surgeon has used a skin graft include wound infection and poor graft take. This happens when the skin doesn’t pick up a good blood supply from its new position on the breast and some of the skin dies away. This can lead to loss of part of the graft, or occasionally the whole graft, when your body will produce scar tissue to heal the areas that have died off.

Special situations

Complications after NAC reconstruction are more common if your breast has been reconstructed using an implant alone, or if the tissues being used for your NAC reconstruction have been irradiated as part of your cancer treatment. Simple techniques such as 3D tattooing are the best in this situation, as the wounds are slower to heal and are more likely to break down.

Conclusions and the future

Modern techniques can rebuild a very lifelike NAC with little discomfort and a high degree of patient satisfaction. In the future, new techniques will focus on creating a more realistic nipple, possibly using innovative tissue engineering techniques.

   I am very pleased with the nipple and it is nice to feel complete. I went abroad a couple of months ago and it was lovely to be able to put on and take off a swimsuit like everybody else.   

   Since having the tattoo done, I am now able to shower in the communal changing room at the swimming baths without worrying about people looking. The colour of the tattooed nipple has gradually faded but I know that I could have that redone if I had the time.   

   The breast looks better with a nipple because there is no longer a blind piece of skin in the centre and it had some interest to it. That makes a lot of difference and I think that it makes me feel more confident. I would have been fine without it but it is rather nice to have it.   

   The nipple has made a difference to the appearance of the breast. I am not as conscious as I used to be when in a communal changing room. I am more embarrassed for other people than me. I am ready to go topless on the beach and can wear a T-shirt without a bra.   

What can you do if you want a nipple but no more surgery?

For some people, the thought of another operation, however minor, in order to have a nipple reconstructed may not be appealing. Another option to consider would be to use a prosthetic (false) nipple, which is attached to the breast using a special adhesive (Figure 10.10). These nipples come in two different forms:

  • Nipples made in silicone by the companies who make breast prostheses. They are available in several sizes and colours.
  • Individually made nipples that are made to match the patient’s own nipple shape and colour. These are usually produced by technicians in conjunction with Breast Units. The advantage of these is that they can look very realistic.

Sometimes it can be helpful to try using the silicone nipples for a while to see how you get on with them if you are unsure about the surgical options. The best way to find out about how to get these is through your Breast Unit. They will be able to tell you what is available.

Figure 10.10 – Custom-made and individual nipples (upper row: commercially available nipple; lower row: nipples made for individual patients).

 

  1. 1   We would like to acknowledge Sister Stephanie Fear and Sister Anne Francis for the nipple tattooing in this image.

  2. 2   We would like to acknowledge Sister Stephanie Fear and Sister Anne Francis for the nipple tattooing in Figures 10.9.

Chapter 11

Improving Balance and Appearance

Andrew Baildam

  • Very few women have perfectly symmetrical breasts.
  • After cancer surgery and radiotherapy, your breasts are very likely to be less symmetrical than before your treatment.
  • Modern oncoplastic surgeons are trained in a range of techniques that can help to restore symmetry.
  • There are three popular approaches, and it’s important to choose the best one for you.
  • Each approach will cause extra scarring, and carries a small risk of complications.
  • Your team will help you to weigh up the risks and benefits of choosing to have more surgery.

Few people would agree what it is that makes a perfect breast. Natural variety in size, shape, position and ptosis is infinite. Opinions on perfection are equally diverse. In a room of 20 people, you may get more than 20 different answers. There’s no such thing as an ideal breast, as every woman is uniquely different, and few women develop a perfectly symmetrical bust. In the natural world, most living things have an asymmetry, sometimes marked, other times very subtle but still there. No woman has two breasts that are the identical mirror image of each other. Every part of a body has built in asymmetry – the width of each side of the chest from the sternum (breast bone) to the axilla (armpit), the length of the arms, the development of the muscles, each of these areas may be asymmetrical. Sometimes the differences are very obvious, sometimes only slight. The idea that each breast is, or should be, a perfect mirror image of the other, is not natural.

Most women, if asked, would be critical of their natural breast in some way. Cosmetic surgeons deal with a whole range of requests – to make breasts bigger, smaller, higher, lower, or to create a different shape. Yet normality encompasses a whole range of sizes and shapes.

If you develop breast cancer, almost inevitably you’ll have to undergo some significant surgery, often followed by radiotherapy. A lot of attention has focused on developing better and more precise and sophisticated surgical techniques for total breast reconstruction, and partial reconstruction.

The breast that has had breast cancer removed can never be the exactly as it was before. Some women who are faced with breast cancer surgery see this as an opportunity to change the way their breasts look. Certainly the appearance of the breast will always change, but whether the breast will do so in a way that is an ‘improvement’ from before is questionable. The surgeon and the patient should agree realistic and achievable goals for breast conservation, or for reconstruction after partial or total mastectomy. Inevitably, even when doing this to the highest standard, the way the breast looks relative to the other side will usually be different. And sometimes very different.

Many surgical techniques used for breast cancer today have been developed from aesthetic breast surgery, particularly from different types of breast reduction procedures. Once your treated breast has reached its optimal shape, size and position, you can have a detailed discussion with your surgeon to decide whether or not to have an adjustment to your other breast to get better alignment and symmetry. There are certain areas in the breast where differences between the two sides can be very obvious. These particularly relate to the position and pointing of your nipples and areolas, your cleavage area in the inner (medial) part of the breasts, and the upper poles, where the breasts ride up over the bra line. Less obvious to you when looking from above your breast, are the lower and outside (lateral) parts of the breast, where it blends with your chest wall, axilla and arm.

Oncoplastic breast surgeons have the skills and the training to be able to provide major and modest adjustments to your unaffected natural contralateral breast. These adjustments can produce an aesthetic result that looks natural and does not clamour for attention every time you see yourself in the mirror. There are a number of techniques that can be offered to adjust your natural unaffected breast. These range from augmentation with an implant, right through to breast reduction. Included in this is the whole concept of reshaping or ‘re-coning’ the breast, and even doing fat grafting, or fat transfer. A full discussion between you and your surgeon should cover all these issues, including what’s feasible, what’s achievable, as well as what’s desirable and at what cost of discomfort, scarring, and risk of potential complications.

After treatment for breast cancer, your affected breast may have undergone reconstruction, either total or partial. Your remaining natural breast usually assumes a special importance. That importance may be related to aesthetic issues, or to anxiety and concern that the breast may itself in time develop a cancer. If you’ve had a reconstruction on the side of your mastectomy, then your natural and reconstructed breasts need to be modelled to achieve closer symmetry. This may well involve putting scars on your unaffected breast, and it’s important that placing scars on the natural breast is carefully considered and comfortably accepted.

Sometimes it’s possible to recreate a breast in a way that matches your natural breast by performing a balanced, aesthetic reconstruction. But with time the natural tendency for the breast is to droop, undergoing ptosis as the years go by, often increasing in size and volume as well. An excellent initial match may become less and less symmetrical, with obvious differences between the natural and the reconstructed breast a decade later. This is especially so after implant-based reconstruction rather than autologous reconstruction, where your natural living tissues are used for the breast reconstruction. Natural transferred tissue from the abdomen particularly can grow and age over years, whereas implants stay the same size and shape.

In cases where symmetry is difficult to achieve, and you’re psychologically and physically affected by what you can and cannot easily and comfortably wear, surgery to your natural unaffected breast is preferable to a prolonged experience of chronic asymmetry and imbalance. It’s most important to discuss fully your expectations of what can – and cannot – be achieved surgically with the unaffected breast.

The broad spectrum of techniques which can be employed on the natural breast comprises three approaches: breast reduction, breast augmentation, and breast lifting – otherwise known as mastopexy. With all of these also comes the need for breast reshaping. Often a combination of techniques is required in order to achieve as close a symmetry as can be reasonably expected, and fat grafting or lipofilling also has a role. Each of these will be considered in turn.

Breast reduction

There are myriads of techniques to achieve breast reduction, and that instantly tells you that there is no single, perfect technique to suit every woman. The blood supply to the breast comes through the muscles into the breast tissue itself and from then, through the breast cone to the nipple areola complex. The main blood supply comes from just outside the sternum, or the breast bone, and from under the arm through vascular perforators. There is also a highly complex rich network of vessels underneath the skin going towards the nipple from the round circumference of the breast ‘dome’.

When a breast is reduced in size it’s important that the nipple areola complex is kept right at the tip of the breast cone. If the cone is reduced, and lifted, then the nipple has to be positioned onto the new cone point. To do that involves making incisions around and underneath your nipple, and removing excess skin as well as breast gland and fatty tissue. It is this surgical dissection that removes a significant proportion of the natural blood supply to the nipple. Your surgeon has to consider very carefully where the blood supply is coming from to the nipple that is going to be separated from the rest of the breast, lifted and repositioned and sutured into its new place on the tip of the breast cone. This is why there’s a tiny risk of nipple-areola loss when a breast is lifted and reduced, particularly if it’s reduced or lifted markedly.

Your surgeon keeps the nipple alive by preserving some vessels coming towards it, and the tissue which is used to support and preserve the nipple is known as a pedicle. Pedicles can be created by your surgeon from the lower part of the breast (called an ‘inferior pedicle’), from the lateral part of the breast (called a ‘lateral pedicle’), and most usefully, from the upper inner part of the breast, the ‘superomedial’ pedicle. Your surgeon may use a plan similar to that shown in Figure 11.1.

Figure 11.1 – Planning right reduction mastopexy.

The scarring from a breast reduction can range from firstly, a short vertical scar, in the six o’clock position of the breast, going straight from the nipple areola down to the bra line; to secondly, a ‘tennis racket’ type of incision, around the areola and then down to the bra line; to lastly, fully inverted T- or anchor-shaped Wise pattern scars. This latter option is where the incision goes right the way round the areola, down to the bra line, and then curves up to the medial and lateral sides of the breast in the bra line itself, or what is called the ‘inframammary fold’. This is shown in Figure 11.2 which illustrates the scars after right reduction mastopexy.

Figure 11.2 – Scarring after right reduction mastopexy.

At the ‘T-junction’, where the vertical scar joins the bra line scar, the distance from the breast blood supply is the greatest. Your surgeon has to close the incision with as little tension as possible on this T-junction, as it’s prone to delayed healing from time to time. Particular issues which can predispose to poor healing include diabetes, obesity, cigarette smoking, and previous radiotherapy to the breast. Great care has to be taken by your surgeon to join the skin together with delicate sutures in layers, to avoid tension in the scar. Modern techniques of wound closure use predominantly absorbable-type materials which are synthetic and can be buried in the deep layers of the skin to close the edges. Similar stronger types of sutures are used to shape and support the breast tissue internally. Steristrips™ or skin glue are often used at the surface to produce a smooth scar.

It’s good practice to send any removed breast tissue from breast reduction surgery to the pathology laboratory for full analysis. Your surgeon may recommend imaging your breast before surgery if it’s been sometime since you’ve had a screening mammogram.

Breast enlargement

Breast enlargement, or augmentation, is most commonly carried out by placing synthetic implants behind the natural breast tissue. As discussed in previous chapters (see Chapter 4 and Chapter 5), implants are commonly made of high molecular weight, cohesive silicone gel. This is not liquid in the sense that it pours, but stays in its manufactured shape when cut or damaged. The gel is contained within a silicone elastomer ‘shell’ – there are a number of different varieties and textures of these shells.

Breast implants are manufactured by a wide range of companies; most of them now produce catalogues full of implants in different sizes, shapes and styles. The most commonly used implants are dome-shaped, known as ‘round’ implants, and teardrop-shaped, known as ‘anatomical’ implants. Anatomical implants are more naturally aligned with the breast shape, and increasingly they’re the preferred option. They do require significantly more attention to technical detail and placement compared with round implants.

Choosing the correct implant is very important. Your surgeon may use different ‘sizers’ – either within your bra at the clinic, or using a sterile sizer in the operating theatre. Together with your surgeon, you can choose which range of sizes go with a particular style at the clinic. This will help your surgeon who can then cross-check with single-use sterile sizers in theatre when you’re asleep to get the best match with your other breast.

Breast implants are usually placed in the space behind the breast itself, known as the pre-pectoral or sub-glandular position. They can also be placed partly behind the pectoralis major muscle in the upper half of your breast, the so-called ‘dual plane’ technique. Where there’s very little natural breast tissue, this technique can be preferable to the pre-pectoral technique, as the upper pole of the implant is more subtly concealed by the overlying muscle.

Implants are usually inserted through an incision in the breast bra line, or the inframammary fold. Other approaches are sometimes used, including incisions in the axilla or at the edge of the areola. Each incision is associated with specific risks and complications that must be discussed and understood. Scars may fade, but they’re permanent. There are complications with implants as there are with any operation. Most implants will have a natural life expectancy of between one and two decades, when they may need to be replaced. Implants can develop a hard capsule of scar tissue around them, which can distort the breast and may make it feel uncomfortable. Infection must be avoided at all costs, because once an infection develops next to your implant, it will almost certainly need to be removed. Prophylactic antibiotics should be used during and after surgery.

Figure 11.3 – Before left augmentation with implant: the left breast is smaller than the right following cancer surgery.

Figure 11.4 – After left augmentation with implant: the difference in size restored after implant surgery.

Figure 11.5 – Typical scarring from implant operation.

There have been reports in the media of a very rare form of cancer known as Breast Implant Associated-Anaplastic Large Cell Lymphoma, (BIA-ALCL, see Chapter 4). The cause has not yet been clearly determined, but it does seem to be related to certain types of implant surfaces and low-grade chronic infection with particular types of bacteria may also be involved. Whilst this is extremely rare (reported following about 1 in 24,000 implantations), symptoms which are particularly important and should raise an alert are firstly a sudden swelling in your augmented breast, and secondly a thickening or lump adjacent to your implant. Treatment of BIA-ALCL involves removing the implant as well as the capsule, and then undergoing any further treatment as necessary.

Breast augmentation can also be achieved by lipofilling or fat grafting. Natural sources of fat are taken from your own abdomen, flanks or even outer thighs. There are a number of techniques for fat grafting, all of which involve removing fatty tissue from a range of donor sites (see Chapter 12). Up to 70% of transferred fat can survive and grow, but fat transfer for augmentation is not as rapid or as instantly dramatic as placement of an implant. There are complications associated with fat transfer, and these include microcalcification and oil cyst formation. As a result, mammography may show some scarred areas and calcification. Bruising can often develop in the donor sites, particularly in the abdomen. All the evidence suggests that transferred fat takes around 4–6 months to graft into place, when the full benefit is achieved.

Augmentation mastopexy

A number of women require both a breast enlargement as well as a breast lift to achieve closer symmetry. The combination of these two together is known as an ‘augmentation mastopexy’. As with all surgery, the risks must be discussed in detail, and particularly because this combination is the most likely to produce complications. Augmentation mastopexy aims to shorten your breast skin, remove skin and tissue, and elevate your breast and the nipple. Blood vessels are divided as they naturally cross the incision lines. Positioning a breast implant behind the natural breast tissue requires your surgeon to divide the small vessels that come through your muscle and fascia, up into the breast. If the dissection in these two areas is substantial, then the remaining breast is starved of much of its blood supply. This leads to a much increased risk of nipple loss of part or all of your nipple, and wound breakdown.

For these reasons your surgeon will often recommend that augmentation mastopexy takes place over two operations separated by several months. They can be done together when your surgeon judges that a very modest lift with an implant, or a modest implant with a lift are technically feasible and likely to be safe for an individual patient. Many patients want everything to be done at once. But it’s important that you don’t misunderstand your surgeon if you’re advised that two operations several months apart would be a safer and a more reliable way forward.

The scars that result from augmentation mastopexy are similar to those illustrated in Figure 11.2.

Risk-reducing mastectomy

Finally an operation which some women consider for the contralateral breast is risk-reducing mastectomy. This can be done with immediate reconstruction in order to match a reconstruction on the other side, or maybe done without breast reconstruction depending on your choice. Often women who carry a breast cancer-related gene mutation such as BRCA1/2 do ask for a risk-reducing mastectomy of the unaffected side to reduce the subsequent risk of a second breast cancer. But women without proven gene mutations are increasingly requesting contralateral risk-reducing mastectomy. Most say it’s not because they believe that it will affect their overall survival, but rather that they don’t wish to undergo any of the diagnostic or treatment issues associated with breast cancer again.

Every situation has to be discussed entirely on its own merits, with your own views and wishes being paramount.

Summary

In this chapter we’ve considered the common techniques that are undertaken to achieve closer symmetry between a breast treated for breast cancer and the unaffected breast on the other side. There’s no ‘one size fits all’ and every woman is unique. Many patients don’t wish, nor do they require contralateral symmetrisation. Many are comfortable even when there’s clear asymmetry between the two breasts. It’s important that your surgeon is honest with you about the benefit from contralateral surgery, and whether the outcome is going to be sufficient to justify you going through further surgery on your normal breast. It’s also important that the surgeon undertaking your breast reconstruction is fully aware of the different techniques available for your other breast to achieve a closer match. They need to be skilled both in discussing the options in the clinic, and in delivering the choice technically in the operating theatre. To this end, the true oncoplastic breast surgeon needs to be a sculptor of living tissue and a communicator.

Chapter 12

Lipomodelling

Natalie Chand, Susanna Kauhanen

  • Lipomodelling is a clever technique which uses fat cells harvested from your own body to build up tissue in your breast. It’s also called ‘lipofilling’, ‘fat grafting’ or ‘fat transfer’.
  • There are a variety of uses for this technique, both after breast conserving surgery (lumpectomy), and for women who’ve already had breast reconstruction or who are thinking about it.
  • The tissue will have a natural feel because it’s all your own.
  • Patients often require more than one operation if a large volume of fat cells are needed to build the breast tissue up.

   Good experience, although needs some perseverance. The new breast feels nearly the same as the old one.   

   … it feels far more comfortable and natural compared to a … bra prosthesis which is very uncomfortable.   

How does it work?

Free fat transfer is a method used in plastic surgery which moves your own fatty cells (‘autologous tissue’) from one part of your body to another. The fat cells are carefully harvested using suction from their original site (the donor site), and then injected into the breast (the recipient site). The body then builds up new blood vessels to nourish them once they’ve been transferred, and they start to grow into place as healthy fatty tissue.

In the first 3–72 hours after transfer the fat cells get their oxygen through diffusion, which means sucking in oxygen from surrounding tissues. They then gradually build new capillaries (small blood vessels) to connect themselves to surrounding tissue. Those cells which build a good blood supply survive (retention), but those which die off are removed by the body’s natural systems (resorption).

Figure 12.1 – Injected fat cells forming a new blood supply.

Figure 12.2 – A syringe filled with fat, ready for injection.

The take rate (the amount of fat that survives) depends on many factors. These include whether you’ve had radiotherapy to the breast, the amount and quality of your skin, and blood flow in your tissues. The grafting technique is also really important, placing fat cells carefully in thin rows so that they are all in close contact with healthy tissue. Aftercare is also important, so that grafted cells are not disturbed by anything which could disrupt delicate new blood vessels such as pressure, friction, or shaking forces.

When can it be used?

This technique can be used in a number of situations, for example:

  • Lipofilling after lumpectomy: Helping to replace the volume that’s been lost because of the surgery, improving the appearance of your breast.
  • Lipofilling to create a new breast after mastectomy: You will need several episodes of lipofilling to build up a moderate breast shape.
  • Lipofilling to improve the appearance or your breast when it’s already been reconstructed: The size and shape can be changed using this approach after all types of reconstruction.
  • Improving the tissues of your chest wall when you’ve had radiotherapy after a mastectomy: This can lead to scarring in your pectoral muscles, causing pain and limiting your arm movement. Your skin and fatty layers may also be affected, becoming more fragile and less elastic, lowering the success rate of any type of reconstruction. A session of fat grafting can improve the quality of your tissues, and may be recommended to prepare you for reconstruction.
  • Improving chronic pain: Grafted fat contains stem cells, which encourage the body’s anti-inflammatory mechanisms. It has been used with success in some patients with long-term pain.

Below are photos of a 69-year-old lady who has had a mastectomy and implant-based reconstruction, and then shown after lipomodelling to improve the look and feel of the reconstruction by softening the edges and thickening the skin.

Figure 12.3.1 – Before.

Figure 12.3.2 – After.

Below are the photos of a 55-year-old lady who has had a mastectomy, and then shown after four lipomodelling procedures to reconstruct a full breast.

Figure 12.4.1 – Before.

Figure 12.4.2 – After.

Advantages and disadvantages

Table 12.1 – Potential advantages and disadvantages

Potential advantages

Potential disadvantages
  • Minimal donor site side-effects
  • Tiny donor site scars
  • Day case surgery
  • Quick return to work (typically 1–7 days depending on your job)
  • Occasionally the harvest results in a slimmer waist, thinner thighs or a flatter tummy.

To achieve the desired result, it is likely that a series of operations are needed. The number of operations depends on the reason for using this technique, but you can expect around:

  • One to three procedures to plump up a free flap reconstruction
  • One to two procedures to thicken the skin over an implant
  • One to two procedures to improve the appearance after lumpectomy
  • Two to four procedures to convert an implant reconstruction to your own tissue
  • Three to four procedures to create a new breast reconstruction (moderate size).

   It was a difficult experience because I needed three operations. However I am satisfied with the end result and the breast feels my own.   

   Even though the trip was long it was worth it, thank you.   

What to expect

The most common donor sites are the abdomen, the inner and outer thigh, and the waist. In some patients, the backs of the thighs, lower back or back of the waist can be used as well (which might mean you would be lying on your front when asleep in the operating theatre).

Once a particular donor site has been used, it becomes a little scarred and subsequent harvests do not yield as much fat (even if the area still looks plump). So if a series of fat grafting procedures are planned it’s preferable to plan the donor sites in advance. For example, using your upper abdomen for the first round, your lower abdomen for the second round, and your thighs for the third and fourth rounds.

We know that after your fat is re-injected, not all of it will grow into place. In the long-term, typically about two-thirds of the fat survives. When a cup of fat (about 250 ml or half a pint), is injected into the soft tissues covering the chest wall, it will produce a layer with a thickness of about 1.2–1.5 cm (half an inch). The fat that successfully grafts into place will then be permanent, and will behave just like any fat elsewhere.

   The operations themselves went well and recovery period was relatively short. The fat did not all remain, but I chose to stop after four treatments. The end result is okay.   

   In my case it was not successful, and we decided not to continue. I am really disappointed with the asymmetry, but reducing the size of the other breast has really improved things.   

Postoperative care and recovery

  • Most fat grafting operations are planned as day case surgery, meaning that you can go home the same day.
  • The areas used to harvest the fat ideally should be covered with pressure garments for at least two weeks after the surgery, or for as long as they feel bruised. Usually, the donor sites settle quite quickly, but it can sometimes take a few months for them to return to normal.
  • The chest should be kept warm and free of any pressure. This means avoiding wearing a bra (or wearing a very loose one) for the first two weeks after surgery. Vigorous physical exercise and massaging the area should be avoided. If you have had lipofilling for full breast reconstruction, it is recommended that you avoid using a prosthesis during the two weeks after surgery.

Figure 12.5 – Compression garment worn over donor sites after lipomodelling.

Source: EurosurgicalTM. Available from: https://esshop.co.uk/

  • Side effects are uncommon after lipofilling. The commonest side effect is bruising of the donor site. Occasionally, small patches of numbness can develop at the donor site, but infection and significant bleeding are very rare.
  • The vast majority of the fat cells that do not graft are reabsorbed without any problems. In some cases however, the cells can form lumps called fat necrosis or oil cysts (typically 6–12 months later). These often feel like peppercorns and are painless. Finding a new lump can be worrying, and although fat necrosis and oil cysts are not dangerous, the lumps will nevertheless need to be assessed carefully, usually with an examination, ultrasound and sometimes a needle test.

       I may have made a different decision if I had known that fatty lumps can be formed as a complication. They lead to worry about breast cancer recurrence. Every lump has to be examined.   

Cancer safety

You will continue to have your usual breast imaging. Mammography should be avoided for three months after lipomodelling, and so ideally it would be best to schedule your surgery after your regular check.

Large clinical series haven’t shown any increase in breast cancer recurrence (cancer coming back in the breast or elsewhere) following fat transfer. But it’s very important that you keep up to date with your follow-up plan. It’s also important that you check your breasts regularly, and report any new symptoms so that they can be checked out by your surgeon.

Chapter 13

Complications and Cancer Treatments after Breast Reconstruction

Siobhan Laws, Raghavan Vidya

  • Complications are less common in fit and healthy women.
  • They include those following any operation, and those associated with a particular technique.
  • Most complications can be treated effectively with good overall outcome, but your surgeon should explain your risks before you give your consent.
  • Cancer treatments should not be delayed by reconstruction.
  • If you need radiotherapy, you may be advised to delay your reconstruction particularly if you’ve chosen an implant technique.

You’re thinking seriously about having a reconstruction, but you want to know about the risks of this kind of surgery. What can go wrong? How bad can complications be, and what’s the best way to avoid them? Will they delay my cancer treatment?

Complications after breast reconstruction

All of your questions should be answered before you give your consent for surgery. You’ll be asked to sign a form that should summarise exactly what’s going to be done. It should also give a brief summary of the complications that can happen. Doctors are expected to let you know about serious and less serious mishaps. It can be quite frightening to list every possible complication, so you must ask your team to explain any particular complications you are worried about. For example, if your work or sports activities involve pushing your shoulders backwards (such as golf, cross-country skiing, vacuuming), this may be slightly impaired by a latissimus dorsi (LD) procedure, and you may decide to choose a different type of reconstruction.

General health

Your surgeon will take into account your occupation and will also want to know if you’re fit enough for major surgery. Both your anaesthetic and operation carry risks, but generally the fitter you are, the better the outcome. You’re less likely to have complications if you’re not overweight, young, physically active, don’t smoke, and don’t have any significant health problems. But we’re not all perfect, and there are other factors than can increase the risks of your surgery. Obesity is associated with an increased chance of chest infection, clots in the leg, wound infection and wound breakdown. Smoking is associated with chest infection, wound infection and problems with the blood supply to your tissues. This could lead to problems with the healing of the skin of your mastectomy flap, or the skin of your flap if you’ve had a latissimus dorsi or DIEP reconstruction. At the very worst, this could mean that the flap won’t survive and will have to be removed.

Lung problems

When you’ve had a general anaesthetic you’re more prone to developing plugs of mucus, which can block part of your lungs. This is because it can be difficult and uncomfortable to move around and take deep breaths and cough to clear your airways. Your nurse or your physiotherapist can help you to take a deep breath and cough to get rid of any blockage, but this can be difficult after major surgery because it’s uncomfortable in the early days. Pain relief, deep-breathing exercises and keeping well hydrated are all very important after surgery, and can help to prevent any blocked parts of your lungs from getting infected. This is important, as this type of infection can occasionally lead to pneumonia if not treated early.

Thrombosis (blood clots)

Clots in the leg are more likely after operations because your blood gets stickier following surgery – the blood pools in your calves as you lie still on the operating table and because you may become dehydrated. Steps can be taken to prevent clots forming with injections to thin the blood, compression stockings, calf squeezers in theatre and other manoeuvres. You can also help yourself by paddling your feet up and down every fifteen minutes or so, and by shifting about in bed. Try to move about as much as you can and ask the nurses to help you to sit out of bed as soon as you’re feeling strong enough. Drink plenty of water, as the atmosphere in hospital tends to be dry.

Infection

Any surgical wound can become infected, but if you develop an infection around your breast implant, this can be a real problem. Implants are made of inert synthetic material that your body’s defence mechanism can’t penetrate. If bacteria get into your wound during surgery or on the ward, they can settle round your implant and are almost impossible to eradicate. If this happens the implant may have to be removed, although it’s usually possible to replace it with a new one once the infection has settled down. Infections are usually caused by the bacteria that live on your own skin getting into tissue that has been traumatised by surgery. You’re more likely to get an infection if your immune system is weakened – for example if you take steroid medication or have diabetes.

Figure 13.1 – Infection with cellulitis in in a patient after left mastectomy and immediate reconstruction.

If the blood supply to the tissue is poor because of atheroma (clogging of the arteries) or because of smoking, which causes spasm of the small blood vessels, infections can take hold. Infection may be no more than redness or soreness of the wound, but it can progress to cellulitis (a spreading infection of the skin (Figure 13.1)), or it can form an abscess. Usually a course of antibiotics is all that is needed to deal with the infection. Very occasionally, the infection can lead to blood poisoning (septicaemia), which can turn into a very serious, life-threatening condition unless it’s treated early and effectively.

Many of these problems can be avoided if your surgical team uses a very careful theatre technique to prevent any infection getting into your wound. National guidelines are now available that help to cut the risk, including the use of specific antibiotics while you’re asleep.

Scars

There will always be scars after surgery. If these are carefully placed and stitched up well, the final scar will be nearly invisible, but it can take up to two years for scars to settle and for the redness to disappear. Some people are more prone to develop raised, thickened and red scars, known as hypertrophic scars (Figure 13.2). A very small number of people will develop keloid scars that continue to thicken and don’t settle down without treatment. Younger women and those with darker skin tones are more likely to be affected. Continued pressure on the wound with tape or silicone gel may help to reduce the likelihood of these thickened scars developing. Most surgeons now use an ‘invisible mend’ type of suture (sub-cuticular stitches), but clips and removable stitches can give good results if they are removed early.

Figure 13.2 – Scars after bilateral mastectomy (right side normal scar, left side hypertrophic scar).

Bruising and haematoma

Drains are used to collect fluid and blood from the operation site immediately after your surgery. Great care is taken during surgery to prevent any bleeding – coordinated teamwork of all the theatre staff is essential. Electrical cautery (which heats the blood vessels) is used to seal the smaller vessels, and clips and ties are used to seal the larger vessels. A small amount of bleeding after an operation is very common and usually shows itself as bruising. Occasionally, bruising can be quite extensive (Figure 13.3), and may look very dramatic (Figure 13.4). If this happens it will disappear in a week or two. Larger collections of blood are known as haematomas. These are usually left to clear of their own accord if they are not rapidly enlarging, causing pain, or putting pressure on the overlying skin or implant. Smaller haematomas can usually be treated by sucking the fluid out with a needle and syringe. Occasionally, haematomas continue to enlarge and need to be emptied or evacuated. This is usually done under a general anaesthetic in theatre. It can happen within hours of your operation – usually because a large artery has ‘popped’ – or a few days after surgery when a vein starts to leak. Sometimes the bleeding is enough for a blood transfusion to be needed. It’s essential that you let your surgeon know if there’s any reason why you can’t have a blood transfusion before you go ahead with your reconstruction. If a transfusion is likely and your reconstruction isn’t urgent, you can arrange to donate some of your own blood before your operation, or boost your iron levels with tablets or injections before your surgery.

Figure 13.3 – Extensive bruising after lumpectomy.

Figure 13.4 – Localised bruising after reconstruction.

Seromas

Seromas are collections of fluid that have accumulated in spaces left behind after your surgery. They are not dangerous and are the expected result of any operation. Sometimes the fluid builds up pressure and becomes uncomfortable. If this happens under your arm, it may be difficult for you to put your arm down by your side. Fluid often builds up in the gap if you’ve had the latissimus dorsi (LD) muscle taken away from your back, the donor site (Figure 13.5 and Figure 13.6). This can feel like walking around with a hot water bottle on your back, as the fluid sloshes around when you move about.

A build-up of fluid may be uncomfortable, and it can occasionally become infected. Seromas can also interfere with the planning of other treatments, such as radiotherapy and chemotherapy. Your surgical team will usually aspirate the fluid (taking it away with a needle) if it’s uncomfortable or if you’re waiting to have other treatments. This should be completely painless because the area is numb after your surgery, so you shouldn’t feel the needle. Sometimes this will need to be repeated several times until the fluid goes away. Care will be taken to avoid introducing infection into the seroma by using a sterile technique and by reducing the number of times the seroma is drained.

If the fluid isn’t bothering you, it will be left alone to reduce the risk of introducing infection. Some surgeons use techniques that may reduce fluid collecting in the tissues, such as closing the gap with stitches. Seromas are less likely to be troublesome after delayed reconstruction or flaps involving your tummy.

Figure 13.5 – Seromas in both donor sites following bilateral latissimus dorsi reconstruction.

Figure 13.6 – Large seroma in latissimus dorsi donor site after left breast reconstruction.

Sometimes seromas persist for many months. If this happens, the tissue around them becomes hardened and this ‘bag of fluid’ may have to be removed by surgery.

Pain

Part of the anaesthetist’s job while you are asleep is to ensure you feel as little pain as possible after the operation. Most breast operations are surprisingly painless, but with reconstruction, because there’s been more surgery, there’s a greater need for pain relief. The anaesthetist will discuss pain relief with you before the operation. A local anaesthetic is often used to deaden the nerves in the wound as well as a regional anaesthetic that blocks the nerves coming out of the spine that supply the area. It’s quite likely that you’ll have a little button to press to control any pain when you wake up (Figure 13.7). This delivers a small dose of a very powerful painkiller straight into your bloodstream (patient-controlled analgesia, or PCA). If it’s been used, it will be replaced by a cocktail of other painkillers, including anti-inflammatory drugs, within 12–24 hours of your operation. You may need to take painkillers for 3–6 weeks after your reconstructive surgery.

Figure 13.7 – Patient using a Patient Controlled Anaesthesia (PCA) device.

Your reconstructed breast and the upper part of your arm will normally feel numb when you wake up. This is because the nerves that supply the skin of your breast are cut away as the breast is being removed. The nerves to your breast never really recover and most of your breast will always feel numb. The nerves supplying the skin on your arm will often recover, particularly if your surgeon has taken care to preserve them. They are usually stretched during the operation and may take 3–4 months to recover. The skin on the inside of your arm near your armpit may feel strange while the nerves are recovering – burning, pins and needles, and tingling are common sensations that usually take 2–3 months to settle down. If your nipple has been preserved, it will almost certainly be numb and usually won’t become erect.

Lymphoedema after reconstruction

Lymphoedema means swelling of your tissues. It happens because fluid from your lymphatic system gets trapped and cannot escape. Your lymphatic system is a network of fine vessels that help to defend yourself against infection. After breast surgery this fluid can build up and affect your breast or your arm. It can happen after any kind of surgery to the glands in your armpit and it’s no more likely to happen after reconstruction than after surgery without reconstruction. The chances of it happening will depend on how much surgery has to be done on your glands, and whether or not you need to have radiotherapy to your armpit.

The lymph glands in your armpit normally act as nets to capture and destroy particles that could do harm if they got into your bloodstream. Cancer cells are close enough to normal cells to fool the lymph glands, so cancer cells can settle and grow in these glands. It’s usually the first sign that the cancer is on the move if the glands are involved. That’s why it’s important to know about your lymph glands, to give you an idea of how well you’re going to do in the future.

Lymphoedema of the breast

Sometimes removing the lymph glands under your arm will block the drainage of lymph fluid, which then builds up in the tissues of your breast, or occasionally your reconstructed breast. This can produce heaviness and swelling of the breast skin, which then looks similar to the skin of an orange, so it’s often called peau d’orange. Gentle regular twice daily massage can help redirect the fluid away from the tissues towards the lymph drainage areas. This problem usually gradually settles down.

Lymphoedema of the arm

Performing surgery in your axilla can also block the flow of lymph from your arm. This is not usually a problem immediately after surgery, but occurs several months or years later (Figure 13.8). Even a small amount of surgery in the axilla can trigger off lymphoedema. Removing glands as part of your cancer surgery, as well as finding the blood supply to a latissimus dorsi flap can affect the lymph channels from the arm. About 1 in 20 women who have glands removed from the axilla will eventually develop some swelling of the arm. A small cut or graze on your arm or hand can set off cellulitis if you’ve already got lymphoedema. This means that your arm becomes suddenly swollen, sore, and red. You’ll be given written information before your operation explaining how to avoid this problem, and the importance of early treatment with antibiotics.

Figure 13.8 – Lymphoedema of the left arm.

Lymphoedema may not affect the whole arm – it may involve the hand, the forearm, or the upper part of the arm. In its early stages the fluid can be treated by compression or massage. It can be prevented from getting worse by wearing a compression sleeve. If the fluid remains for any length of time it can act as an irritant and cause scarring within the tissues. This makes the tissues harden and more difficult to treat. Radiotherapy to the armpit increases the chances of lymphoedema following surgery. So it’s very uncommon to give radiotherapy following removal of all your lymph glands, because up to one in every four women treated in this way will get lymphoedema.

Sentinel node biopsy

Although your doctors need to know whether your cancer has spread to your lymph glands, it may not be necessary to remove very many glands to do this. Sentinel node biopsy is a more refined approach using a blue dye and a small injection of radioactivity to find the lymph glands most likely to have cancer in them. The technique isn’t suitable for all women, and the dose of radioactivity is tiny (less than living in Aberdeen or Cornwall for a year). Between one and three glands are usually removed, and further surgery may be required if cancer is found in the glands that have been removed.

Will breast reconstruction affect my cancer treatment?

The key aim of your treatment is to prevent your cancer from coming back, and you can be reassured that your overall treatment won’t be delayed if you choose to have a reconstruction. Radiotherapy can have an adverse effect on your reconstruction, especially if you’ve chosen an implant technique. For this reason your team may advise you to delay your breast reconstruction if they think it’s likely that you’re going to need radiotherapy after your surgery.

When you’ve had your operation, the pathologists will examine your tissues carefully and they’ll look for a number of features that will tell them much more about your tumour. This will help you, together with your doctors, to decide which treatment is best for you. It will also give everyone a much clearer idea of the chances of the cancer coming back, and your chances of a good overall outcome. Depending on what this examination shows, you may be advised to have further treatment to cut down any chance of the cancer coming back as much as possible. These additional treatments may include radiotherapy, chemotherapy, hormonal treatments and antibody treatments – all of which are given to fight cancer.

Your doctors will advise you which treatments are best for your individual case, depending on what kind of tumour you’ve developed and what kind of benefit you’re likely to gain. Some patients don’t need any further treatment at all, some need all of these treatments and some need a selection. Your cancer specialist (oncologist) will be able to give you an idea of the benefits (and the risks) of each treatment and will help you to make a decision.

Radiotherapy and breast reconstruction

Your team will advise you to have radiotherapy if there’s a real risk of the cancer returning in the area where your breast was removed. Although chemotherapy may be effective in reducing this risk a little further, it’s not as effective as radiotherapy. Radiotherapy will reduce the risk of cancer returning in the region of your surgery by about two-thirds, and it’s also a routine part of your treatment if you’ve only had part of your breast removed and reconstructed (see Chapter 8 and Chapter 9). But it isn’t needed for eight in ten women who’ve had a full mastectomy. Radiotherapy can have an adverse effect on the appearance, texture and comfort of your new breast.

The early effects of radiotherapy

The early effects of radiotherapy are the same in patients who’ve had a mastectomy whether or not they’ve had a reconstruction. The same number of patients may experience dryness and reddening of the skin during their radiotherapy treatment.

Longer-term effects of radiotherapy

Much is known and understood about the changes caused by radiotherapy in the breasts that haven’t been reconstructed. Although initially the breast tissue seems normal and the breasts appear symmetrical, there will be changes that continue for many years. A number of studies have also looked for these changes in women who’ve had breast reconstruction. There’s less information in this group, because fewer women have had immediate reconstruction in the past. They haven’t been followed up for long enough to give us a full picture. But results suggest that the timing of radiotherapy as well as the type of reconstruction are important factors.

Timing of breast reconstruction and radiotherapy

Reconstruction may be carried out either at the time of initial surgery – immediate reconstruction – or after all additional treatments such as chemotherapy and radiotherapy have been given – delayed reconstruction. Immediate reconstruction has many advantages but if radiotherapy is required, the risk of scarring and loss of softness of the reconstructed breast is greater than if the reconstruction is delayed until after radiation treatment has been completed. These risks are also higher in patients who have radiotherapy immediately after surgery, rather than several months later after chemotherapy has been completed.

Radiotherapy with breast implants

When an implant alone has been used for the reconstruction, there’s a real risk that the breast will become hard, painful and distorted, giving a cosmetic result that is less than satisfactory. This is because of firm scar tissue that forms around the implant. Overall, when radiotherapy has been used after reconstruction using an implant, a third of patients rate their physical and cosmetic result as good, a third rate it as satisfactory, and a third rate their appearance as poor. Because of these effects, if you’re likely to need radiotherapy after surgery your surgeon may advise you to delay reconstruction until you’ve finished your radiotherapy. Alternatively, a different technique using your own tissues that avoids implants altogether may be a better option (see Chapter 6 and Chapter 7).

   After the tissue expansion was completed, my reconstructed breast was much smaller than the other side, I was told that this was because I had radiotherapy and the skin would not stretch so well. I was offered an operation on the other breast to make it smaller and lift it up to match the reconstruction.   

Radiotherapy and breast reconstruction with your own tissue

Radiotherapy may also cause problems following reconstruction using all your own tissue, including the autologous LD, DIEP and the TRAM flap techniques (see Chapter 6 and Chapter 7). But the chances of a poor result appear to be much less than following reconstruction with implants alone. Again, the risks are higher when radiotherapy is carried out immediately after surgery rather than when it is delayed or carried out before surgery. It may lead to hard patches in your new breast (fat necrosis), as well as some shrinkage and loss of movement of your breast. Nevertheless, about eight of ten patients feel that the cosmetic appearance of their new breast after autologous flap reconstruction only and radiotherapy is excellent or good.

Other things that may add to the effects of radiotherapy

There are also some aspects of your general health and lifestyle that can add to the effects of radiotherapy. If you smoke, suffer from high blood pressure, have circulation problems, or you’re overweight, the effects of radiotherapy and the complications of your surgery may be increased.

Chemotherapy and breast reconstruction

Your doctors may advise you to have chemotherapy after your surgery, once samples of your tissues have been examined by the pathologists. This treatment is usually started about four weeks following your operation or when your wounds have healed. Even if you develop complications, it’s unusual for your chemotherapy to be delayed for more than a week or two. There’s no evidence that this affects the success of your treatment, or that chemotherapy causes any harm to your reconstructed breast.

Hormonal treatments and breast reconstruction

Your team may recommend hormonal treatments, and again there is nothing to suggest this will have any adverse effect on your reconstruction.

Monoclonal antibodies and breast reconstruction

In the future, we’re going to see more and more use of monoclonal antibodies against various cancers. These treatments, including Herceptin®, target and kill off cancer cells. There’s nothing to suggest that these sophisticated treatments that are given alongside chemotherapy have any adverse effects on breast reconstruction.

Summary

In summary, if you’re given radiotherapy before surgery, immediately after surgery or after chemotherapy, it can change the tissues to make them feel firmer and look less natural. These changes seem to be less common after reconstruction when your own tissues have been used. All the same, most patients are happy with the cosmetic outcome and where there’s a real risk, radiotherapy helps to stop the cancer returning in the breast. It’s important to realise that once you’ve had radiotherapy it has an effect that continues throughout your life. That’s good in one sense, because if you’re at risk it will help to stop your cancer coming back in your breast. On the other hand it may gradually change your breast shape, preventing the enlargement and ptosis of the breast that happens naturally as you get older. The most important thing is to treat your breast cancer thoroughly, giving you the very best chance of cure. A careful discussion with your team about the timing and types of reconstruction will help you to decide the best approach.

Chapter 14

Reducing Risk by Surgery and Other Approaches

Diana M. Eccles, Barbara Parry

  • Genetic testing to see whether a faulty gene was part of the cause for the cancer is offered to a person who has already had a breast or ovarian cancer.
  • Genetic predictive testing is offered in healthy people if you have a relative who carries a faulty gene.
  • Different susceptibility genes are associated with different levels of increased risk.
  • You can choose from several options if you’re found to have a faulty gene that increases breast cancer risk.
  • Your doctors should ensure you’ve had enough information from a range of experts before making a decision about irreversible interventions like bilateral mastectomies.

Genetic susceptibility to breast cancer

Approximately 3% of all breast cancers develop because of an inherited faulty gene. The most common genes associated with a high risk of developing breast cancer are BRCA1 (first sequenced in 1994) and BRCA2 (first sequenced in 1995). Since the discovery of these two genes, many others have been identified, mainly associated with lower levels of increased risk. In addition there are many thousands of minor variations in the usual genetic code, sprinkled throughout each of our genomes that together make up our genetic background. Several hundred of these variants contribute to the risk of developing cancer (or provide protection from cancer) in the general population. It turns out that this genetic background is important for working out individual risks even for carriers of a high risk gene like BRCA1 but particularly for working out the risk for other single genes with lower risks than BRCA genes. This genetic testing is advancing year on year. It’s important to get expert and up-to-date advice about risk and genetic testing before making decisions about managing your risk.

It is best to start testing for a faulty gene in a member of your family who’s already developed a breast (or ovarian) cancer. When testing for genetic susceptibility was first introduced, it was offered only to cancer patients who had a very strong family history of breast and often also ovarian cancer. However with advances in sequencing technology, and the discovery of new treatment approaches that may be more effective in BRCA gene carriers, testing is being extended. It’s increasingly being offered to younger breast cancer and most ovarian cancer patients soon after their cancer diagnosis. This can be a confusing time for a patient who’s already anxious about the diagnosis of a life-threatening illness and making choices about treatment for their cancer. Adding a discussion about genetic risk can be overwhelming for some people as it has implications about the risk of new cancers in the future as well as the risk to close relatives. Genetic testing to clarify risk of future cancers and risk to relatives can be offered at any time after diagnosis, so it is important that each individual makes an informed choice about testing at a time that feels right for them. People who are identified as carrying a high risk genetic susceptibility will be expected to share the information with their relatives to ensure that they too have the choice to access testing and screening or prevention options themselves.

If you are someone who carries a breast cancer gene and have breast cancer, it can be treated in the same way as breast cancer in anyone else with the same chance of being cured. This includes treatment that conserves the breast if the cancer is small at diagnosis. However if you have a strong genetic risk it means that you have a higher chance of developing another (new) breast cancer at some stage in the future – either in the same breast or in your other breast. It’s likely that even an early breast cancer would need additional treatment, including chemotherapy and radiotherapy. Some women, knowing they have inherited a high risk gene, decide to have both the breast with cancer and their other healthy breast removed as a preventative procedure. Once breast cancer is diagnosed, the priority is to treat the cancer and to reduce any threat of the cancer returning. Surgery to reduce the risk of developing breast cancer in your other breast is not a routine part of breast cancer treatment so this choice can be delayed and considered again after all your treatment has been completed and you’ve made a full recovery.

About 2–3% of all breast cancer patients will have an underlying faulty BRCA1 or BRCA2 gene. If a BRCA gene fault is identified in an individual, close relatives can then be offered a predictive genetic test to see if they might have a high risk as well. Breast screening for high-risk women uses a very sensitive technique called magnetic resonance imaging (MRI) which is offered annually from age 30 years. This is much more frequent than breast screening offered to all women by the NHS, which starts at 50 years with mammograms every three years. Although the breast cancer risk for men who are BRCA2 gene carriers is higher than for men in the population, it is still lower than the risk for all women in the general population, so breast screening is not offered to male gene carriers. The estimated lifetime risk of breast cancer for healthy women with a faulty BRCA gene ranges from 3–8 in every 10 people affected. This compares to just over one in every ten women in the general population. The most common age at diagnosis of breast cancer when it occurs in women with a BRCA1 or BRCA2 gene fault is between 40–50 years which is more than 10 years younger than the most common age in the general population.

Even with a strong family history of breast cancer, genetic testing to identify a single high risk gene is generally most useful if it is initiated in a family member who has had a cancer. If a causative gene fault is identified, healthy relatives can then have a predictive genetic test. Genetic testing to identify a faulty gene may be possible in a healthy person with a very strong family history if there are no living cancer-affected relatives that can be tested but is less informative than starting with the cancer-affected individual. Your regional genetics service can evaluate a strong family history and give advice about long-term cancer risks and available options for genetic testing and risk management. They will help you to formulate an action plan for managing your risk appropriately.

The risks

On one hand, a predictive genetic test may show that you haven’t inherited the faulty BRCA1 or BRCA2 gene that’s causing the high risk of breast cancer in your family. You can be reassured that your risk is similar to the risk of breast cancer in the general population. On the other hand, if genetic testing shows that you do carry a high risk gene, there are a number of options to help you manage that risk. If you have a strong family history of breast cancer, you often feel very vulnerable and your own previous experience (such as the death of a close relative) can naturally influence your concerns about your own risk of breast cancer. It is important to take your time to consider all the relevant information in coming to a decision about what intervention is going to be best for you.

Your options in general terms if your testing shows you have a high genetic risk include:

  • Enhanced surveillance – this includes breast awareness, magnetic resonance imaging (MRI) and more frequent mammograms at older ages
  • Risk-reducing measures using medication, such as tamoxifen (chemoprevention)
  • Risk-reducing measures using surgery, such as removal of both your breasts (bilateral risk-reducing mastectomies) and/or removal of both of your ovaries and fallopian tubes.

Enhanced surveillance

High risk breast cancer screening is now offered as part of the National Breast Screening Programme for BRCA1 and BRCA2 carriers. Screening requires the genetics service to refer to the screening programme and can be started from 30 years. MRI is a highly sensitive imaging technique that requires an injection of dye and scanning is carried out face down in a circular tube surrounding the chest area. A few people find the MRI scan intolerable because they feel too confined but most find it acceptable. MRI is a more sensitive technique than mammograms at young ages. Screening recall is carried out every year and as age increases, mammograms are introduced. Around 50 years of age MRI is dropped and annual mammograms continue.

Chemoprevention

Trials involving thousands of women who have never had breast cancer but who have a family history of the disease have shown that taking a drug called Tamoxifen for five years halves the chance of being diagnosed with breast cancer in future. This risk reduction is still apparent 15 years later. So for many women taking an oestrogen-blocking treatment like Tamoxifen may be an attractive option. As with any drug, there are potential side effects and it is important to discuss this option with either your GP or the family history clinic. A helpful decision aid can be found here: https://www.nice.org.uk/guidance/cg164/resources. The recommended treatment differs depending on your level of risk and your age.

Risk-reducing breast surgery

For some women who carry a high-risk breast cancer gene, the decision to have both breasts removed (bilateral mastectomy) before cancer is diagnosed seems simple, for others it’s very difficult but may feel like the only option, and for yet others it’s just not an acceptable option. Each individual needs to be provided with full information on more than one occasion with time to reflect carefully. In general, if you’re looking for help to make up your mind you’ll have plenty of opportunities to discuss different strategies with experts. You’ll be encouraged to explore and discuss your options, and to come to your own decision about managing your breast cancer risk.

If you’re thinking about bilateral mastectomy to reduce your risk, you’ll be given the opportunity to see a range of experts. These include the clinical genetics team, a breast surgeon, a reconstructive surgeon (many breast surgeons are expert in both breast cancer and reconstructive surgery), a breast care nurse and a clinical psychologist or specialist counsellor with expertise in this area. Your surgical team will discuss a range of options with you (Figures 14.1–14.3). You may also find it helpful to meet other women who have undergone this sort of surgery, and see the results for yourself. The short-term risks and long-term outcomes as well as the potential psychological and psychosexual impact of this type of surgery need careful consideration by you and also by your partner. Attendance of partners at these sessions can be very helpful, and is strongly encouraged.

Figure 14.1 – Bilateral skin-sparing, risk-reducing mastectomy and immediate latissimus dorsi reconstruction with implants, awaiting nipple reconstruction.

Figure 14.2 – Bilateral nipple and skin-sparing, risk-reducing mastectomy and reconstruction with pre-pectoral implants.

Figure 14.3 – Bilateral risk-reducing, Wise-pattern mastectomy and latissimus dorsi with implant reconstruction, nipple reconstruction declined.

Lifestyle

For many women and their families, being able to contribute to reducing the risk of breast cancer coming back is important and there are positive ways in which your nutrition, physical activity and other healthy lifestyle factors can help. For more than three decades scientific research has shown the health benefits of putting healthy lifestyle changes into the package of care that women receive. The science has begun to explain how nutrition and physical activity can influence the way genes work and we are continuously learning more about what helps to reduce risk and how changes in lifestyle can positively support health and wellbeing after diagnosis and treatment.

Achieving and maintaining a healthy weight is important and following an eating pattern based on plant-derived foods (that is low in fat, added sugar and which ideally avoids alcohol) reduces risk. By planning meals around fruit, vegetables, grains, beans/pulses, nuts and seeds, you increase your intake of nutrients and other food components that are known to be anti-oxidant, anti-inflammatory and/or anti-cancer in other ways. Being physically active can help with weight control but it is also has anti-cancer effects in other ways. Keeping active can reduce side effects during cancer treatment and aid recovery from surgery alongside good nutrition.

The World Cancer Research Fund is a charity that funds UK and global research and provides evidence-based guidance about how food, nutrition and physical activity can prevent cancer. It’s a recommended source of information if you’re seeking more details about how you can help yourself to have the best possible outcomes of breast cancer treatment. You can also ask to be referred to a registered cancer specialist dietitian for tailor-made dietary advice and support.

   My grandmother had ovarian cancer and my mother had breast cancer, as did my sister. My middle sister was also diagnosed with the BRCA2 gene and has recently undergone preventative surgery and reconstruction. I knew that I was a high-risk candidate given my family history, and I wanted to be proactive in mitigating against that risk.

Before I had the test, I visited the genetics clinic and discussed the issue with the staff. They were extremely supportive and wanted to ensure that I fully understood the implications of having the test, and what it would mean to me if it came back positive.

‘A journey of 1000 miles begins with the first step’ and I felt that this was the first and hardest step to take. I did not believe that I would not have the gene; I just did not feel that lucky! I knew that if I started on this journey, then I had to be sure about what my intentions were if I had one of the BRCA genes. I was not going to have the test and then not do anything about it. I had watched my mother die, and my sister fight cancer. I did not want to go through that myself.

We discussed how the test was done, what the lab would be looking for. As my sister had already had the test, the lab would just look for the particular strain that had been discovered in her. It was explained to me how long the results might take, and we also talked about what my options were if I had the gene. Most importantly for me, and this might not be the case for everyone, we talked about what I thought the result would be. I needed to talk to someone who understood my fear of not knowing but also the fear of knowing. Although I felt prepared for the result to be positive – I did think I would have one of the BRCA genes, it was an enormous shock when the nurse told me, just to hear those words spoken out loud. I was understandably upset, and needed time to absorb it. Even if you expect bad news, it is still a shocker when it arrives.   

   At least six members of my family, including my grandmother and mum, have had breast cancer. Another aunt had ovarian cancer. My mum died when I was 24.

I wasn’t keen to be tested to start with, I suppose because I was quite young – in my 20s. I didn’t feel that it was a problem for me at that time. As I turned 30 and had my own family, I became concerned that if I did have the gene, then it could become a problem for me. I then made the decision to have the gene test.

I was seen in the Genetics Clinic a few times before I was tested and I was made aware of screening that was available to me. It was very reassuring to be given so much information. It made the decision much easier for me to make. I was not under any pressure to go ahead, just well supported. I made the decision to be tested. My husband was very supportive and felt that I was doing the right thing by being tested.

I felt disappointed when the results of the gene test showed that I had a breast cancer gene. I had hoped that I wouldn’t have it. That was partly because of my daughter as well. I just wanted it to end and stop with me. I have been surrounded by people with breast cancer since I was young. It wasn’t a huge surprise, just a bit sad really. I knew before I was tested that if the result was positive I would have surgery.   

   I was upset when I was told that I had a breast cancer gene, even though I knew it was possible because of my family history. It was final then. However, I needed to know.   

   Although I decided before undergoing genetic testing that if the result was positive, I would have preventative surgery, discussing mastectomies and breast reconstructions when I was fit and healthy was one of the hardest things to come to terms with. I felt like a fraud, taking medical help away from people who were actually sick. This was the issue that I spent the most time talking about to the breast care team. Whilst I understood that taking a preventive step in the first place would hopefully save all the subsequent treatment if I had developed cancer, it still took some time to become comfortable with the concept.

I was put in touch with a lady who had been through a similar situation. It was particularly helpful talking to someone who knew what I was going through. My husband and I also went for psychometric testing prior to the operation. This gave us the opportunity to talk through intimate issues as a couple and also individually with a counsellor.

After the operation I felt numb – very bruised and battered. I looked at myself in a mirror lying down on the first day. I was by myself and I just needed to see how I looked. The second day, I stood in front of the mirror for a long time; it took some getting used to, but I needed to get to grips with the reality of how I now looked physically. I also knew that once the bruising and swelling had gone down, things would look a lot better.

I am an extremely fit person. I was back at the gym within seven weeks of the operation. I started swimming and underwent a series of hydrotherapy treatments, which were amazingly beneficial.

I had almost seven months off work in the end. I had originally planned to go back to work after four months but I had some emotional difficulties, particularly with the way I looked, and in the end, I did not go back to work for another three months.

During the recovery period, I would advise people to do only as much as they feel like doing. If they are tired, lie down. If they start to feel emotional and blue, seek help early.

I am happy with my overall look. I take more care over my appearance now; it is very important for me to look feminine and attractive, and I am sure that is linked to losing my breasts. My husband thinks I look good, probably fitter than I did before! Sexually he misses my nipples and we don’t make love face to face as much; he won’t say that the way my breasts look are an issue, but I am sure that he misses the feel of a natural breast. He is just too considerate to tell me, and would not want to upset me.

I have found it hard to come to terms with the loss of an essential part of me that makes me a woman. My breasts do not feel the way they did before; they are not soft or pliable and there is no sensation, but I would do it all again. The relief that I am not going to wake up one morning and find a lump is tangible.

Overall, the experience, give or take a few events, was exactly as I imagined and had been described to me. I felt I was as prepared as I could be for the operation. Emotionally you have no idea how the operation is going to impact on you. I am a strong person, and believed that I would be able to cope with it. I did, but it took a while; you will feel and look differently as a woman – this experience has changed my outlook on many things.   

   I knew before I was tested that if the result was positive I would have surgery. My husband felt that I was doing the right thing to have the surgery once I found out that I had the gene. In his mind I had been tested, I had the breast cancer gene and I had a problem. The only solution was to have the surgery and he gave me all the support that I needed.

I was 35, with three children aged 4 years, 3 years, and 9 months. Contemplating major surgery when I was fit and healthy was a solution to a problem in my mind; it was something that had to be done and I was keen to get on with it so that I could move forward.

I have a cousin who really didn’t want to have mastectomies and breast reconstructions and it took her a long time to come to the decision. It was the only option that she had but she still didn’t want to have it done. Now, she is glad that she did go ahead and she doesn’t regret it.

When I first woke up I felt as though I had been hit by a bus. I was quite shocked at how battered I felt. It is hard to prepare for that because I have never had anything done that has made me feel like that. I was in hospital for six days. I did feel that I made progress as time went on. I didn’t really feel strong enough to go back to the house with three toddlers but actually, when I got home the family were very good and it worked. I was discharged with six drains still in. I carried them about with me. My children thought that they were wonderful and were very curious. They were removed at home later.

I needed a lot of help when I got home, especially with the children. I wanted to do a lot of things myself and got frustrated because I couldn’t do them. I did more things gradually as I improved.

Having both breasts removed and surgically reconstructed was a major thing to go through and I would advise others to make sure that they have lots of support. You have to explain to people that you are going to be very tired and restricted. Even after three or four weeks, you may look better and have your drains out but you still feel very sore, particularly on the back. The tiredness persists and you have to make sure that you get lots of rest. It is two or three months out of your life when you are going to feel battered and bruised and frustrated that you can’t do the things you normally do, but it is a small price to pay and an easier option than having breast cancer and going through the treatment that goes with it.

Eighteen months after having both breasts removed and reconstructed I am fully able to cope with a demanding family life and hard physical work as well. It has been worth going through all of this to lessen my chances of getting breast cancer. The only thing left from the operation is that the scar across my back is tight but that is better than having breast cancer. It doesn’t show with swimming costumes. I didn’t expect to be pleased with the result of the surgery but I am.   

   After the mastectomies and reconstructions, I was upset in a way because although my breasts had been reconstructed, I felt as though part of me had gone. That feeling improved and I did not grieve for my breasts later.

I developed an infection in the wound and that delayed everything. The infection lasted from September to January, when the implant was removed. I then had six months without the implant. The time without the implant wasn’t good but you have to keep going. I had support. My family were great, my husband was good. I felt awful having to go back into hospital to have the implants put back again. It was the thought of having to go through all that again. I had to have them done again though because I wouldn’t give up. I got there in the end. I didn’t want to do without breasts.

I am pleased with the look of my breasts now. I don’t think that they have changed much over time. I think that they have dropped a bit and there are a few creases here and there. I am confident in most clothes. It feels a lot thicker under my arms. Apart from that, it doesn’t bother me.

There were bad times during the infection but as far as my appearance is concerned now, I don’t regret that at all. I only have to think about what my mum went through and that justifies it.   

Here’s a husband’s viewpoint:

   To me, once we knew that my wife had a breast cancer gene, deciding to have surgery was a simple logical decision. Why wouldn’t you do it? If anyone gets breast cancer, they have the operation done. All of a sudden, due to cancer research, the doctors are able to tell you whether you have the risk before you get the cancer.

My concerns weren’t about me but about how it would affect my wife emotionally. It was an unknown to me. I never discussed the operation with anybody. I always felt that it was never my business to do that.

You could get stressed out beyond belief, but all a man should tell himself when his wife is having that surgery is to think how you would feel if she was having the surgery for cancer. I was grateful to be in the position of having a wife who was not trying to get rid of breast cancer with the chance that it could come back. We knew that there was an 80% chance that she would get breast cancer but we knew that with surgery, there was no more risk of getting breast cancer than the person sitting next to us.

It was an anxious lead up to the time of and during the surgery but the second it was done, particularly for my wife, there was a great anxiety lifted. The healing took place quite quickly. The anxiety that we would otherwise live with for the rest of our lives had disappeared. To my mind, the plastic surgery that my wife had is amazing.

I would advise any husband or partner to take a deep breath for a few weeks while it is all going on and hold on tight and then thank everyone afterwards. It is easy for the bloke to give advice because we don’t have to have it ourselves, but if I was told that I would get testicular cancer unless I had surgery done, why wouldn’t I have it done? I would be an idiot not to. I didn’t have to persuade my wife to have the surgery done. She made her own mind up anyway.   

Chapter 15

Supporting Your Surgical Treatment

Clare Clayden-Lewis

  • Take time to find out about the different types of reconstruction which are suitable for you.
  • Don’t be rushed into making a decision about breast reconstruction. It has to be the right choice for you.
  • It’s important to make a checklist of questions and to take someone with you when you meet your surgeon. Your team will be able to answer questions about recovery and how the reconstruction may look and feel.
  • If the reconstruction you want can’t be carried out in your local unit you can and should ask to be referred to another unit.
  • Some women find it very helpful to talk to others who’ve had breast reconstruction. It’s a great way find out about their experience and see the results for yourself. Some units offer a special ‘breast reconstruction awareness’ evening, as well as support groups.
  • Photographs, written material and websites, other resources and information can help you understand more about breast reconstruction.
  • Recovery will vary depending on the type of operation, as well as your own health, lifestyle, and motivation.

Considerations

You may have recently been given a new diagnosis and you’re facing decisions about different treatments at a very stressful time. Or you may be someone who’s thinking about breast reconstruction sometime after your mastectomy (delayed reconstruction). Whichever situation you find yourself in it’s important to understand and think about your options carefully before making your decision. Take time to consider the long-term outcomes of breast reconstruction. Will you need further surgery as the years go by? And how will your reconstructed breast look and feel as you get older?

Think about your lifestyle, and how reconstruction may influence your physical and psychological wellbeing. Physical things to consider include your general health, any previous medical or surgical history as well as practical considerations such as the timing of surgery, your home commitments and how much help and emotional support you’re going to get. And you need to ask your team about the look, size, and feel of your reconstructed breast. Will it be lop-sided, or droopy, and how much scarring will there be?

Most people want to have their surgery as soon as possible, but it’s really important that you fully understand all the pros and cons of reconstruction before you make your mind up to go ahead. Also be realistic in your expectations, and remember that however perfect your reconstruction may be, your new breast will never be exactly the same as the one you’ve lost.

Here are some patients’ thoughts:

   The hardest thing was deciding what surgery to have as I was given so many different options. Some were quite tempting but at the end of the day it would have taken too long to get back to normal. I started off not wanting something artificial but this is what I ended up with due to practicalities – getting back to work, being able to drive – as I was on my own.

I was only given one option but probably could have had a choice of different reconstructions if I had asked more questions. In an ideal world, people should have the chance to consider all options, as well as seeing people who have had them by the same surgeon. With hindsight, I did not have enough information to make a balanced judgement. The issues that I did not know about were how much additional surgery I would have and how long the whole process took. People need to have realistic expectations and understand that the reconstructed breast may be a good imitation but not exactly the same. What is good for one person may not be good for another.

I had two weeks to make up my mind, although I could have had longer. I didn’t want to keep putting off the inevitable. It is hard, because you try and cope with the diagnosis of cancer and all the worries that brings, and at the same time try to decide between different procedures. It is impossible to know what the outcome is going to be. It was never an option for me not to have reconstruction. I knew that even though it was hard, in a way it was probably quite good for me because it made me focus on something other than the cancer. This was something that I could control and decide. I thought up loads of questions and took my sister with me to the appointments when we were discussing the options.   

It’s often helpful to take a friend or relative with you to listen to your consultant and to support you in your decision making. Writing down your questions and the answers will help you remember the discussion when you get home.

   I was a bit numb because I had just been told I had cancer. My husband asked all the practical questions.   

Helpful questions to ask:

  • Is breast reconstruction suitable for me?
  • What are my options, and why?
  • Can this be done immediately or should I wait until later?
  • Will I need further operations later on?
  • How long will my recovery take?
  • Will breast reconstruction affect my lifestyle?
  • What are the risks and complications of breast reconstruction, compared with the benefits?
  • Can I see pictures and speak to patients who have had breast reconstruction?
  • Are there any other options you don’t provide here?
  • What will the scarring look like and how will the reconstruction feel?

Your breast clinic

If you’ve been referred to your breast clinic and no one has mentioned breast reconstruction, ask your surgeon whether it is suitable for you and which procedures are carried out at your hospital. A variety of different types of breast reconstruction are carried out across the country and today many surgeons are trained to do both mastectomy and reconstruction. In some centres the breast surgeon will carry out the mastectomy before the plastic surgeon performs the breast reconstruction, either at the same time or at a later date.

Because there are several different types of reconstruction it’s possible that your breast team won’t be able to offer you the full range of procedures. If you’re interested in finding out more about one particular type of reconstruction and it’s not available at your hospital, you should ask whether you’d be suitable for this technique. If so, your surgeon will be able to refer you to another team for an opinion. Occasionally breast reconstruction won’t be available locally at all. If so, you’re entitled to be referred to the nearest centre for your treatment. If you’re unsure about the options you’ve been given, you can always ask to be referred to another centre for a second opinion.

   In talking this through with my surgeon, I was told about his colleague who was an oncoplastic surgeon and could do the two operations of a mastectomy and breast reconstruction at the same time. I asked to go and see this surgeon and he was happy to refer me. The second surgeon suggested that I should have a lumpectomy first, as I had not had radiotherapy in the past and he also went through all the different types of reconstruction. He agreed with me that because of my large droopy breasts, the DIEP flap would give me a more realistic reconstruction. He said that if I did want to have that, he would refer me to a plastic surgeon who specialised in it.   

Your breast care nurse

Breast care nurses should be available in your Breast Unit to discuss reconstruction. Your nurse may either be your own breast care nurse if your breast surgeon will be doing the reconstruction, or a nurse working with the plastic surgeon if they’ve been asked to do your reconstruction. They’ll give you time to discuss your surgical options in more detail so you fully understand what’s involved. You’ll have an opportunity to look at photographs of different types of reconstruction and talk about the practical aspects of the procedure and your recovery. You should get lots of practical information and advice about your admission to hospital, what to expect after your operation and how much time you’re going to need to take off work. Your team should also give you written material and guide you to useful websites which can help with your decision making. These appointments are often separate from your consultation with the surgeon and give you a good opportunity to think about any questions you forgot to ask before. It’s worthwhile remembering that all your questions are important, particularly when they help to relieve your fears and anxieties about what lies ahead. They can also provide emotional support to you and your partner, family or friends. If you’re not introduced to your breast care nurse in clinic, make sure you ask how you can arrange to meet later.

Talking to other patients

As well as talking to your breast team and looking at photographs, some women find it very helpful to talk to patients who’ve already been through breast reconstruction and to ask about their experience and recovery first hand. These patients can be contacted in a number of ways – through your breast care nurse, through patient support groups, or through a number of national organisations (see Chapter 20). Some units run breast reconstruction awareness meetings or support groups where you can meet others who’ve had breast reconstruction. These offer a very personal perspective about their operations, their recovery and their overall short- and longer-term experiences. If you’re considering more than one type of breast reconstruction you may find it helpful to talk to several patients so you can compare their experiences.

   Attending a breast reconstruction awareness evening would have helped me. It was useful talking to my sisters but if there had been a meeting I would have attended to talk to others. I looked through the reconstruction book and was shown pictures of ladies who had been through the operation which was helpful. I felt that the information was all there and speaking to people who had gone through it was more helpful than looking on the internet. Some people may go into their shell, deal with it, close the door and get on with it. For me it was helpful to talk to others. It made the decision that bit easier, if that decision can be made easier.   

   I was offered the opportunity to talk to other patients who had undergone breast reconstruction, and seized that opportunity. The surgeon told me to go and have a chat with them, have a look at their reconstructions and then make up my mind. He said that it was a big decision and I should take my time. I was told that there were two options and spoke to one person for each type. As soon as I phoned the first person up, she was brilliant. She was positive, reassuring and full of energy. I went to see her and we chatted as if we were old friends. I knew when I saw her breast that I did not want to have that type of reconstruction. Seeing this in the flesh as well as in the photographs was very helpful. I then spoke to the lady who had a latissimus dorsi reconstruction three years earlier. She was full of energy and back at work. We chatted for a long time and when she showed me what her reconstruction looked like, I couldn’t believe it. I thought that I had the wrong person because it looked marvellous. I knew then that was the choice for me. To those who are not sure whether to talk to other patients, I would say that it is a must. I now speak to other patients myself. They tell me that they want to know how it actually is, how they are going to feel each day, how long before they will feel better, what to take into hospital and what they can or cannot do afterwards. If I meet them I show them my reconstructed breast as well. When they get to the stage of nipples, they pop round again to have another look. It does help to allay worries by talking to someone who has had the surgery before. I did want to have a look at someone else but wouldn’t have wanted to have it forced on me. I was glad to know what to expect before the operation. That helped me to be comfortable with it.   

   I had a buddy who was lovely. She was very open and showed me her scars. We went through all the little details – the operation, what was tough for her, the recovery, first few days, practical things. If I talk to others now I always say I can only tell them about my experience. You are the only one who knows you and what is right for you.   

   I did not talk to anyone who had already had breast reconstruction, although I was told that there was a group that met near my home, where I could talk with someone who had gone through it. In hindsight, it probably would have helped me to have seen a finished reconstruction. You don’t look any different. I was apprehensive about looking at the breast after the operation but after I had looked, I felt much better. Don’t worry if you would prefer not to take up this option if it is offered.   

   I didn’t talk to anyone who had the operation beforehand as I didn’t want to frighten myself with someone else’s experience. At the end of the day, whatever happened to me was going to happen and how I dealt with it was down to me.   

Access to relevant material

Most public libraries provide a comprehensive selection of books and leaflets on breast reconstruction if you ask them. You may also be able to find some useful information on the internet, but do remember that it’s often very detailed and may not reflect what your own surgeon is able to provide. Your breast care nurse will help by recommending the best websites, and take a look at the useful contacts in Chapter 20. It’s also possible to use the internet to communicate with other women who’ve gone through different kinds of breast reconstruction.

   The information I was given was helpful, I read everything I was given. I also went online and joined forums but you have to be careful what you are looking at and what you read.   

   I read as much information as I could get my hands on and the plastic surgeon told me about the websites to look at. I was told to bear in mind that only the best results would be on there. I also discussed it with my family. I wondered how on earth I was going to make a decision. I was lucky enough to speak to two women who had the breast reconstruction I was considering. That was very helpful.   

Some questions to consider before your operation

What will I look like and how will the breast feel?

The shape, size, symmetry and feel of your reconstructed breast will depend on the type of reconstruction you’ve had. For example, an implant based reconstruction is likely to feel firmer than a reconstruction made from your own tissue or muscle. When you first look at your breast following reconstruction it will probably look swollen and bruised, and may look a different size and shape to your natural breast. This may take a while to get used to as it settles down and heals.

   Because of the tissue expansion, when I first looked at my new breast, my chest looked massive and I couldn’t escape it. I wanted to forget about it but it seemed so much there. You have to keep positive because it doesn’t look good to begin with. It helps to think back to the photographs of the end result and know that you will get there.   

   The day of the surgery the doctor asked me if I had looked yet and I said yes. I know other people may be different, they may not want to look, but I did. I looked as soon as I came round and I was happy with what I saw. For me getting on with it helped me through it.   

Sensation in your reconstructed breast, your arm and other areas affected by the surgery can again differ from person to person. Some women will have loss of sensation, others may have altered or reduced sensation – ask your surgeon what to expect from your operation.

What will the scars be like?

The position of your scars will depend on the type of reconstruction you’ve chosen. The best way to find out is to ask to see photographs and talk to other patients who’ve had similar operations. But remember that their experiences may not be the same as yours, as scars and healing rates will vary from person to person. A good guide is to look at any other scars you may have from previous surgery. If you’ve developed thick, raised, or red scars in the past, there are topical silicone creams and dressings which can help to avoid this problem. Smoking can delay wound healing and increase the risk of post operative complications, so you’ll be advised to stop smoking prior to surgery to minimise these risks. You may find it helpful to look at your scars for the first time in hospital or when you have someone around to support you when you get home.

   It’s a shock when you first look, I remember that being really tough. However the more you can look, however daunting, I really recommend that.   

What sort of dressing and stitches will I have?

You’ll be advised about wound dressings and stitches either before or after your surgery. Most wounds are closed using stitches hidden under the skin which don’t need to be removed. Some units use a surgical glue to cover wounds instead of dressings. You may have some drains to remove any fluid, helping healing. They shouldn’t restrict your movements and you can go home with them if needed. You’ll be given advice on how to look after them until they’re removed.

Will the operation be painful?

Immediately following your operation it’s possible that your operation site and arm movement will be uncomfortable. You shouldn’t be in pain, as most surgeons put a long-acting local anaesthetic into the wound. You should also be offered regular painkillers, sometimes using a system that allows you to provide pain relief yourself by pushing a button. As mentioned previously, this is called ‘patient controlled analgesia’, or PCA. Other forms of pain relief include tablets, suppositories, or injections. You should be offered these regularly, but do ask the nurses if you need more.

How long will I be in hospital and what will I be able to do afterwards?

This can vary depending on the type of operation and your recovery. Check how long your team expect you to stay in hospital and what help you’re going to need once you get home. Also ask about the Dos and Don’ts and how long you need to be careful for.

How long will I take to recover?

Again this varies depending on your operation, previous treatments, your general health, lifestyle, and any complications post surgery. You’ll feel tired and may find it difficult to concentrate for a while after your surgery. Take time to talk this through with your surgeon or breast care nurse prior to your surgery. Recovery from some types of reconstruction takes longer, so check this out and try to be realistic about this from the outset.

How long will I be off work?

This will depend on the type of work you do, your choice of reconstruction and how quickly you recover. Your team will be able to guide you but remember to tell your employers that this could change depending on how quickly you recover. Don’t try to go back to work too soon, and see if you can start part time to begin with, building up as your confidence and energy returns.

   I was anxious about going back to work, especially with the side effects from my treatment, but going back to work was the best thing. The thought of it was hard but the reality of going back was easier.   

When will I be able to drive again?

This will depend on the type of breast reconstruction you’ve had. It may take longer to be confident driving if you’ve had more extensive surgery moving tissue from your back or abdomen. If in any doubt, always check with your team and also your car insurance provider.

What sort of bras and clothing should I wear?

Some surgeons like their patients to wear specific supportive bras after breast reconstruction. Check whether this is the case for you and if so, whether these are provided by the hospital. If your surgeon doesn’t have any special recommendations, get advice from your breast care nurse about the type of bra to wear afterwards and find out if you need to take it into hospital with you.

   I was advised to get a sports bra by the hospital to wear after the reconstruction. What I actually wore was a vest-type top with a bit of support, rather than a bra. I found that the bra strap irritated. Vest tops with part support were very good.   

   I wear sports bras for comfort but know that I can wear prettier ones for occasions. I have bought a bra with no wire in and that is quite nice and does give me support. I can’t just go and buy any bra but have to try them on. The ones that I think are nice don’t always fit properly. The reconstructed breast is a better shape than the other one.   

   The one thing that I do not like is the fact that I cannot wear the type of bras that I used to wear, which were underwired and dainty. Whilst I have found bras that are comfortable, they are not as feminine. I went to Eloise [a shop specialising in bras and accessories designed to be worn after breast surgery] for underwear and found them extremely helpful. I have bought their lingerie ever since. I wish that there was a bra that was wider under the arm. You don’t feel discomfort at the front, it is at the side.   

   Because the area that has been operated on is sensitive, a lot of bra fabrics are itchy. Certain laces were difficult and cotton was better. I think that it took about a year after the operation to get back to normal bras. I now change in a communal changing room and once I have a bra on, there is no difference, apart from the radiotherapy scarring.   

Will I need to do exercises after my operation?

Exercises after surgery will help you to recover more quickly and build up your confidence. Ask your team if you need physiotherapy, and you should get clear advice about specific exercises to start from day one. You’ll need to avoid very strenuous exercise for a few weeks after your surgery. But once your wounds have healed, getting back to gentle exercises in the gym or swimming pool has enormous physical and psychological benefits and speeds your recovery.

   I did the exercises I was given three times a day and I think this helped. It felt stiff to begin with but it became easier with time. I was careful not to over push myself.   

   I walked around at home to keep myself mobile. I was taught a specific way to get in and out of bed. I gradually built up my strength by walking further each day. The process took longer than I expected but I got there eventually with determination and patience.   

   I should have done more physiotherapy sooner. The exercises are really important.   

Will I need to have further operations to complete the reconstruction?

Breast reconstruction is often not completed with one operation. Ask your surgeon how many operations you’re likely to need and how long it’s going to take altogether. If you’ve chosen an implant-based reconstruction, you may need further surgery to exchange your implant, remove scar tissue or adjust the position of your breast – sometimes many years later.

   After the diagnosis I had my mind set on the implant-based reconstruction but then I realised that if I went down that road I would have to come back to have the implants exchanged at some point. That kind of put me off because I felt that once I had had a mastectomy and reconstruction I wanted it to be final rather than having to come back to have different stages done. For me it was important to have all the information to hand and know my options.   

A patient describes having further surgery following complications:

   I had a DIEP done a year after losing my implant following an infection. I was told that there was a year waiting list and I was a bit disheartened when I went away. I found the loss of my implant hard, harder than the mastectomy and reconstruction.   

Sharing with your partner and intimacy

Some women find it helpful to show their partner the results as soon as possible, but this is a very personal choice. Both of you may need time to adjust to your new appearance. Take your time, talk about your feelings with your partner and do whatever feels right for both of you. If you feel you need more support, talk about this with your team. They’ll be able to refer you to a trained counsellor for further help and support.

   It was hard at the beginning, you think how could anybody love me, but my husband was very supportive. Everyone is different, it takes such a lot out of you, it takes a while for you to build that confidence back up, but it does come back. In fact it’s made me a bit more confident because I think if you can go through that you can go through anything.   

   My husband didn’t like to touch my breast. He didn’t know what to touch. Whether to touch me there or not, because he worried about upsetting me. Upset me and do it or upset me by not doing it. He didn’t know what to do. But as time went on it didn’t present itself again. As time goes on it helps. We talked about it. My husband is the same as me, he sees it as a mark of ‘I fought cancer’. He never once made me feel uneasy, that he doesn’t feel the same way for me.   

Body image

A 50 year old lady comments on her body image following a delayed DIEP breast reconstruction:

   Ninety-eight percent of the time it doesn’t bother me but sometimes, when you are feeling a bit fed up, I think I don’t look very good there. If I am feeling sorry for myself I sometimes think I look a bit of a freak because I have one bigger than the other and without a nipple. Other days ‘No’, it’s proof that I fought cancer. I still wear the same clothes I worn before, just with a camisole.   

A 52 year old lady reflects on her body image following a DIEP breast reconstruction 18 months ago:

   I think it looks amazing. I was hoping for as natural a look as possible and to be the same size and shape as the other one. In terms of outcome I am very happy. I sometimes can’t believe that it isn’t my natural breast. The only thing I find difficult is not having the nipple. I delayed having a tattoo, I wasn’t sure. I know there is the option of having a nipple reconstruction and I think I might still consider that.   

This lady discusses a delayed nipple reconstruction and tattoo:

   That was very important. It wasn’t anything I had really considered, I hadn’t contemplated that I wouldn’t have a nipple anymore, it hadn’t dawned on me. Afterwards, looking at myself, it helped my self-confidence.   

Partners

Two patients discuss their partners’ feelings:

   My husband was brilliant. He struggled quite a bit because I think it is true what they say, bizarrely it’s easier for the patient going through it than the loved ones around. We talked about it, he gave his opinion but he said that it had to be my decision. I knew that I had to make the decision. It’s a personal one.   

   My husband found it harder than I did. The breast care nurse suggested counselling at one point but he never did it. I think he should have gone. He’s not a crying man, he’s a stiff upper lip man but he broke down a couple of times. That was hard, seeing him like that.   

Recovery

Regardless of the type of surgery you have, you’ll probably feel tired. It’s important to take things easy and at your own pace because recovery rates vary a lot from person to person. Don’t be surprised if you experience a range of emotions. You’ve got a lot of new things to cope with, and need to be kind to yourself, particularly when you feel tired. Your recovery may be affected by complications, and anxieties and concerns about further treatment such as chemotherapy or radiotherapy. You’re likely to have good days and bad days during this time but the number of good days will gradually increase as you recover.

   When I first woke up from my latissimus dorsi breast reconstruction, I felt that it was behind me and I was on the road to recovery. I could do everything when I went home but it took quite a while to get my strength back. I wouldn’t say that it is an easy operation because it was six months before I could sleep on my side. That was a minor thing though. I had nearly six weeks off work.   

Here’s an account from a 34-year-old woman who had a latissimus dorsi breast reconstruction. Her two small children were a priority in her recovery:

   It was decided that I would have a latissimus dorsi breast reconstruction with a tissue expander at the same time as the mastectomy. I did get upset in the first few days afterwards because I couldn’t see the light at the end of the tunnel. You have to be prepared for the incapacity afterwards. I felt that it was important to get moving as quickly as possible. I couldn’t do a huge amount when I first went home and did have help getting the children to school. I drove again after about a month and that gave me much more freedom. After that, the recovery was quite quick. About six weeks after the operation, everybody came to us for Christmas and I did quite a lot of the cooking. It was only my back which hurt. I still couldn’t do things like putting a duvet into the cover but the movement came back in time.   

Some bonuses come from accepting help from family members during the immediate recovery period:

   The children were eight, seven and nearly three at the time. We are a very close family and my mum and dad came and stayed to help look after the family for the first two weeks. My dad retrained the children while I was in hospital. He said that I did far too much for them, which was true. He said that they were old enough to tie their laces and taught the youngest one to climb into her car seat because I couldn’t lift her for a while. The children wanted to help because they knew I had been poorly.   

Recovery after a TRAM flap reconstruction can be slower than with other operations:

   I couldn’t do a lot when I first went home. My husband did the cooking and looked after me. One of the main things that strikes you is how tired you get. You very quickly find out that you cant do what you thought you could. It is easy to become impatient. I found that I got used to it and settled into making the most of being home. I drove again after two months. That wasn’t purely because of the physical side. I felt that because I had been out of it for so long, I wasn’t sure that I was up to speed mentally. I went back to work after ten months and had a staggered return. I have been back at work full time for a year and I do get tired sometimes but I think that I would have done anyway. I have quite a demanding job. There are no practical things that I still find difficult.   

These accounts show how recovery from breast reconstruction can vary enormously depending on the type of surgery you’ve had, your general health, and your personal circumstances. Going into hospital to have an operation can be a daunting thought, but research suggests that patients experience less anxiety and distress if they’re well prepared. Talk as much as possible to the team looking after you. Ask them plenty of questions and they’ll be able to give you a good idea about what to expect in the first few days after your operation and in the weeks that lie ahead once you’ve gone home. The whole team looking after you will help and support you and your family throughout this time.

Chapter 16

Physiotherapy and Rehabilitation after Breast Reconstruction

Catriona Futter

  • Movement and exercise will help you to recover more quickly from your surgery.
  • Your team will explain the kind of exercises you’ll need to take to avoid stiffness and to get back to normal.
  • Your speed of recovery will depend on your own fitness and the type of surgery you’ve had.
  • Incorporating your exercises into your daily routine after you’ve recovered will help to prevent stiffness and maintain full movement.

With all that is happening to you at the moment and all the decisions you’re having to make, physiotherapy may not be at the front of your mind. However, rehabilitation following your surgery is very important, as this woman describes so well:

   I was given exercises by the physiotherapist in hospital to do at home. I did not realise how important that was. My back became stiff while I was having radiotherapy and I had some more physiotherapy. I wish that I had had more physiotherapy help earlier.   

The aim of the exercises and advice given to you after your operation is to regain normal movement in all areas affected by your operation, and get back to being independent as soon as possible. This is important in restoring some sense of control over what is happening to you. In the early stages in hospital, the whole experience can feel quite overwhelming. Being able to function independently, even in simple things at first, can help towards your recovery. The exercises will be given to you either by a physiotherapist or a breast care nurse.

Every hospital will have their own way of doing things, and the particular exercises and advice you’re given after your reconstruction may differ between units. This section contains general advice on your rehabilitation and the importance of physiotherapy, and what you might expect after each type of reconstruction. Always speak to your own surgeon, physiotherapist or breast care nurse about what exercises are appropriate for you to do. If you find that once you’ve gone home after your operation you’re having problems moving your arm, and you haven’t had any physiotherapy, ask your breast care nurse about speaking to a physiotherapist. You might be having your reconstruction at the same time as your mastectomy, and know that you’re going to have radiotherapy soon after your operation. It’s particularly important then to make sure you have good movement in your arm and can get into the position required for your radiotherapy treatment. Speak to your breast care nurse or physiotherapist if in doubt.

Why are exercises important?

In the early stages immediately after your operation you’ll probably be given some simple exercises to do to stop your shoulder getting stiff and to help you get back to normal activities. Doing any kind of exercise may be the last thing that you feel like doing. You may be feeing sore and stiff, and you may have wound drains in, which can be uncomfortable. However, even simple things such as brushing your hair with your affected arm may at first seem hard, but will get much easier after doing your exercises.

   The exercises were painful but it became easier. Doing a little bit at a time helps you to get a bit further.   

You may find that after your operation you tend to protect your affected arm by hugging it in to your body and not using it. Whilst this is a very natural and understandable reaction, it will actually make things worse by causing your shoulder to stiffen up. It can also make the muscles around your upper back and neck become tense and uncomfortable. Gentle exercises started early will help you regain normal posture and enable you to use your arm for light activities, and get your confidence back. It’s important that you don’t use your arm too much until the wounds have all healed, but it’s equally important that you don’t let your shoulder stiffen up. Your wounds will probably take about 4–6 weeks to heal if there aren’t any complications.

How soon can I resume my activities after the operation?

You can get back to activities such as reading and knitting as soon as you feel able after your operation. Light housework such as dusting or a little ironing can usually be started after four weeks or so, if you’re feeling up to it. Leave heavy housework such as vacuuming and heavy lifting for at least eight weeks. It will always depend on how you’re feeling, and check first with your surgeon or physiotherapist if in doubt. Your recovery is exactly that – yours alone, so never compare yourself with anyone else. Expect to be very tired at first, and accept any help that is offered. It can be hard to have to sit back and let your family or friends do your cooking or housework, but if they offer to help, let them, as you’d probably do the same for them!

Both these women had DIEP flaps and found their recovery times quite different:

   My husband has always been the homemaker but nobody did any more for me than they would normally have done. I was determined to get up and about. I drove after four weeks because I was keen to do so. My family were amazed.   

   I found it very difficult to do much at home. This was partly because of the tummy scar which ran from side to side. I found walking hard and getting to the shops at the top of the road after two weeks at home was an achievement. I always had someone with me who could carry the shopping. If I had little goals, it made me do a bit more each time.   

It’s usually possible to start driving after 4–6 weeks, depending on how you’re feeling and what type of reconstruction you had. The main concern is that you’re safe and can handle the car in an emergency. Most women find changing gear (if the left arm is affected) and manoeuvres such as reversing and parking the most difficult.

If you have a sedentary job, it may be possible for you to return to work about 6–8 weeks after your operation, assuming no other treatment or no complications. If you have an active job, discuss returning to work with your consultant or physiotherapist — it’s likely that you’ll need to be off work for 3–6 months or more. This woman took a very sensible approach to returning to work after a DIEP flap:

   I went back to work after six months part-time to begin with and gradually built it up until I did a full day’s work. You want to get back to a normal routine and in reality there is no way that you can do this straightaway. It is tiring and I was frightened that people would knock me.   

Returning to work part-time at first is a good idea, if your work will allow it. In terms of when you’ll be able to resume sports and other activities, it does depend on how fit you were before your operation, and whether you have any complications or need other treatments such as chemotherapy or radiotherapy. It will also depend on your own surgeon’s views. In general, assuming everything is straightforward, gentle exercise such as walking can be started as soon as you feel able once you go home. Indeed, it can help to get out for a walk and get some fresh air. Sports such as swimming, yoga, or pilates can be resumed within 2–3 months, but you would need to wait at least 3 months or more before resuming very active sports such as tennis, keep fit, running, and so on. It will depend very much on which type of reconstruction you had and how you’re feeling. It will also depend on how much movement you have and which arm is affected. Always check with your surgeon or physiotherapist before resuming any sport.

You might be having your reconstruction at the same time as your mastectomy and then going on to have chemotherapy and/or radiotherapy immediately after your surgery. In this situation, how soon you return to all these activities will depend as much on how your treatment affects you as on how you recover from the surgery itself. It’s very important to continue your exercises for quite a long time after your surgery, and especially after radiotherapy. This is because your arm and shoulder can stiffen up for months after your treatment has finished. It’s good to have a long-term view, and expect the treatment to take a year out of your life, as this woman who had a DIEP flap describes:

   I had chemotherapy after the operation and it is now a year since the reconstruction. I started going to the gym a few months ago and I do rowing and things like that. The arm on the reconstructed side feels as strong as the other one.   

How long should I do my exercises for?

Keep on doing the exercises once you go home as it may take several weeks until you have normal movement back and you may have some stiffness for several months. If the operation has been straightforward and there have been no complications, there’s no reason why you shouldn’t regain full movement and get back to normal activities.

   My arm was quite stiff but the movement came back fairly quickly because I did my exercises regularly.   

It’s worth incorporating your exercises into your daily life, so that they become a habit and part of your normal routine. Doing them in the shower, or stretching every time you’re waiting for the kettle to boil, or when the adverts come on the television, will help to prevent the exercises becoming boring, but will also encourage you to keep exercising and stretching until you regain full movement.

   There comes a terrible boredom threshold [with exercises]. If you don’t exercise, you become stiff and you have to realise that you may be in for exercises for the rest of your life.   

Doing some sort of formal exercise that you enjoy will also help, as you can incorporate your specific exercises into more normal routines or sports — swimming, gym work (either using machines on your own or going to exercise classes), pilates, yoga or tai chi, running, and so on.

How can I prepare for my operation?

Your surgeon will make sure you’re medically fit for your operation and will discuss the different types of reconstruction and what is available to you from their point of view. Try to make sure you have full movement in the affected arm before your surgery. It’s worth doing some simple stretching exercises beforehand to improve your movement, especially if you’ve had previous surgery to your chest or shoulder, or shoulder problems. If you know you have a problem with your shoulder, it’s worth mentioning this to your surgeon. It might be possible for you to see a physiotherapist before your operation. This will depend on your hospital. It also helps if you have good general fitness, especially before a longer operation such as the reconstruction using abdominal tissue.

What can I expect after reconstruction with an implant?

Reconstruction using an implant involves placing the implant in a pocket under the muscle on your chest wall. In the days immediately following the operation, it’s important to avoid stretching the wound, or using the muscle until the wounds have healed. For the first 2–3 weeks or so it’s generally recommended that you avoid:

  • Stretching your arm above your head, either forwards or sideways
  • Stretching your arm behind your back
  • Lifting or carrying anything heavy with the affected arm
  • Fastening your bra behind your back — fasten it in front and swivel it round behind you
  • Pushing or pulling open a heavy door.

If the implant is to be inflated gradually (a tissue expander), this process usually starts about two weeks after your operation. This will depend on your own surgeon. But once the process of inflation has started, you can start using your arm normally, gradually at first and within a pain-free range. It’s normal for the front of your chest and your arm to feel tight for several weeks following your operation, but this should improve with exercise and normal use.

Following this type of reconstruction, it’s very normal to develop a protective, round-shouldered posture because the front of your chest feels tight and bruised. However, this will generally make you feel even stiffer and can lead to muscle tightness and spasm around your neck and shoulders. As well as doing gentle exercises to keep your arm moving, it helps to be aware of your posture. Try to keep your shoulders relaxed and pulled down. Rolling your shoulders up, back and down regularly will help avoid too much tightness and make you feel less stiff.

What can I expect after reconstruction with a latissimus dorsi (LD) flap?

The most important thing to remember after this operation is that the muscle that’s been moved to the front of your chest to make your new breast still has its nerve supply, so it’s still going to behave like a muscle. It will contract in its new position when you move your arm in certain ways. This can feel very strange indeed! Generally over a period of months, this sensation lessens, although it can remain troublesome for some women.

In its normal position, the muscle acts strongly to bring the arm in to the side of your body and to extend the arm behind your body. The muscle is used in activities that pull your arm in towards the body, such as rowing. It also works strongly to raise your body up such as pushing out of a chair or bath, or climbing. For the first few weeks after the operation it’s recommended that you don’t stretch or use the muscle that has been taken from your back, or the muscle under your new breast, until they’ve had a chance to heal. The types of movements and activities to avoid with your affected arm would include:

  • Stretching above your head or behind your back
  • Pushing open heavy doors
  • Pushing yourself off a bed or chair
  • Carrying anything heavy
  • Fastening your bra behind your back
  • Lifting objects onto/off a shelf above your head.

Immediately following the operation, you’re most likely to feel discomfort and tightness across your back, sometimes going right down to the small of your back even though the wound is likely to be around your shoulder blade. This is a result of the surgery involved in detaching the muscle from your back so it can be swung round onto your chest wall. A very common description is that it feels like you are wearing a tight corset that you cannot take off. This feeling of tightness is perfectly normal and does wear off, although it can take a few months.

You should get most of the movement back in your arm within 6–8 weeks of your operation. It takes much longer for the tight feeling in your back to go away, and indeed, it may feel tighter as the wounds start to heal. Exercises to stretch and move your shoulder blade, combined with deep breathing exercises help to ease the tightness. Once the wounds are healed, try to massage the skin all around the scar on your back and around the side under your armpit. This helps to keep the skin loose and prevent any further tightness.

   You spend the first year doing exercises, especially with the arm concerned. Massaging the back where the muscle has been taken is also important.   

The kind of movements that take longest to get back include taking a pullover sweater off over your head, reaching high above your head, pulling shut the car door, stretching forward. However, it’s expected that you’ll get full movement back in your arm, and be able to resume most if not all of the activities you enjoyed doing before your operation. Activities such as heavy housework, vacuuming and heavy lifting, and sports such as swimming, keep fit, and so on, can be resumed after about three months. This is assuming there are no other complications and your surgeon is happy. And after all your treatment is finished and you’re fully recovered, you want to be able to live life to the full and enjoy it, as this woman most certainly does!

   I can still do very rigorous exercise. I belong to the gym and walk and took up golf after the reconstruction. I explained to the golf pro that I had reconstructive surgery and he understands that I haven’t got quite the same follow-through but it’s not a problem. The only thing that I stopped deliberately was downhill skiing because I didn’t think that I was secure enough to stop myself and also because I have hip arthritis. I don’t think that reconstruction has stopped me from doing anything.   

What can I expect after reconstruction with an abdominal flap (TRAM/DIEP)?

This is major surgery, and there’s no point in saying otherwise – described once as like having a hysterectomy and mastectomy at the same time. The initial few days can be really rough, with you feeling sore, stiff, fairly immobile, and wondering about the wisdom of your decision! However, things generally improve quickly once you are up and about, so take the early days one at a time and don’t panic.

Your whole abdomen will probably feel very tight and uncomfortable. When you stand or walk this tightness will encourage you to stoop. This is normal, and the tightness will ease. How long it takes for you to be able to stand upright varies between women from a few days to several weeks depending on the extent of the surgery, and your own height and shape. There’s no right or wrong, and it’s important not to over-stretch your abdominal wound too soon.

   I was fine immediately after the operation. I had to keep still for the first two days, which was hard and stayed in bed for five days altogether. I started walking about after four days and it felt quite strange. I tended to want to shuffle, as opposed to walking properly.   

Pelvic tilting exercises, where you gently tip your pelvis forwards and backwards whilst keeping your hips bent, can help ease off the tight feeling and any discomfort in your lower back. Once the wound has healed, and usually after at least six weeks, gentle stretching exercises can help ease off any remaining tightness. Try to massage the scar and whole abdomen firmly with moisturising cream. This will help soften the scar and abdominal wall. Avoid any heavy lifting, and any heavy push/pull action, for example vacuuming, for at least 6–8 weeks to allow your abdominal muscles to heal.

For the first week or so after your operation it’s usually recommended that you avoid stretching your arm above your head so as not to stretch the blood vessels connecting your new breast. Depending on your surgeon, and on how you’re doing, you can usually start using your arm normally after the first week or so, gradually at first and within a pain-free range.

   The surgeon was very strict about how much I should do with the arm on the reconstructed side, in case I damaged the blood vessels which had been joined under my arm.   

   You have to be very careful with the affected arm in case you damage the blood vessels. I got out of bed after three or four days and because the arm was weak, it was helpful to have things where I could reach them. I went home after two weeks.   

Carry on doing your exercises once or twice a day for as long as you feel the benefit of them, and certainly until you regain full movement. It is expected that unless you had any restrictions before your operation, you should regain full movement in your arm within a few weeks. Returning to full activities will take much longer, six months or more. However, if you have any complications with your wounds it may take longer – again there’s no right or wrong. It’s very important to note that everyone reacts differently to this operation.

How far you want to take your exercises after your operation is up to yourself and will depend on your own lifestyle. If you’re keen to do more strengthening exercises for your abdominal muscles, speak to your physiotherapist, or a fitness instructor if you go to a gym. Pilates exercises are excellent for developing strength in the deep, protective abdominal muscles, and encouraging good posture.

What can I expect after reconstruction with an SGAP flap?

This is a much less common type of reconstruction. In terms of using your arm, the same advice applies as after an abdominal reconstruction. The most important thing is to avoid over-stretching your arm in the early days so as to not to pull on the blood vessels connecting your new breast. The wound on your buttock will make sitting down and bending your hip uncomfortable at first. Try to avoid bending your hip forwards too much until your wounds have healed. This can take 4–6 weeks. Once the wounds have healed, massaging them with moisturising cream will keep them soft and supple. In the long term, because there are no major functional implications of losing the muscle from your buttock, you should be able to get back to all normal activities after three months or so.

   I am fit and supple from doing yoga but found not being able to do things like lift my arm far quite frustrating. Things like shopping on my own were difficult at first. Using a trolley or a suitcase on wheels was helpful. You need to be prepared for several months of recovery and do have to take it easy. The recovery was slow, but not desperately so.   

What further information might be useful?

You should be able to get all the information you need about exercises and rehabilitation, both in the short and long term, from your physiotherapist. If you don’t have direct access to a physiotherapist, you should be able to access physiotherapy services through your breast care nurse, consultant or GP.

Chapter 17

Anxieties, Concerns and Decision Making about Breast Reconstruction

Diana Harcourt, Philippa Tollow

  • The diagnosis and treatment of breast cancer can be a very distressing and emotional experience for many women.
  • Breast reconstruction is not a remedy for all your worries and concerns about recovering from cancer, but many women find that breast reconstruction is a very positive experience.
  • It’s important to make a decision that is right for you.
  • You may find it difficult to make a decision about breast reconstruction.
  • Your breast team will be able to help you to decide.
  • It’s better not to go ahead with immediate reconstruction if you can’t make up your mind. You can always leave it until later on, when you’ve made a full recovery from your treatment.

In this section we’ll take a look at some of the psychological issues that affect women who are thinking about breast reconstruction and, in many cases, their partners too. We’ll consider the worries, anxieties and concerns that many women report throughout the process of reconstruction, especially during the period of decision making and later when adjusting to their reconstructed breast or breasts. It’s important to remember that deciding to undergo reconstructive surgery is a very personal and individual experience, and you might find that not all of these issues apply to you. You may also have some worries that aren’t touched upon here. If this should be the case, your breast care team and the organisations listed in Chapter 20 can offer advice and support.

The psychological impact of mastectomy

It’s well known that the diagnosis and treatment of breast cancer can be a very distressing and emotional experience. Throughout this time, and beyond, you’re likely to experience a wide range of emotions. Some of these may be positive, such as relief following a good treatment outcome and feelings towards friends and family offering their practical and emotional support. Other emotions – such as fear, anxiety, sadness, uncertainty, frustration, indecision, anger and helplessness – can be much more difficult to handle.

As well as concerns about their diagnosis, many women worry about the impact that treatment can have upon their appearance and the way they feel about their body. Undergoing a mastectomy can be especially difficult, and some women report that this is the most distressing and emotional aspect of their cancer journey. Research suggests that about one in three women who undergo mastectomy experience significant levels of psychological distress at some stage. In a society that seems to place so much emphasis upon appearance, reactions to a mastectomy can be very complex. Some women adjust very well, whilst others find this much harder. For some women, their breasts are integral to their feelings of femininity, attractiveness and sexuality. Breasts might also be associated with breastfeeding and rearing children. Other women place less importance on these aspects, but still fear that loss of a breast or both breasts can feel like an assault on their body image – the internal view they have of their body. They worry that losing a breast will leave them feeling unbalanced and incomplete, as well as acting as a reminder of their cancer and its treatment.

Many women find that an external breast prosthesis is a good solution to their concerns, but others worry about using a prosthesis – concerned that other people will notice it, that it might fall out or that it might restrict their choice of clothing and activities. And a prosthesis may be a reminder of the surgery. Breast reconstruction offers the chance to recreate a breast shape and often provides psychological benefits in terms of improved quality of life and body image for those women who want to avoid an external prosthesis. But this isn’t always the case, and reconstruction isn’t necessarily a solution for all of the challenges associated with mastectomy. Undergoing breast reconstruction is a major commitment, and both the physical and psychological outcomes of surgery are hard to predict. This can sometimes make it very difficult for you to decide whether or not to undergo reconstructive surgery.

Making decisions about breast reconstruction

For some women, the decision whether or not to undergo breast reconstruction can feel like the first genuine choice they’ve had since hearing their diagnosis. But this isn’t a decision any woman wants to be confronted with. Nobody wants to be diagnosed with breast cancer, and consenting to undergo a mastectomy might not feel like a genuine choice.

You may face a number of difficulties when making a decision about reconstruction because:

  • The decision has the potential to influence the way you will look for the rest of your life.
  • The options are likely to be presented soon after the diagnosis of cancer has been given and various treatment choices are being discussed. Even if it’s anticipated, hearing the diagnosis is still likely to come as a shock. This is a natural reaction to bad news.
  • Many women report feeling as if the doctors were talking about somebody else – a sense that ‘this isn’t really happening to me’.
  • The range of options about the types of procedures and the timing of surgery can sometimes make decision making both complex and daunting. Making the choice is likely to involve having to consider complicated information and to weigh up numerous alternatives. It can be hard to take in, and remember, all the information that is being provided.
  • Whether or not to have breast reconstruction, or which type of breast reconstruction to have, is often a shared decision between you and your breast care team. They are experts in breast reconstruction, and you are an expert in what is important to you, including your own goals and preferences. By bringing these areas of expertise together it is hoped you can agree on a decision that is right for you.
  • Even women who are usually very decisive and find it easy to make complicated or major decisions can find themselves overwhelmed by the choices available to them at this time.
  • Some women worry about making the wrong choice or what other people might think. This can add to the anxieties already being experienced at this emotional time.

There are several ways that women who are finding it particularly difficult to make their decision can find help; these include information-seeking, preparation and talking to other people.

Information preferences

People vary in the amount of information they need to be able to make a decision. Some people want as much information as possible and can find it worrying and frustrating not to have this to hand. Others want much less detail and find that too much information can cause anxiety. It can be useful to think carefully about the type and level of information that you want before making your choice. For example, how do you normally make decisions? Do you like to have lots of detail about all your options? Or do you prefer to be told only the information that you need to know to make a decision?

Research has shown that having sufficient, appropriate information can help patients to have a feeling of control about their cancer and its treatment. It’s also thought that those women who are more satisfied with the information they had about reconstruction, and felt they had sufficient time to make their decision, are more likely to be satisfied that they’ve made the right choice.

Looking for information online

It is natural to want to gather information or find other women who have been through a similar experience. Many people look for this information on the internet and there are a range of websites, forums and blogs which some women find helpful. Think carefully about how reliable the information you are looking at could be and try to use trusted websites wherever possible (there are some useful websites included in the resources listed in Chapter 20). Be aware that some websites may include graphic images of surgery and remember that everybody’s experience is different. You might want to discuss the information you find with your healthcare professionals, as they can explain anything that isn’t clear and help you to consider which aspects of this information is most relevant for you.

Preparing for discussions about surgery

Discussing major, personal issues with healthcare professionals such as surgeons and breast care nurses, can feel difficult and cause anxiety, so it’s useful to prepare yourself in advance for any consultations. It can be very helpful to draw up a list of questions you want to ask. This can be particularly helpful when the consultation involves discussions about reconstructive surgery. You might also want to take a friend or family member with you to these appointments, as it can be hard to remember everything that is being said. You could also take notes or ask permission to record your consultation.

The advantages and disadvantages as you see them

It can also be useful to draw up a list of what you, personally, see as the advantages and disadvantages of having breast reconstruction, followed by the pros and cons of each type of procedure and timing. This is your personal list – there aren’t any right and wrong answers since what is an advantage to one person might be a disadvantage to another. It’s important to write the list down, rather than just think about it, because the process of putting pen to paper will help you to clarify your thoughts. You might also want to take this list into consultations to discuss with your healthcare professionals, or show it to friends and family.

The things that are important to you

Think about the things that are really important to you. These might include physical factors, such as breast size, symmetry, shape and sensation. They might also include the views of family and friends, activities such as sports, your work, or the types of clothing you like to wear. Thinking about the impact that undergoing breast reconstruction (or not) might have upon these things might help to clarify your choice.

How would you react to possible scenarios?

It can be helpful to take time to try to think about how you might feel or react to a number of possible scenarios, for example:

  • How might you feel if you needed to have more surgery than you had anticipated?
  • What would you do if the results of surgery weren’t quite as you had hoped?

This can be difficult, and while thinking about things is not the same as experiencing them directly, it can help to clarify your choice and possibly prepare you if they should actually happen. It’s also helpful to talk these through with other people, for example your partner or breast care nurse. You might also find it helpful to speak to other women who’ve had reconstruction and are happy to share their experiences around the time of the operation, as well as long term. Some women are very happy to show others the results of their surgery.

Making a good decision

Remember that when you are making your decision, you’re trying to make the choice that’s best for you, not one that is best for anyone else. One way of looking at a decision is to think of a good choice as one that you won’t regret later.

What should you do if you are still unsure?

If you’re unsure whether to go ahead with the surgery, you might prefer to put the decision on hold for the time being and discuss with your healthcare professionals whether this is something you could come back to at a later date. Circumstances might change, you might find that you can clarify your preferences more easily in the future, and the decision might be much clearer and easier to make at a later date. Delaying the decision at this stage can be an effective way of coping with some of the stress around your diagnosis and could be preferable to making a rushed decision that might be regretted later.

Having made your decision, you might still think of questions and concerns – before or after surgery has taken place – and you should still ask your breast care team about these. If you’ve decided to undergo delayed reconstruction, you may have to wait several months before the surgery takes place. It can be helpful to meet with your surgeon or breast care nurse once more before the surgery is due to take place, as an opportunity to raise any further questions you may have.

The experience of breast reconstruction

Having realistic expectations

A reconstructed breast is not the same as your natural breast, and it’s not a true replacement. Women who’ve undergone reconstruction can still experience a sense of loss for their breast. Those who expect that a reconstructed breast will look and feel the same as the breast they’ve lost are likely to be disappointed. Having realistic expectations of the outcome of surgery is vital. To this end, it is useful to discuss your expectations with your surgical team since they’ll be able to determine whether your hopes are likely to be met. They’ll be able to correct any of your misunderstandings, and it will help them to have a better understanding of what you hope the surgery will achieve.

One of the difficulties surrounding breast reconstruction is that it’s very difficult to describe how a reconstructed breast will feel. If other parts of the body were involved in the reconstruction, known as donor sites, then these may also feel different after surgery. Photographs can give you a clear idea of what it might look like, but it’s hard to describe and understand physical sensations until you’ve experienced them. Some women describe experiencing a tingling sensation in their reconstructed breast for some time after the initial surgery. For others this is more painful, and some women have no sensations at all. Talking to women who have undergone surgery can give you an indication, but there’s no guarantee that your own experiences will be the same as theirs.

Coping with your emotions

Any type of surgery typically provokes anxiety and it’s natural to feel nervous before the operation takes place. Anxiety is particularly great amongst women undergoing breast reconstruction because of the high hopes about the outcome of the surgery. It’s not unusual to feel tearful around the time of surgery, both before and after it’s taken place, and it might sometimes feel as if you are on an emotional rollercoaster. There are likely to be days when you feel down, and others when you feel very well and maybe elated at the results of surgery. In the following account, a woman describes how she felt during this time and offers some useful advice:

   You need to take it one day at a time and be allowed to have moments when you are upset. Crying is not being weak. You have to be allowed to be like that in order to build yourself up again. You need time to get back to normal and not think you are different to everybody else. There will be knock backs.   

Seeing the results of surgery for the first time

Looking at your breast area (and donor site, if relevant) for the first time after surgery can be a significant event and a time of mixed emotions. Women often feel relief that the surgery is over, that the disease has been removed and that a breast shape remains, but some also report feelings of loss and suggest this can be a distressing time. You might want to ask your breast team in advance when you will see the results of surgery for the first time, what it will look like initially and who will be with you. It can be a good idea to look at the results of the surgery for the first time whilst still in the hospital environment, but you might want to ask for privacy at this moment or for someone to be with you. It’s important to remember that the initial outcome of surgery may not be the same as final results since bruises need time to fade, scars take time to settle and further procedures may be needed. Massaging cream into the scars can be a way of getting used to touching the reconstructed area while also helping to keep the scars soft.

Getting used to your new breast

Even if the results of your surgery are better than expected, it can take some time to adjust to the look and feel of a reconstructed breast. Some women soon feel very comfortable with it and incorporate it into their body image well. Others find this harder, and the process of adjustment can be a prolonged and enduring one, sometimes taking a year or more depending on the amount of surgery. Again, it can be helpful to talk to your breast care team if you’re having problems getting used to your new breast. They may be able to help you with your concerns themselves, or can direct you towards other sources of support when needed.

There are many different ways of coping with the worries and concerns associated with breast reconstruction. What helps one woman will not necessarily be helpful for another and similarly, what’s helpful for an individual woman might change over time.

Keeping a record of your experiences

Some women find it helpful to keep a diary throughout this period as a way of recording and reflecting on their experiences and feelings. Others find it helpful to keep a photographic record or journal. This might sound a little strange, since we usually take photographs of happy occasions such as weddings and birthdays, rather than difficult and sometimes distressing experiences such as this. This woman found this to be very therapeutic:

   When we came home, as soon as the dressings were taken off, I decided that I wanted to keep a photo diary because I wanted to be able to see the progress. If I had a down day, I wanted to be able to look back and see the improvements. It was very helpful because there are times when you don’t think you are improving and it’s good to look back and compare it with other times. I kept the photo diary until the uplift operation had been done on the other side and the whole thing was almost complete. It would probably even be helpful to compare again because another six months have passed. I have found that things change constantly. None of it stays static. For me, it gives me confidence to look back. If you do look at yourself in the mirror, you do not look perfect but I was never perfect. It helped me; other people may feel differently about it. It does help if you feel comfortable about looking at yourself objectively.   

Other people

Decisions about cancer treatment, including those about breast reconstruction, don’t take place in isolation. It’s likely that other people, especially partners, family and friends, have been distressed by the news of the cancer diagnosis. They might also have their own views about breast reconstruction that could influence your own decision. Although this is your own choice, you might want to ask those people who are important to you what they think about it. It’s usually far better to ask them and discuss it with them than to assume you know what they think.

Sometimes women worry about being a burden on other people during the post-operative period, when they aren’t able to carry out their usual routine. Family and friends often report that they want to provide practical support, for example helping with shopping, driving and caring for children, since this helps them to feel involved and to demonstrate their support. This is illustrated by the husband of a woman who underwent reconstructive surgery:

   The husband’s role is a supporting role. You can’t really help with the decision making. It has to be the wife’s decision. There is not a lot you can do about the frustrating times, other than trying to be there and being supportive.   

What about the children’s reactions?

Women often worry about their children during this time, in particular whether to tell them about the surgery and how they will react. This woman who had reconstructive surgery describes her experiences in relation to her young children:

   My daughter, aged five, wouldn’t talk to me about the operation. It did upset her and she didn’t like it when I had to go into hospital again. My three year old son would ask me point blank how things were. I think the fact that the children expected life to carry on helped me to carry on. I had to keep it together for them. The children were wonderful and have seen the reconstruction at every stage…They just take it for granted that is what you look like and you are Mum.   

Handling other people’s reactions

Dealing with other people’s reactions to the surgery can be a significant event when they see the results for the first time. Some people who know about the surgery might be intrigued, ask questions or hope to see the results for themselves. It’s worth thinking about how you might handle such situations in advance. A polite, prepared response and a deliberate change in the topic of conversation can let others know if you would prefer not to discuss it in detail, if that’s the case.

Intimate relationships

Partners of women who have undergone breast reconstruction have reported the concerns and feelings of isolation that they experience during the process. Although they want to support their partner while she makes her decision and undergoes surgery, they might also want to talk to somebody about how they are feeling themselves, but worry about over-burdening their partner at this time. Often they don’t know anyone else who has had breast reconstruction and might feel uncomfortable about talking about the surgery to their friends.

They might also feel worried about hurting their partner or opening scars if they touch the reconstructed breast. The woman herself might also be worrying about intimate relationships after surgery. She might be feeling conscious of the reconstructed breast and worrying about possible pain and levels of sensation. In this situation she may interpret her partner’s behaviour as a rejection or of evidence that they no longer find her attractive. This misunderstanding can lead to communication problems and heightened anxiety for both partners. Although it might be difficult, creating an atmosphere of open and honest communication between partners throughout the whole process can make things easier in the longer term and offers the potential for both to benefit from the support of the other partner.

This woman who had reconstructive surgery describes how both she and her husband took some time to get used to her reconstructed breast:

   My husband has never been into great physical beauty, he is not that sort of person. I was never concerned that he might look at me and think ‘how revolting’. He will ask me why I am spending time doing my hair because it doesn’t matter. I had the reconstruction because I still wanted to look sexy. I didn’t want to have something on my chest that I was ashamed of because it was hideous. The reconstruction has not affected our sex life. It doesn’t feel the same, but I have got used to the difference. It did take a bit of time. My husband used to avoid it a bit and I had to tell him that he didn’t have to. It does feel different – like someone touching you through several layers. The breast can feel a bit cold because it doesn’t warm up. I do notice it in summer when it is hot and I have a cool breast.   

Women who aren’t in an intimate relationship can face the dilemma of whether (and when) to tell a new partner that they’ve had a mastectomy and reconstructive surgery. This can be very worrying and, as ever, there are no right or wrong answers. Talking about intimacy and sexual issues can be difficult in any circumstances, but a diagnosis of cancer can sometimes compound this, and worrying about a partner’s reaction to breast reconstruction can make this even harder.

Professional support

Specialist nurses are trained to offer emotional support to all women facing breast reconstruction. In addition, some women can benefit from referral onwards for further psychological support – for example, those finding it very difficult to decide whether or not to have the surgery, experiencing difficulty in adjusting to their appearance or needing help with a relationship after surgery. Your breast care team will be able to help you with these referrals.

Members of your breast care team or your GP might be able to help you with any worries or concerns you have about intimacy or sexual issues, but again it can be difficult to talk to healthcare professionals about this personal subject. In these circumstances, the organisations listed in Chapter 20 will be able to help.

Conclusion

For many women who’ve faced a diagnosis of breast cancer, reconstructive surgery is a very positive experience, and one that can help to reduce their distress. But it must be remembered that this is a major surgical procedure and it’s not necessarily a remedy for all of the anguish caused by the diagnosis and mastectomy. Taking time to make an informed decision can reap benefits in terms of improved adjustment to the reconstructed breast after surgery. Making the decision is sometimes difficult and your breast care team are there to help you. They can provide information, recommend credible websites, arrange meetings with other women who’ve been through the same experience and make referrals to other sources of support. It’s important for women, their partners and families, and healthcare professionals to remember that breast reconstruction is a major commitment and it’s quite normal for women to feel anxious or concerned about it.

Chapter 18

Breast Cancer and Survivorship

Rosie Stanton

21 September 2016

Everything will be fine in the end. If it’s not fine, it’s not the end.

– Oscar Wilde

I had really only just recovered from getting my CCT (Certificate of Completion of Training) in General Surgery (Breast). Thirteen years, one ex-husband, two beautiful children (one sickly), more exams than average, Graves’ disease and finally the love of my life, another little boy, now five, and my CCT. I suppose it was the long route, but the whole motherhood-career thing is rather difficult to do perfectly. I don’t have the answers yet. I had always assumed I would do one day. Probably, there aren’t any. Just choices. A bit like cancer surgery.

So many things cross your mind when you are diagnosed with breast cancer.

I was furious. I was in the middle of trying to get a consultant job. My mind was totally elsewhere. It took me a while to bring my mind round from jobs to cancer.

If I hadn’t dared to be happy, do you think it would have happened?

In the supermarket queue, I found that I was jealous of all the old people in front of me. Not nice, not something to be proud of.

Even now I feel a little bit older and a very tiny bit distant from the rest of the world.

I have tried to worry about the possibility of death. It seems so abstract though. How do I worry about such a thing meaningfully? Should I change the way I live my life. Should I work less? Do I have this illness because I work too much? Apparently I have an 11% chance of having distant metastasis in ten years. What exactly should I do about that? Live more? Live less? I would like to have more inner peace and less raaaah in my world. That doesn’t sound very surgical does it? I think it would be good for me.

We were on holiday in Crete when I found the lumps. We were having a really wonderful time. We had never taken the kids abroad before, we were all so easy to please. My eldest daughter has allergic colitis. Eating out in the UK is almost impossible, but in Greece wheat and dairy free is just normal. Not having to cook, all the time, for the first time ever, was a real break.

I found the lumps in my breast and then I prodded and worried about them for days and days. I know other patients have done the same. I had breast fed for years in total, because of the food allergies, so there was barely any structure to my breast. Even so, the lumps seemed to come and go. Sometimes they felt like cysts, sometimes I wasn’t sure they were there and every now and again this hard, little grain of rice or lemon pip would pop up and I would be scared. I told my surgeon about two of them. The whole upper outer aspect of my breast had changed. It was thicker. I thought there was probably a third lump towards the centre, but I wasn’t sure, so I didn’t mention it. How silly is that? It was very small, 3 or 4 millimetres, it took a little while for my doctors to find it.

My radiologist scanned me. She told me there were two lumps and that she would like to biopsy them. I asked her how she had scored them. U4 (suspicious of malignancy). The biopsy result would be academic, she was good. The lymph nodes under my arm were clear on ultrasound. I cracked a joke.

Some of the important things that have happened were accidental. My surgical colleague saw me in clinic. I’d seen two new patients whilst I was waiting to see him. It wasn’t really clear whether I was at work or not.

I had known him for nearly 20 years. On 21 September 2016, as he left the room he turned back and opened the door again.

‘You know this is going to go through the MDT (multi-disciplinary team). Do you want me to tell the team?’

I shrugged my shoulders, ‘Yep?’

Thank God for that question. The news was out. The decision to tell people had been made. The first few weeks I could easily have told no one, hidden from the world and not left the house. Talking to people took enormous courage. I had to re-learn how to interact with people and them with me. Somehow, I had changed.

There were lots of tests and lots of results after that. I felt a bit like Dr Seuss’s Sam about the cancer. I just did not like it. Things ‘weren’t too bad’. I was lucky. It could be a lot worse. Your risk of recurrence is ‘only x%’. But I didn’t feel lucky and you know, last week I didn’t have any risk at all. There was all this exciting stuff going on with surgery and reconstructions. But for me, it was all about the cancer. And it was about my family. My very first question was the children.

My breast care nurse advised me how to talk to them. I know she said something really helpful, but I have no idea what that was. Information passed right through my head. So, in the end we waited until we had the biopsy results and then we sat down with the children that day.

We told the older two first. My daughter is 12 years old. She is beautiful, intelligent and empathetic. There was no hiding anything from her. At least my training meant that I had answers, and that I was used to giving them. If not in this exact setting. There were a lot of questions. We covered basic tumour biology. The definition of malignancy. Different grades of cancer. Spread. Surgery. Her eyes, her ears and her very senses assessing every answer. Are they hiding something from me?

She read the books I had been given.

‘Mummy, so which one of these cancers do you have? Lobular or ductal?’ It was like a knife in the back. Bad things don’t just happen to other people. They happen to me too.

I know there were tears at school. She told me as much. Her friends were very kind. Remarkably mature. We travelled this journey together. Pulling each other up and down. Tied together by rope.

Of course, everybody tries to be very kind. There were lots of offers of help. The real problem is the BIGNESS of everything.

Having cancer is expensive.

Having cancer is time consuming.

Having cancer drains your mind.

The treatment hurts.

The process of the diagnosis hurts.

You hurt.

Your family hurt.

Having cancer re-boots your life. Some of that is good.

So, when people ask if they can help. How do you answer? Please can you take little Jonny to football on Saturday because we have been down one driver and one parent for three months. The problem is that in reality, and completely understandably, everybody has lives. Their Saturday mornings are just as horrendous as yours. And they cannot take 21 days of annual leave to take you to two-day case operations, one in-patient operation, one emergency operation, two ultrasound scans, one MRI scan, one CT angiogram, three pre-op visits, one breast care nurse appointment and a reconstruction group. They cannot visit you every day for 11 days when you are an in-patient. That was my husband.

I don’t really know yet what my eldest son thinks. He is nine. Terribly gentle. Very loving. Bright: chess, Lego, maths and football.

‘So are you alright now Mummy?’

‘Yes.’

‘I’m going to play football okay?’

Recently he told me that he had thought that I was going to die, then and there. There was no sign of this at the time.

The youngest (five years old)

I told him that I had a hard bit in my breast. I told him that it had to be cut out, because it could make me sick. He asked a lot of very practical questions. Particularly when we talked about reconstruction. ‘Why do you need to fill the hole in the breast. Surely you could just leave it?’ Not a reconstructive breast surgeon by nature! He came in to our bed every night for a week after that. He was very worried about something. He did not really know exactly what that was, or what it meant.

A few weeks later he asked if the doctors had cut all of it out. Was there any left….? And several months later, in the middle of a little outing together. Is your breast getting better now Mummy? Do boys get breast cancer?

I wanted to be treated in my unit. There was no question about that. I trusted them and knew they would look after me. All animals are equal, but some animals are more equal than others.

The medical stuff

The ultrasound found two 6 millimetre areas suspicious for malignancy (U4). One low in my right upper outer quadrant and the other nearer my armpit. They were 30 millimetres apart. The nodes looked normal. The mammogram was M3 (probably benign). Core biopsy confirmed two, grade II cancers. Both HER2 negative and strongly oestrogen receptor positive (these results help to decide how the cancer is treated). There was some ‘intermediate grade’ DCIS (pre-invasive breast cancer) associated with the upper tumour. I have a medium-sized breast. I wore a 32D cup bra.

I really did want to conserve my breast, if possible. I had next to no tissue on my back, but my surgeon thought probably enough for a little local flap to replace the tissue removed from my breast. We booked me for a quadrantectomy (first stage of a local ‘perforator’ flap) and a sentinel lymph node biopsy as a day case on the next list.

Just enough time to write a will.

4 October 2016 – Operation one

I went down for ultrasound marking prior to my surgery, which is when we found the more central, third tumour. Not really ideal.

I do know absolutely that I had wonderful cancer surgery. I know that because I have done many hundreds of operations with my surgeon. He is meticulous and precise. I think I am only sane now because I know this. How would it be not to trust your surgeon? If I have learned one thing from this process, it is how important we are to the lives of our patients and their families. That may not be rocket science. Patients have said it to me before. Now I believe it.

My colleague told me that he had taken the skin very thinly over the upper tumour to get clearance. He took an inferior ‘shave’ (an extra rim of tissue) too. I went back for the results at the clinic the following week. This is where the wool started to unravel.

‘Blah, blah, blah, blah and the MDT have recommended we do a mastectomy.’

‘Clear nodes. Blah, blah, blah, blah. Lots of different options. A bit of conversation. Let me know which one of those you might want.’

There was no wanting anything. I was fairly cool with a wide local excision. I was fairly cool with having my back attacked to harvest tissue. I wasn’t exactly looking forward to radiotherapy, but I would have done it. I did not want a mastectomy. I did not want a reconstruction.

Most of all I wanted to be left alone. The other me, who is not a surgeon, would have had a simple mastectomy and walked away. The surgeon one said, ‘You’ll regret that later. It will matter to you.’

Twenty-four hours later I was sat on the other side of a desk, talking to a plastic surgeon about a DIEP (abdominal) flap. I had worked in her hospital the previous year as a senior Registrar. I had gone across and performed many skin sparing mastectomies for her. We were friends.

The best stories start at the beginning. The whole medical history thing is important. I found it very reassuring, that my plastic surgeon treated me just like any other patient, and took a full and complete history. She examined me. She thought about what was best and what was possible.

I had just about enough tissue on my abdomen to make a tummy flap an option, if I wanted it.

I thought long and hard about having a simple mastectomy without a reconstruction. I am not quite sure what drove that wish. Certainly, I knew then, and I know now, that I would have struggled with the result. Perhaps, I had insight, into quite what a hard route a reconstruction was going to be?

The histology from the wide local excision had revealed three, grade II breast cancers. There was also non-spreading breast cancer (ductal carcinoma in situ, or DCIS). This spanned 55 mm top to bottom, paused for breath and then started again in to the inferior shave. That made 65 mm altogether. There was, in fact, a clear margin of DCIS of 1.5 mm, but the skip lesion made everyone worry, and we are a 2 mm unit. I was happy with the oncological decision to take more. With some prodding from my breast colleague, I was happy to keep my nipple.

There was a wait of three weeks for my nipple-sparing mastectomy and immediate DIEP flap reconstruction. During this time, I had a formal surgical retro areolar biopsy (operation two). I read, listened and watched every relevant article I could find on breast cancer treatment, survival and reconstruction. I grieved for my lost breast. I grieved for the loss of the femininity that I had not appreciated or knew that I had. I cried when I made love to my husband. I cried for all that would be taken from me. I cried for the tamoxifen. I cried because I was frightened by the cancer. I told my oncologist that the planned mastectomy felt like rape. It was the most enormous breach of my privacy.

The flap

The breast cancer care reconstruction leaflet detailed the outline of the operation. Facts, figures, incisions. No emotion. My plastic surgeon did not have an information booklet for patients. Booklets published by other units online were very dry.

I went to a reconstruction group and I went out of my way to talk to other patients before my surgery, but they were difficult to access. Two health care professionals very kindly spoke to me about their experience. One had ductal carcinoma in situ. In her eyes, the mastectomy was preventative, which is accurate. She had popped in to hospital, had a mastectomy and immediate DIEP flap reconstruction, everybody was very nice, her surgeon was lovely, she need a few paracetamol for a week or two and she was back to work, lifting patients at eight weeks. The other was more guarded. She had had invasive disease, a mastectomy, chemotherapy, radiotherapy and a delayed reconstruction. She was on tamoxifen. She was delighted with her breast reconstruction. A couple of years on, the memories of the operation were slightly clouded. But yes, she was tired for a long time after the surgery. In fact, she was still tired. Was that the tamoxifen? Yes, her tummy had been very tight for many months, although now it was fine.

The true magnitude of the operation really only came across when I spoke to non-medical patients. A friend of mine was diagnosed with breast cancer towards the end of her second pregnancy. She had the baby and went on to have chemotherapy. She had a simple mastectomy, complicated by skin flap necrosis – when part of the skin dies off and healing is delayed. For weeks she told me, her body smelt only of dead tissue. She carried death with her wherever she went.

She had a delayed DIEP reconstruction one year later. Now, she cannot feel much of the front of her tummy or anything over her reconstruction. Her husband is not allowed to touch her here. The space between her breasts is acutely sensitive. It took her five years to feel that the reconstruction was really part of her. She went on to have a mastopexy (a lift) of the other breast some years later to even her up. I sense that she and her breasts rub along fine now. They are not quite a team, but good friends. I know that she went through a lot to get to that point.

She is well. She went on to have a third child. She leads an extremely full, happy and normal life. She is an extremely beautiful lady and a very beautiful person.

8 November 2016 – My DIEP flap

This was my first operation away from my own unit. I emerged, glued to the bed by drip stands, a pain catheter in my abdominal wall, a patient controlled analgesia pump, a warming air blanket, a pneumatic calf compression pump (left leg), a blood pressure cuff (right leg), two abdominal drains, a breast drain, a catheter and the after effect of a very long general anaesthetic with large amounts of intravenous fluids.

I was nursed on my own in a side room. Sleep was not possible for three days. Every hour my nurse would come in to the room, encourage me to drink, measure my blood pressure, temperature, pulse and check the flap to make sure that blood was still going in and going out. As a patient, I was absolutely dependent, for my life, on the care of the nurses and doctors looking after me.

I had very bad and very unusual complications. I know that most people have a much smoother course, and it is important to keep this in mind. I lost a lot of blood in my drains from the beginning, and then, in the small hours, I lost so much blood that I became totally disorientated. My blood count dropped from 14.4 to 7.7, and continued to fall. When I closed my eyes I saw odd, pixelated images of cave men and horses. I did not always feel listened to by the doctors. There were times when I did not feel safe. This was extremely frightening.

Fortunately, the bleeding stopped without the need for further surgery and I was given a blood transfusion. I charged at recovery like a bull in a china shop and managed to get free of all the plastic medical accessories and home by day five. I was particularly pleased to lose the urinary catheter, if only because I could finally put on a pair of pants and regain a little bit of dignity. I forced my way in to the bathroom the day after my blood transfusion and washed my hair at the sink. My nurse washed me gently with a flannel. I felt filthy. I was filthy. Getting clean lifted my spirits and made me human.

I went home but bounced back just under a week later with sepsis. The blood had collected in my flanks and become infected. I was as close to intensive care as it is possible to get without walking through the door. I had a white cell count of 20 and a CRP of 275, both very high. My temperature was 38.9º, my heart rate 116 and my systolic blood pressure 70. Unfortunately, my blood pressure is always fairly low, so nobody was really sure what to do with it.

I had been seen the day before and sent home. I had arrived to a queue at the reception desk, which I simply did not have the ability to wait in. I told the doctor who saw me that I felt too ill to stand up or think. These are warning signs that somebody is very unwell. My temperature, my heart rate, my respiratory rate and my blood pressure were not measured. No bloods were taken. I was sent home with a diagnosis of an uncomplicated wound infection on tablet antibiotics. We lived over an hour away with three young children. I should have come back that night, when I became even more unwell.

Instead I came in first thing in the morning. This time I was less opaque. ‘You know all that sepsis stuff you have to do when someone is sick? You need to do it to me.’ There are strict protocols for antibiotic and fluid delivery in sepsis. By this point, I needed the kitchen sink. When, I arrived in theatre the infection was spreading across my abdomen in front of me. The theatre staff asked me to move across from the bed to the operating table. The combination of my tummy wound and the sepsis meant that I could not, even nearly, manage it. I cried. I begged them to give me stronger antibiotics. My body was not doing any of the things it should do. I desperately needed a surgical washout, and fortunately this made me better.

Pain and sensation

I had this peculiar thing going on in my arm after my breast and axillary surgery. Every time I tried to use the shoulder, a shearing pain would shoot through the muscles underneath my armpit. None of us really knew why. I could not chop an apple. By week four, I could still not drive. I lost quite a lot of weight. I tried once or twice, but pulling down on the steering wheel was totally impossible. Agony. Fortunately, this pain receded with my second operation (a biopsy of the tissue behind my nipple) and gabapentin.

My response to this pain was interesting. I feel a bit embarrassed really. I should have known, the amount of pain I had was not normal, after a wide local excision and sentinel lymph node biopsy. A lot of people have asked me how it is to be a breast surgeon with breast cancer. I have not really known how to answer that. Obviously, I understood the technical and oncological aspects of my treatment better than a lay person, but I still felt their consequences as anybody else. I had never felt pain after a wide local excision before. Perhaps this was what it was really like? I didn’t know. I didn’t want to make a fuss. Everybody will interpret this disease and its treatment in their own way. There is no normal. That is what makes practising medicine so challenging and so rewarding.

I had a touch of ‘altered sensation’ over the distribution of the intercostal brachial nerve. All of these things change you. They make your body less you. Exactly whose armpit am I putting deodorant on? For the first few weeks, it did not feel like my own. It felt unpleasant, painful. Now (week ten) it is fine. I still have pain however where my arm touches my side. I sleep with a pillow between them at night, so they do not touch. Sitting still in the lecture theatre at the Association of Breast Surgeons multidisciplinary team meeting last week was uncomfortable. In the end, I rolled up the programme and stuck it under my arm so the arm did not touch my side. I have been taking gabapentin for a while now. It seems to help.

Obviously, I have numbness over my reconstruction. Also round my side. Sometimes I brush my hand over my breast, as I dress. It is a shock each time. The first few flap observations were incredibly odd. I was aware the nurse was touching something that was a part of me. I could see him reaching his hand down to the skin under my breast, but there was nothing there. Nothing I could feel.

But to look at, I have this incredibly beautiful nipple. Sat rather proudly and perfectly on the centre of my breast mound. I cannot feel it, but it can feel the world. It stands up and blushes when it should. To whom is it answering?

December 2016 – Getting strong again

The sepsis took all my strength. My discharge haemoglobin was 7.5 g, pretty much half its original value. I had been discharged on antibiotics. I was still seeing oncologists and plastic surgeons. The hamster wheel was still turning.

In the early weeks of my recovery I walked in our village every day and quite often my son Harvey would come too. I was incredibly slow. I had no useful physiology. The left side of my tummy hurt if shaken, where we had harvested the flap. My breast hurt when jolted. My body would call a halt to all activity without sensible warning. Sometimes I had to sit down where I stood and wait for my body to re-calibrate. Quite often I would come home and sleep for several hours afterwards and then go to bed at 9pm. I slept and slept and slept. Deep, healing sleep.

I was given the all clear to swim five weeks after my reconstruction.

Initially I was only able to walk in the pool, moving my arms against the water. Within a week, I started to swim for twenty minutes, very slowly. My nine year old would wait until I was half way down the pool and then whizz past me. I progressed quickly though. I went every day except Christmas Day and Boxing Day (the pool was closed). The exhaustion was immense. Walking to the car afterwards, I had not a drop of strength left. I felt like I had a whole avalanche of snow on my back. My mind loved it though. It held me together, and I am sure allowed me to get better much more quickly than anything else I could have done.

I saw the physiotherapist every Thursday for three weeks. She had pummelled the scar under my arms and given me new and harder exercises to do. I had two individual swimming lessons. It is lovely to think about front crawl: turning my head to breathe, keeping my head still, swinging my hips out of the water. Not doctors.

Recently Harvey said to me, ‘You know, you are literally our real mummy again, perhaps even fitter.’ How awful it must have been, not to have your real mummy.

I still have not really decided what I think about my reconstruction. The skin over the breast cancers was initially very hard and woody, but time over my well-vascularised flap seems to be relaxing it. I have had a lot of pain. It will be nice when that goes completely. Having a nipple, particularly one that is erectile and pink, makes the reconstruction feel like it is part of me. I try to feel the breast regularly. I try to look at it every day. Nobody has asked me to. It just seems sensible. Even so, I think it will be some time before I accept the reconstruction as part of me. It will also be some time before I forget the severity of the complications I have, and the extent to which the surgery broke me apart physically.

January 2017 – My head, my work, my arm

Surgeons are a rarified group. As you would expect, a whole spectrum of people and skills. Certainly, good health is needed. Surgery is demanding of both physical and emotional well-being.

I am fortunate that I have the kids, my next job, and my husband to distract me from being sick. In my own mind, I am a surgeon. I want to go back to work. Being a patient has been necessary, but I hope only a road through to somewhere else.

And so, it was an extra punishment when the physiotherapist explained that my ongoing shoulder weakness was because my scapula was ‘winging’ on the side of my surgery. Ran through a few exercises, and arranged to see me in two weeks.

Every muscle is supplied by a nerve. Serratus anterior – a muscle which sits very close to the breast – is supplied by the long thoracic nerve. Long, because it meanders its way down from the neck, along the side of the ribs towards its destination behind the scapula. Serratus anterior pulls the scapula on to the rib cage. It allows the other muscles to act on the scapula and rotate it up, as the hand moves out to the side and the shoulder moves up. Without the nerve, the muscle does nothing. The patient, me, can no longer raise their arm to the side completely, shrug their shoulders, their arm is weak where before it was strong. Movements high in front of me are careful and deliberate. I struggle to push a trolley at the supermarket, I cannot pull a heavy duvet across the bed, small bags feel very heavy. Our kitchen work surfaces are now high, preparing food is difficult. I struggle to stir pots. I can no longer hold up my arm to play the violin, my movements are not quick enough for tennis. I was shown pictures of my own faulty shoulder from behind. The right now clearly different from the left. Another me, in the mirror, that I could not recognize.

The very bottom of the barrel

I literally lay down on the floor at home and cried. I had no more capacity for bad news. It had all been used up. I had muddled through the cancer stuff, the complications and the pain, but my job was sacrosanct. It was my life and my pleasure. I was absolutely heart broken.

I am not very good at asking for help. A fault, I know. But then, there are lots of character traits that we are supposed to have, all at once, to be the perfect doctor. Resilience, humility, intelligence, independence, innovation. Oh, and we have to be team players. Right then, I didn’t feel like being a perfect person. I did not have the strength. But I did ask for help from my colleagues, and they did not know what to say, or what to do. They could not make it all better. They did not know how to deal with the raw agony that this loss uncovered. Right then, I needed tea and sympathy. Not medicine.

June 2017

Pain

Emotion: electric and palpable

Fear

So, so determined

I went back to work 12 weeks after the flap surgery. For the first few weeks I was the very best doctor I have ever been. I will never be so good again. I did not tell the patients that I had suffered with breast cancer. I felt strongly that this was their time, not mine. Equally my words resounded with truth, understanding and detail only really known by patients. My ears listened, my new-found medical knowledge, from all of my reading, shared.

My colleagues were rather wary of me in the MDT. Friend or foe? Colleague or patient? It took a couple of weeks for this to settle. My breast care nurse could not cope with me now I was back in the work place. She passed me over to her mentor, a psychologist for any support I might need. I took all the help offered to me. I was absolutely clear that coming back to work was going to be a success.

My arm did not like this project. Driving, sitting, writing, typing and operating. All new and demanding. The consultant who had been my surgeon, was now my educational supervisor, my referee and my closest surgical colleague. I stripped him of as many of these hats as possible, but I was still his Registrar, his right-hand man and his patient.

My driving was so poor that I knew this was the only hospital I could work at. My head and my body were fragile. This was not the time for a change of unit. I needed to use every advantage I had, particularly familiarity. My nerve injury was diagnosed the week of my return to work. The tamoxifen, with its sweats, its aging, its sleepless nights and the oh ever-so-painful sex, put its boot in. The hits kept on coming.

…and so, I swam.

I was so frightened of operating. What if I couldn’t? So I nearly didn’t. My shoulder surgeon told me that it would be all right. He told me that his patients achieved incredible things. Again, he had known me for many, many years. He believed in me.

I tried, and it hurt. It hurt whilst I operated and it hurt for two days afterwards. It hurt so much that I wished he could cut my arm off to stop the pain. Other patients had said the same, he told me. I didn’t understand. Surely all of the swimming would make the arm strong? It made the arm strong for swimming, the orthopaedic surgeon explained, but not for operating.

There were times when the emotion of the job bought my whole body to a standstill. One of my very first patients cried on my shoulder the day after her mastectomy. The loss of her breast too much to bear. Unfortunately, although I had known this before my surgery, I had not understood it. The young ladies I consented for reconstruction – of course they touched me. The husbands crying for their wives, or just as bad, the stoicism of support. I knew how hard this journey was for all who are loved and love.

I was carried through by an absolute determination to make it succeed. The most important person to lose out, should I not work again, would be myself.

I was back at work full-time within two weeks of my return and operating on my own within the same time frame. By the time I took my first week of annual leave at six weeks I had marked, consented and harvested my first latissimus dorsi flap without supervision.

When I returned from annual leave, I felt that I had really turned a corner. Doctor and surgeon. No longer patient.

And to be clear, it was the most incredible achievement and it was an achievement attained not only by me, but by my husband who supported me through every hiccough, emotional and physical, and by my wonderful surgeon turned surgical colleague. I am very proud of all three of us.

28 September 2018

It is fairly exhausting thinking you are going to die.

I found a hint of a lump in my reconstruction, just at the point the cancers had been removed. It took a couple of days for the worry to set in: after all it was most likely to be fat necrosis, but soon it was all I could think of. I know that my medical colleagues are very upbeat about my future, but my reality is not the same as theirs. I no longer worry about my pension. I no longer wonder about my grandchildren. I don’t really worry about my other breast. I know that my problem is likely to be the (three) cancers I have already had, not the cancer I may never get in the breast that remains. It is my assumption that none of these things will be in my life. If old age and all its challenges come my way, I will embrace them. For now, I do not have confidence in the future and so I live in the present. I had rather assumed, however, that I would have a few years of respite. That is the way ER positive disease works.

I have come to realise that there is a tiny, paper-thin veneer between feeling fine and having metastatic breast cancer. When I saw my surgeon, I had run through all the tests, scans and treatments that were likely to come my way and was getting down to planning what sort of surgery I would want this time.

However well-adjusted I seem to be, after all, I am going to work, enjoying life, doing a wonderful oncoplastic fellowship, raising incredibly successful and well-adjusted kids. In fact, I stand, always on the edge of a cliff: no cancer / cancer; my life / a life controlled by others.

It was all fine, but I know everybody was worried. By the time I had been scanned and biopsied, my husband, my surgeon and the breast care nurse were all standing outside the door, anxious. I had the advantage of knowing and trusting the radiologist. I had seen her be right so many times before, so that when she said it should all be fine I believed her. I did not need the biopsy result. Just as I knew nothing was fine at my very first ultrasound.

November 2018

I worry about lots of other things now. Not breast cancer. I think that is a good sign. Sometimes a situation will creep up on me. Unexpected. I am only just starting to give my whole self to my family. For a long time, I held something back as protection. To help my wounds heal.

My right breast is now mine. Even though it does not feel the world around it. Even though the nipple dances slightly apart from its partner. I still wish I could have my old breast back. I would certainly like my old arm back.

I am working hard. I love that. My arm now allows me to operate as I wish. There is not enough time in my day to do all the things I would like. This is my time for living.

Chapter 19

Final Comments: Would I Do It Again?

Clare Clayden-Lewis

When reading about breast reconstruction there’s plenty of information available on your immediate recovery and what to expect. But there’s limited information on how patients feel several years on. We’ve interviewed the following patients who’ve kindly agreed to share their experiences, in particular their decisions about surgery, and whether they’d make the same choices again.

C had an immediate latissimus dorsi and implant reconstruction 20 years ago:

   I was diagnosed, and received my treatment for breast cancer 20 years ago. I was initially diagnosed with DCIS but this was later confirmed as invasive cancer. When I saw the consultant I was expecting to be told that I had a cyst and was in a state of shock to hear my diagnosis. During the consultation I was informed that I needed to have a mastectomy and reconstruction using my back muscle and an implant. I went for a second opinion and the consultant confirmed that I needed a mastectomy.

Following surgery I needed to have radiotherapy. The effects of this has caused some scarring and tightness to the implant which now feels hard and tight like a tennis ball on my chest. Initially I had tremendous itching under the skin and under the implant, however this settled with time.

Pilates helped with my recovery and regaining mobility in my arm and shoulder.

My back and arm are still numb in parts and I get some tightness under my arm. I also have some weakness to my right shoulder however this does not affect my ability to play golf. I still enjoy pilates but am slightly restricted with some movements.

At the same time as my mastectomy I was offered a reduction on the left side. Over the years this side has continued to grow and I now need to wear a prosthesis (breast form) on the same side as my reconstruction.

In hindsight I would not have had a reconstruction if I had known the above but I’m alive and very grateful for the treatment I’ve received.   

When possible, your surgical team is likely to advise you to avoid immediate reconstruction using an implant if radiotherapy is planned. This is to prevent tightening and possible loss of the implant because of the effects of radiotherapy. Occasionally a temporary implant is used to keep the skin and shape of the breast while you’re having radiotherapy. This prepares your tissues for a second longer-term reconstruction once your treatment is completed.

J’s surgeon thought that she may require radiotherapy after her mastectomy so she considered the different options of both immediate and delayed reconstruction. After careful consideration she decided not to go ahead with breast reconstruction:

   When I was diagnosed with breast cancer I was told that I needed a mastectomy. I was referred to see a plastic surgeon who could offer me immediate breast reconstruction. I remember it being hard to make a decision as I was in a state of shock and given too many options in such a short time frame. They discussed using my own tissue but I did not want scars on my back or tummy. I considered a silicone implant reconstruction however they thought I might need radiotherapy and chemotherapy so I had a mastectomy without reconstruction.

I was upset at losing my breast and sad to see it go but afterwards it was fine. I have a neat scar.

My surgeon deliberately left me with extra skin to allow for delayed reconstruction and I went back four to five years after my mastectomy to discuss the option again. I was told that I would need to have an expander implant to stretch the skin over a couple of months and then a second operation to change the implant. I was shown some pictures but I wasn’t that impressed. I didn’t want to see myself naked with a breast like that, an alien boob that isn’t mine. I wanted something that looked like me. I decided not to go ahead with reconstruction.

It was a shock seeing and wearing a breast form for the first time. I find that it’s in the summer months that wearing it bothers me the most. They are hot and heavy to wear and you are limited with the style of clothing you can wear. The mastectomy bras are disappointing and there isn’t a huge range. I have tried a contact breast form but it came unstuck and didn’t last long. I have recently bought a lighter prosthesis for hot days and this has made a huge difference.

Nine years on I still miss my breast and having a cleavage. If I had been 20 years younger I would have had an immediate reconstruction.   

Breast reconstruction may not be right for some women and J’s account highlights how personal this decision is. There are continuing improvements to the range and style of mastectomy bras and breast forms available. Mastectomy bras have also become easier to buy, with larger retail stores stocking items instore and online shopping being accessible to most people. The technology and shape of breast forms are constantly changing. Designs have become lighter in weight, and new heat exchange technology has made a difference to the comfort and feel of the breast forms when worn.

D had a mastectomy six years ago and chose a delayed latissimus dorsi and implant reconstruction a year after her original surgery:

   I had my surgery about six years ago. I was offered a lumpectomy or a mastectomy, with or without reconstruction. I decided to have a mastectomy without a reconstruction as I would have had to wait longer for my surgery if I had a reconstruction straight away. This was the right choice for me.

I wore a prosthesis for a year before I had a reconstruction. During this time I spent time researching different types of reconstruction. I talked it through with my consultant, breast care nurses, and family. I read books and spoke to people who had had reconstruction. It was important for me to get a good understanding and weigh up the advantages and disadvantages to the different types of reconstruction. I found this valuable and felt well prepared for my surgery and recovery.

I could have lived with wearing a prosthesis and I found it easy to find bras which fitted and were pretty. However I was young and due to get married; wearing a prosthesis restricted me wearing some tops. I also felt conscious that the top of the breast form may be seen when I moved or wore certain clothes. Initially it was hard to look at myself as I looked different, but now they are a part of me and I don’t actually think about it.

When I came to have my reconstruction I also chose to have a mastectomy (with immediate reconstruction) on the other side. I am very pleased with the result and wouldn’t have done anything differently.

I still have some stiffness and weakness to my back, and sometimes to the front but exercise and stretching has helped. I am able to do yoga and enjoy cycling and walking. It took a while for me to be able to do exercises (like the plank) but I listened to my body and took my time. I initially had some numbness to my back but I can feel that area again now.

Since my diagnosis and surgery my confidence has grown and it has changed my life. I now help others and work with a breast cancer charity.   

This interview shows the improvements in prosthesis and range of bras available. It also demonstrates that there can be positive and life-changing outcomes following a cancer diagnosis and treatment.

A had an immediate latissimus dorsi and implant reconstruction nearly 20 years ago:

   I was 33 years old at the time of my diagnosis and I had three children under 9 years. I was seen on the Monday and was having surgery on the Wednesday. It was all very quick. I had a mastectomy with immediate latissimus dorsi and implant reconstruction. I was shown pictures before my surgery but I couldn’t look. If I had my time again I don’t think I would have a reconstruction straight away. I would rather have woken up without a reconstruction. This may be partly because my reconstruction wasn’t right after my radiotherapy and I needed to have the implant removed as it became firm, like a cricket ball. I needed to have fluid drained from my back for up to 8–9 weeks which I found hard.

Because the first reconstruction went wrong I had this changed to a DIEP reconstruction when I was 40. My family later told me that they were not keen on me having more surgery but they didn’t tell me that at the time and I know it was my decision. My husband was very supportive. I felt guilty for being vain and felt lucky to be alive, but following the DIEP surgery I feel more like me. I’m still a bit restricted with underwear and have a slight dip which may be noticeable in a swimming costume. I had one lot of lipomodelling but was black and blue afterwards and I haven’t had any more sessions. I also had a nipple reconstruction but after time this didn’t look as good.

Time has helped. Initially I turned my back if I looked in the mirror and felt self-conscious.

I had counselling and was invited to speak to medical students about my journey. This lead to me helping with their dissertation and helped me in a positive way to move forward.   

Sometimes the timeline between diagnosis and surgery may not allow patients much time to decide on the type of reconstruction, especially if you have been given multiple options. This can be an important factor to consider when deciding on the type of reconstruction and whether you have an immediate or delayed reconstruction.

Further surgery is often required with implant-based reconstruction and a reconstruction using their own tissue can feel more natural for some patients. This was the case for H who had a DIEP reconstruction following an implant-based reconstruction ten years earlier:

   I found the first lump in May 2000 and had a partial mastectomy and a small implant. I did my exercises every day even though it was uncomfortable at the time. You’ve got to be prepared to put the work in. In January 2010 I found another lump and as a result of this had a mastectomy and was flat chested for a while. However, I didn’t like the look in the mirror and mentally it was very important to me to have a reconstruction, so in September that year I had a DIEP reconstruction.

I was given a few different options, but after reading through all the information I decided on a DIEP. This felt like the best choice for me as it did not involve using any muscle and would not leave a visible scar. I knew other ladies who had had a reconstruction using the muscle and had experienced discomfort and complications afterwards.

I’m quite slim so the only drawback was that they struggled to get enough flesh so I also ended up having some lipomodelling a while later, but you would never know the difference with my bra on. On the plus side, if you have a large or flabby tummy you get a free tummy tuck! I was fortunate that I experienced no discomfort during my recovery.

I had some problems with my tummy wound and this needed to be dressed every day but this was totally painless, just a nuisance. I certainly wouldn’t let that put anyone off, even if you are slim and well into your sixties as I was at the time!

I have never looked back, it was all positive. The surgeon did a brilliant job and I will be eternally grateful to them and the NHS for allowing me to have this operation, it has made a world of difference to me.   

For some people there may be limitations to some forms of reconstruction but the above highlights that age should not be a barrier to having a reconstruction and the positive outcomes this can give.

P was diagnosed with DCIS. After several operations she needed to have a mastectomy and describes her experience of deciding which type of reconstruction to undergo:

   I was diagnosed with DCIS following my first mammogram and I was told that I needed to have surgery. Although I was shocked and frightened I was relieved that there was the option of having a lumpectomy.

After three attempts there was still DCIS present and I was told that I would need to have a mastectomy. In a way I felt a relieved shock. This had been going on for a long time and I was worried that other areas in the breast might change into a cancer.

I decided straight away that I wanted a reconstruction but I remember finding it very difficult to make a decision on the type of reconstruction. I was given the option of a latissimus dorsi or subpectoral implant reconstruction. When I asked the surgeon what they would recommend they advised the latissimus dorsi as they felt this would give a better cosmetic result.

I remember going with the breast care nurse to look at photographs. I found these reassuring and felt that I would come out from surgery with something fairly similar to my natural breast but I had doubts following the consultation. I was concerned about the scars to the back and front and also the altered sensations that I would have. The breast care nurses put me in touch with two ladies who had had implant reconstructions. They were both happy with the results but I felt I needed to speak to other women too. I went to the local support group and spoke to a group of women and following this I decided to have a reconstruction using an implant.

On the day of surgery I had a discussion with the consultant about preserving my nipple. This was important to me and I am very glad that I was able to keep this. It has made a difference when I look in the mirror.

After my surgery I had a lot of bruising and painful cording; I remember being frightened and feeling ill prepared for this. I wish I had known to expect this. I had physiotherapy for the cording. This was excellent and the cording improved within a few weeks by doing exercises and some manipulation. The bruising and look of the reconstruction settled with time and I would tell others not to expect it to look wonderful straight away.

About 3–4 years after my surgery I went to a coffee morning to support a lady who was finding it difficult to make a decision about reconstruction. We all shared our experiences and showed each other our reconstructions. I would have found this really helpful when I was making my decision.

I was dissatisfied with my reconstruction as although it looked fine in isolation it was not a good match to the other side. However, when I saw the other ladies I felt mine compared well to some of the others. Several years ago I had lipomodelling to try and correct the difference in the size of my breasts. This initially made a difference but the volume has decreased with time. I now wear a breast form in my bra and I wish I had done this sooner as my clothing looks better. I was given the option of an uplift on the other side, but I do not want to embark on unnecessary surgery at the moment.

Overall, in asking myself ‘on reflection would I do the same again?’ the answer is definitely yes. I am here, alive and well, with no worries about cancer in the breast. In clothing no one would ever know that I had had a mastectomy.   

The above comments highlight the benefit of speaking to others and sharing personal experiences. For some, sharing information can be very empowering.

It’s not uncommon for people to have surgery on the other breast as the natural breast changes over time. For some this is something that they choose to do when the time it right for them. For others, who may not wish to have further surgery, there may be ways to manage the difference in cup size with a partial breast form.

R had DCIS and later found out that she had the BRCA2 gene (see Chapter 14). Prior to her risk-reducing surgery she was diagnosed with invasive breast cancer. Here she describes her experience and how she managed her diagnosis, BRCA gene diagnosis, and treatment:

   I had been having yearly mammograms from the age of 35 years having seen a genetic consultant due to family history. I was 40 years old when I was diagnosed with DCIS to my right breast. I was living in America at the time and had a lumpectomy and radiotherapy. When we returned to the UK I had a genetic test as I have a strong family history of cancer. I had the referral and received my results quickly. The results came back that I had the BRCA2 gene.

I decided fairly soon after the test that I would have risk-reducing surgery, with immediate reconstruction using my back muscle and implants. I had a psychological assessment as part of the work up to having surgery, but I already knew that I was going to have risk-reducing surgery.

Whilst I was waiting for my surgery I had my regular yearly mammogram. Following this I developed tightening to my right breast and symptoms which were similar to mastitis. I was initially treated with antibiotics as there was nothing to see on my mammogram or ultrasound. I had an appointment with the consultant who took a core biopsy because of my history of DCIS. I just knew it was going to be breast cancer and it was.

I had chemotherapy first and 4–5 months after completing chemotherapy I went on to have my surgery. This was the right decision for me and I chose to have my ovaries and fallopian tubes removed at the same time. I do not remember speaking to anyone else about reconstruction but I do remember being shown the type of implants which were going to be used and seeing some photographs. I didn’t feel that I needed any other support.

I told my daughters everything and was always open and honest with them. I feel that this helped them and it was important for them to know, especially because of our family history. They have both had the genetics test and are both BRCA2 carriers.

It’s 13 years since my surgery now and I haven’t had any problems or needed any further surgery. I had a nipple reconstruction but did not bother having nipple tattoos. I feel that my decision to have surgery was the correct one and I do not regret it. I was well supported by my family, the consultant, and the breast care nurses.   

The patients interviewed here had their surgery between 7 and 20 years ago. During this timeframe there have been significant changes and developments in all areas of breast cancer care. The range of surgical options has increased enormously, supported by a wider range of online resources and information. We’ve also seen a much greater understanding of the needs of patients, and the links between patient choice and both physical and mental wellbeing.

Our patients have been very generous in giving their time to reflect on their experiences in this chapter. They have been honest and open, highlighting both the drawbacks and positive aspects to breast reconstruction. Their comments highlight the fact that decisions about reconstruction remain extremely personal. A range of factors including lifestyle, general health, and personal circumstances play an important role in the decision-making process.

Chapter 20

Useful Contacts and Sources of Information

Clare Clayden-Lewis

Finding out about breast surgeons and clinics

The Association of Breast Surgery (ABS)

Professional representation body for breast and oncoplastic surgeons in the UK (based at the Royal college of Surgeons of England). It provides a list of surgeons specialising in the management of breast conditions, including breast cancer.

The Association of Breast Surgery

The Royal College of Surgeons of England

35–43 Lincoln’s Inn Fields

London WC2A 3PE

Tel: 0207 869 6852

Fax: 0207 869 6851

Email: office@absgbi.org.uk

Website: https://associationofbreastsurgery.org.uk

British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS)

Professional representative body for plastic and reconstructive surgeons in the UK (based at the Royal College of Surgeons of England). It provides advice on the management of conditions and information about the work of the surgeons and how to find a surgeon.

The British Association of Plastic Reconstructive and Aesthetic Surgeons

The Royal College of Surgeons

35–43 Lincoln’s Inn Fields

London W2CA 3PE

Tel: 020 7831 5161

Email: secretariat@bapras.org.uk

Website: www.bapras.org.uk

National organisations providing support, advice and information

Breast Cancer Now

Formed by the merger of Breast Cancer Care and Breast Cancer Now to support those living with and beyond breast cancer. They provide a detailed overview of breast reconstruction including an animated guide and local events for younger women, moving forward, and living with secondary breast cancer. Services include a telephone helpline, an online chat forum, BECCA app, online courses and fundraising events, and the Someone Like Me service (which offers to put you in touch with a trained volunteer who has had or been affected by breast cancer). Breast Cancer Now campaign for improvements in standards of care and support.

Breast Cancer Now

Ibex House

Fifth floor

42–47 Minories

London EC3N 1DY

Tel: 0808 800 6000

Email: src@breastcancernow.org

Website: www.breastcancernow.org

Breast Cancer Haven

Offer support centres throughout the UK. Support programme includes 12 free hours of one-to-one appointment time, as well as assessments, counselling, and a range of therapies comprising of massage, acupuncture, reflexology, exercise and stress reduction.

Centres in London, Yorkshire, Hereford, Worcester and Wessex.

Tel: 0300 012 0112

Email: support@breastcancerhaven.org.uk

Website: www.breastcancerhaven.org.uk

Cancer Care Map

Online directory to help find local cancer care and support services.

Website: www.cancercaremap.org

Cancer Research UK

Contains helpful information on breast reconstruction.

Cancer Research UK

PO BOX 1561

Oxford OX4 9GZ

Tel: 0300 123 1022

Email: supporter.services@cancer.org.uk

Website: www.cancerresearch.org.uk

Flat Friends UK

For women who have had a mastectomy without reconstruction, the charity provides support, information, and advice.

Email: support@flatfriends.org.uk

Website: www.flatfriends.org.uk

Macmillan Cancer Support

Services include a host of information on practical, medical, emotional and financial support for patients, carers and relatives. The charity also provides information on local self-help groups, an online community and details on how to get involved with fundraising and volunteering.

Macmillan Cancer Support

89 Albert Embankment

London SE1 7UQ

Tel: 0808 808 00 00

Email: contact@macmillan.org.uk

Website: www.macmillan.org.uk

Maggie’s

Provide support for patients and their families with centres throughout the UK and internationally, as well as online.

Website: www.maggies.org

NHS UK

Health website covering detailed information on symptoms, conditions, medicines and treatments.

Website: www.nhs.uk/conditions/breast-cancer

Wessex Cancer Trust

Multiple support centres in the South of England for practical, emotional and psychological support. Offer a drop-in service and a wide range of one-to-one or group therapies.

91–95 Winchester Road

Chandler’s Ford

Eastleigh SO53 2GG

Tel: 023 8067 2200

Email: wct@wessexcancer.org.uk

Website: www.wessexcancer.org.uk

Suppliers of bras, clothing, swimwear and prosthesis

Amoena

Provide specialist post-surgery and mastectomy bras, swimwear, prosthesis and accessories. Mail order available, as well as a fitting service and shop in Chandler’s Ford, Hampshire (appointment recommended).

1 Eagle Close

Chandler’s Ford

Eastleigh SO53 4NF

Tel: 0345 434 7334

Website: www.amoena.com

Anita UK Ltd

Specialist bras, swimwear and prosthesis available in some shops.

Range listed on website.

Tel: 01908 524048

Email: anita.uk@anita.net

Website: www.anita.com

Eloise

Post-surgery bras, mastectomy bras, swimwear, clothing, prosthesis and accessories.

Tel: 01908 340 094

Website: www.eloise.co.uk

Nicola Jane

Mastectomy and post-surgery fashion. Online shop and store in Chichester.

7 City Business Centre

Basin Road

Chichester PO19 8DU

Tel: 01243 537300

Email: customerservice@nicolajane.com

Website: www.nicolajane.com

RecoBRA

Post-surgery seamless bra.

Website: www.recoheart.com

Royce Lingerie

Offer a range of online bras including comfort bras, post-surgery bras and a custom pocket service. Website also contains details of nearest stockists.

Website: www.royce-lingerie.co.uk

Silima

Offer a wide range of online mastectomy bras, swimwear, breast forms and prosthesis.

Email: orders@thuasne.co.uk

Website: www.silima.co.uk

Theya

Post-surgery bras made from antibacterial bamboo fabric.

Email: info@theyahealthcare.com

Website: www.theyahealthcare.com

Trulife

Mastectomy bras, speciality collection including swim and leisurewear, and breast forms. Catalogue and mail order.

Tel: 0800 716770

Email: info@trulife.co.uk

Website: www.trulifebreastcare.com/

Womanzone

Specialist in mastectomy lingerie and swimwear.

Tel: 01925 220 932

Email: sales@womanzone.co.uk

Website: www.woman-zone.co.uk

Further useful websites

Chapter 7

Breast Reconstruction Awareness

www.breastreconstructionawareness.org.uk

Chapter 12

Susanna Kauhanen ResearchGate Profile

https://www.researchgate.net/profile/Susanna_Kauhanen

Chapter 14

World Cancer Research Fund (UK)

www.wcrf-uk.org

Chemo Cookery Club

https://chemocookeryclub.com

Chapter 17

Health Talk

https://healthtalk.org/breast-cancer-women/breast-reconstruction-after-breast-cancer

https://healthtalk.org/breast-cancer-women/choosing-not-to-have-breast-reconstruction

Glossary

Acellular dermal matrices/Acellular collagen matrices

Sheets of human or animal tissue harvested from the deepest layer of the skin – the dermis. These have been processed to remove all the cells, leaving a scaffold or ‘matrix’ of supporting tissue. Blood vessels and new cells from the patient grow into this scaffold, building an extra layer of living tissue over the underlying implant

Anaesthetist

A doctor who will give you medicine that will put you to sleep during an operation

Analgesic

Pain-relieving medicine

Anterior Intercostal Artery Perforator (AICAP)

Small arteries nourishing the skin and fatty tissues over the ribs just below your breast

See Perforators

Apex

The most prominent part of the breast

Areola

The pigmented area of skin around the nipple

Arrow flap

A type of nipple reconstruction

See Nipple reconstruction

Aspirate

To draw off with a syringe

Atheroma

Fatty deposits which clog arteries

Augmentation mammoplasty

Cosmetic procedure to increase your breast size using a breast implant

See Mammoplasty

Autologous reconstruction

Building a new breast using only your own tissue without the need for an implant or a tissue expander

Auto-transfusion

Blood transfusion where your own blood has been stored and is transfused back to you

Axilla

Armpit

BRCA

  • BRCA1

The first BReast CAncer gene, that was discovered in 1994

  • BRCA2

The second BReast CAncer gene, that was discovered in 1995

Bilateral mastectomy

An operation to remove both breasts

See Mastectomy

Bipedicled TRAM flap

Breast reconstruction using both of your rectus abdominus muscles and tissue in the abdomen

Body image

The internal view a person has of their body

Breast implant

A synthetic device (usually made partly of silicone) that is put into your breast to enlarge it or replace tissue which has been surgically removed

See Implant, Silicone

Breast reconstruction

An operation to rebuild your breast and restore what disease and surgery have taken away as realistically as possible

  • Delayed breast reconstruction

Surgically rebuilding a breast months or years after a mastectomy

  • Immediate breast reconstruction

Rebuilding your breast at the same time as the mastectomy

Breast reduction

An operation to reduce your breast size

Breast screening

Checking your breast, usually with mammograms or ultrasound scans to look for early breast problems

Capsular contracture

A scar or hard shell of tissue forming around a breast implant

Cartilage graft

A small piece of cartilage taken from a rib or ear lobe that is used to increase the projection and firmness of a reconstructed nipple

Cellulitis

Spreading infection of the skin

Chemoprevention

The use of a medication to prevent someone who carries a high risk of breast cancer from developing the disease. This may be a drug that stops the action of certain hormones which increase the risk of developing breast cancer

Chemotherapy

Anti-cancer drugs

Chromosome

Part of a cell nucleus responsible for the transmission of hereditary characteristics

Clinical trials

Research studies used to compare two or more treatments to help find new or improved treatments

Comfy

A soft, light pad that is often worn after a mastectomy, while the scar is still healing, to restore body shape and give confidence before it is possible to wear a silicone prosthesis to replace the breast

Cosmetic augmentation

An operation to use breast implants to increase breast volume and enhance the bust

CRP (C reactive protein)

A marker of infection or inflammation

CV flap

A type of nipple reconstruction

Deep inferior epigastric perforator

Small branches of deep inferior epigastric vessels that carry blood right into a DIEP flap

See Perforators

Deep inferior epigastric vessels

Branches of the main blood vessels in the groin area that nourish a DIEP flap

Dermal sling

A sheet of tissue made from the deep layer of human or animal skin that helps to support and improve the appearance of the lower pole of a breast implant

Dermis

The deepest layer of the skin

DIEP flap (deep inferior epigastric artery perforator flap)

A type of breast reconstruction using tissue from your abdomen

  • Free DIEP flap

A free DIEP flap is able to preserve the transverse rectus abdominus muscle altogether, by using a different blood supply (the deep inferior epigastric artery) which can be dissected away from the muscle without damaging it. It is then transferred to the mastectomy area

See Skin flap

Donor site

The space left behind once the muscle has been moved

Drainage tubes

Small tubes placed in an operation site that help to drain any fluid away and keep the area dry to promote healing

Ductal carcinoma in situ (DCIS)

A pre-cancerous change in breast cells

Delayed breast reconstruction

Surgically rebuilding a breast months or years after a mastectomy

See Breast reconstruction

DNA

Deoxyribonucleic acid (your genetic ‘fingerprint’)

ER positive

Oestrogen receptor positive

Exchange of implant

An operation to remove a breast implant already in place and replace it with something similar that may give you a better shape

Fat necrosis

The death of fatty tissue due to trauma or lack of blood supply

Free flap/free tissue transfer/microvascular flap

Tissue that is moved to another site in the body having been disconnected from its original blood supply. It is then reconnected to a blood supply in its new location

See Skin flap

Free DIEP flap

A free DIEP is able to preserve the transverse rectus abdominus muscle altogether, by using a different blood supply (the deep inferior epigastric artery) which can be dissected away from the muscle without damaging it. It is then transferred to the mastectomy area

See DIEP flap, Free tissue transfer, Free TRAM flap, Skin flap

Free TRAM flap

Any type of TRAM flap involves removal of some or all of the Transverse Rectus Abdominus Muscle, but unlike a pedicled TRAM flap, a free TRAM flap preserves nearly all of this muscle. After the main blood vessel (the superior epigastric artery) is divided, the flap is free to be joined up to one of the local blood vessels in the mastectomy area by microsurgery

See Skin flap, TRAM flap

Gabapentin

A tablet useful in epilepsy which is very effective in reducing the very particular and severe pain that comes from nerve damage

Genetic code

The part of your gene which contains your genetic fingerprint

Glandular tissue

Breast tissue

Graft take

The ability of the skin graft to pick up its new blood supply and thrive

Haematoma

A collection of blood building up around your operation site

Hernia

A lump that is caused when parts of the body (such as small bits of the bowel) escape through a weakness in the tummy wall

High Dependency Unit

A hospital ward where patients are looked after when they need intensive monitoring or nursing care

Hormone therapy

Using medicines known to block or stop the production of hormones which may be encouraging the cancer to grow

Human genetic fingerprint

The pattern of molecules in the DNA which makes up your genes which is unique to every human

Hypertrophic scars

Raised, thickened and red scars

iBRA

implant Breast Reconstruction evAluation: a national UK study that is measuring the outcomes of implant-based breast reconstruction

IGAP flap (inferior gluteal artery perforator flap)

Breast reconstruction using free flaps of skin and fat from the buttocks

See Skin flap

Immediate breast reconstruction

Rebuilding your breast at the same time as the mastectomy

See Breast reconstruction

Implant

  • Permanent silicone implants

These implants are designed for long-term implantation

  • Temporary expanders

These are used to create the final breast shape before exchanged for a permanent implant

Inframammary fold

The crease at the bottom of your breast where it joins the chest wall

Injection valve/port

Part of a tissue expander which is used to inject saline into the expander

See Port

Keloid scars

Scars which continue to thicken and do not settle down

Lactiferous ducts

Ducts which pass through the glandular breast tissue and the nipple. They transport milk as well as providing projection for the nipple

LAP flap (lumbar artery perforator flap)

A flap that is harvested from the ‘love handle’ area of your hips

See Skin flap

Lateral Intercostal Artery Perforator (LICAP)

Small arteries nourishing the skin and fatty tissues extending from behind the outer border of your breast towards the spine

See Perforators

Lateral Thoracic Artery Perforator (LTAP)

Small arteries nourishing the skin and fatty tissues extending from behind the outer border of your breast towards the spine, but coming from a blood supply that’s different to the one feeding the LICAP flaps

See Perforators

Latissimus dorsi (LD) reconstruction

A way of rebuilding your breast using your latissimus dorsi muscle. This is sometimes combined with using an implant or tissue expander

Lipofilling

A type of fat transfer

Lower pole of the breast

The part of the breast below the nipple

LTP flap (lateral thigh perforator flap)

A flap that’s harvested from the saddlebag area of your thighs

See Skin flap

Lumpectomy

Removal of a cancerous lump from your breast

Lymphoedema

Swelling of your tissues when fluid from the lymphatic system gets trapped and cannot escape

Magnetic resonance imaging (MRI)

Using the magnetic properties of your tissues to build up detailed pictures of your anatomy

Mammogram

An x-ray of your breast used to detect and classify abnormalities

Mammoplasty

  • Augmentation mammoplasty

Cosmetic procedure to increase your breast size using a breast implant

  • Reduction mammoplasty

A breast reduction combined with a breast lift

Mastectomy

An operation to remove a breast

  • Bilateral mastectomy

An operation to remove both breasts

  • Partial mastectomy

An operation to remove a large amount of breast tissue

  • Risk-reducing mastectomy

An operation to remove a healthy breast when it proven that there is a high risk of disease occurring in the future

  • Skin-sparing mastectomy

An operation to remove only breast tissue, preserving the whole skin envelope to provide cover for the new breast

Mastopexy

An operation to lift the breast

Maturation

The healing process of a scar over several months until it is blended into the surrounding tissue

Medial circumflex femoral artery

Main blood supply to a TUG flap

Mesh/meshes

Sheets of woven or perforated human, animal or synthetic material

Micropigmentation

A technique using a number of tiny needles to punch small amounts of pigment into the superficial layers of the skin, changing the skin’s colour

Montgomery’s tubercles

Glands that secrete a waxy fluid to moisturise and protect the nipple and areola

Mutation

A change or alteration of your genes

Myocutaneous muscle flap

Tissue made up of muscle, fatty tissue and skin that can be moved from one part of your body to another to reconstruct a breast

See Skin flap

Necrosis

A condition when living tissue such as skin dies and healing is prevented because of a poor blood supply

Neuro-vascular pedicle

The blood vessels and nerves which keep the flap alive

Nipple-areola complex (NAC)

Both your nipple and the surrounding area of pigmented skin (areola)

Nipple reconstruction

  • Arrow flap

A type of nipple reconstruction

  • CV flap

A type of nipple reconstruction

  • Skate flap

A type of nipple reconstruction

Oncologist

A doctor specialising in medical treatments for cancer

Oncoplastic

A type of operation that combines removal of a cancer with a plastic technique, avoiding major deformity and a poor cosmetic result

Oncoplastic surgeon

A surgeon trained in both cancer surgery and breast reconstruction

Partial mastectomy

An operation to remove a large amount of breast tissue

See Mastectomy

Pathologist

A doctor trained to analyse diseased tissue and body samples

Patient-controlled analgesia

A machine used to give pain-killing medicines after an operation that a patient can control themselves

Pectoralis major muscle

A large triangular muscle lying over the front of your rib cage

Pedicled TRAM flap

Moving lower abdominal tissue into the breast area still attached to its original blood supply

See TRAM flap

Perforators

Small branches of blood vessels

  • Anterior Intercostal Artery Perforator (AICAP)

Small arteries nourishing the skin and fatty tissues over the ribs just below your breast

  • Deep inferior epigastric perforator

Small branches of deep inferior epigastric vessels that carry blood right into a DIEP flap

  • Lateral Intercostal Artery Perforator (LICAP)

Small arteries nourishing the skin and fatty tissues extending from behind the outer border of your breast towards the spine

  • Lateral Thoracic Artery Perforator (LTAP)

Small arteries nourishing the skin and fatty tissues extending from behind the outer border of your breast towards the spine, but coming from a blood supply that’s different to the one feeding the LICAP flaps

  • Thoracodorsal Artery Perforator (TDAP)

Small arteries nourishing the skin and fatty tissues extending from behind the outer border of your breast towards the spine, but coming from a blood supply that’s different to the ones feeding LICAP and LTAP flaps

PET scan (Positron Emission Tomography scan)

A scan that uses a radioactive material to find diseases before they show up on other scans

Physiotherapy

Exercises and advice given to help regain normal movement in all areas affected by an operation, medical treatment or disease

Polymerisation

A chemical process that joins smaller molecules together to make bigger ones

Port(s)

Small chambers placed under the skin that allow your team to inject fluid into your breast expander, or your veins if you’re having chemotherapy

  • Injection valve/port

Part of a tissue expander which is used to inject saline into the expander

Prepectoral

The position of an implant that lies between your skin and the underlying pectoral muscles

Prosthesis

A synthetic breast-form designed to fit into a bra to replace either your whole breast or part of it

Ptosis

Natural drooping of the breast

Quandrantectomy

Removal of one whole quadrant of the breast

Radiotherapy

High-energy x-ray treatment used to damage cancer cells and stop them dividing

Rectus abdominus muscle

A muscle in your abdominal wall

Reduction mammoplasty

A breast reduction combined with a breast lift

See Mammoplasty

Risk-reducing mastectomy

An operation to remove a healthy breast when it proven that there is a high risk of disease occurring in the future

See Mastectomy

Rough surface texturing

A process to make the surface of a breast implant rough rather than smooth to cut down the scar tissue reaction around the implant

Rubens flap

Breast reconstruction using a free flap from the fat deposits over your hips, the ‘love handles’

See Skin flap

Saline

A sterile salt solution, with the same salt content as body fluids

Sentinel Node Biopsy

Removal of the first lymph nodes which drain your breast from under your armpit. Blue dye and radioactive liquid is injected next to the nipple and used to guide the surgeon to the relevant nodes

Septicaemia

Blood poisoning

Seroma

A collection of fluid that accumulates in the spaces left behind after surgery

SGAP flap (superior gluteal artery perforator flap)

Breast reconstruction using free flaps of skin and fat from your buttocks

See Skin flap

Silicones

  • Industrial grade silicone

Silicone with many non-medical industrial and household uses, including the coating of cooking utensils, sealants, insulation, etc.

  • Medical grade silicone

High grade silicone used in the manufacture of implantable medical devices, such as breast implants and heart valves

  • Silicone elastomer

Silicone rubber

Silicone gel bleeding

The leakage of silicone gel through an intact outer shell

Skate flap

A type of nipple reconstruction

See Nipple reconstruction

Skin and tissue expansion

Gradually stretching the skin and surrounding tissues with an adjustable implant to enlarge the area

Skin flap

A flap of tissue made up of skin, fat and blood vessels that can be moved to a nearby part of the body

  • DIEP flap (deep inferior epigastric artery perforator flap)

A type of breast reconstruction using tissue from your abdomen

See DIEP flap

  • Free flap/free tissue transfer/microvascular flap

Tissue that is moved to another site in the body having been disconnected from its original blood supply. It is then reconnected to a blood supply in its new location

  • IGAP flap (inferior gluteal artery perforator flap)

Breast reconstruction using free flaps of skin and fat from the buttocks

  • LAP flap (lumbar artery perforator flap)

A flap that is harvested from the ‘love handle’ area of your hips

  • LTP flap (lateral thigh perforator flap)

A flap that’s harvested from the saddlebag area of your thighs

  • Myocutaneous muscle flap

Tissue made up of muscle, fatty tissue and skin that can be moved from one part of your body to another to reconstruct a breast

  • Rubens flap

Breast reconstruction using a free flap from the fat deposits over your hips, the ‘love handles’

  • SGAP flap (superior gluteal artery perforator flap)

Breast reconstruction using free flaps of skin and fat from your buttocks

  • Thoraco-epigastric flap

A flap of skin and subcutaneous tissue taken from an area below your breast that extends onto the upper part of your tummy

  • TUG flap (transverse upper gracilis flap)

Breast reconstruction using free muscle flaps from the inner aspects of your thighs

  • TRAM flap

Method of breast reconstruction using tissue and muscle from the abdomen

See TRAM flap

Skin island

The skin that is attached to a flap when it is moved from the back or stomach to reconstruct the breast

Skin-sparing mastectomy

An operation to remove only breast tissue, preserving the whole skin envelope to provide cover for the new breast

See Mastectomy

Softie

A soft first prosthesis worn after mastectomy – see ‘comfy’

Subglandular

Under the breast tissue

Submuscular

Under a muscle

Subpectoral

Under the pectoralis muscle

Superficial epigastric vessels

Blood vessels supplying the wall of the lower abdomen

Superior epigastric vessels

Blood vessels coming out of the chest and nourishing the muscles in your abdominal wall

Superficial inferior epigastric vessels

Small branches of the main blood vessels in the groin area that provide an additional source of nourishment to a DIEP flap

Suture

Stitch

  • Subcuticular sutures

Stitches placed just underneath the outer layer of your skin that don’t need to be removed

Tamoxifen

A drug that has been used for over 40 years to prevent oestrogens in your body stimulating the growth and spread of breast cancer cells. Tamoxifen is only used if your cancer has been shown to be sensitive to oestrogens, which amounts to around 80% of women

Tattoo

The use of pigments to colour the skin and enhance the nipple reconstruction

Temporary expander

An implant used to stretch the tissues that can be replaced with a breast implant if necessary

See Implant

Thoracodorsal Artery Perforator (TDAP)

Small arteries nourishing the skin and fatty tissues extending from behind the outer border of your breast towards the spine, but coming from a blood supply that’s different to the ones feeding LICAP and LTAP flaps

See Perforator

Thoraco-epigastric flap

A flap of skin and subcutaneous tissue taken from an area below your breast that extends onto the upper part of your tummy

See Skin flap

Thrombosis

Blood clot

Tissue expander

An expandable bag that can be placed under the skin and gradually increased in size to make the surrounding tissues stretch

TRAM flap (transverse rectus abdominus myocutaneous flap)

Method of breast reconstruction using tissue and muscle from the abdomen

  • Bipedicled TRAM flap

Breast reconstruction using both of your rectus abdominus muscles and tissue in the abdomen

  • Free TRAM flap

Any type of TRAM flap involves removal of some or all of the Transverse Rectus Abdominus Muscle, but unlike a pedicled TRAM flap, a free TRAM flap preserves nearly all of this muscle. After the main blood vessel (the superior epigastric artery) is divided, the flap is free to be joined up to one of the local blood vessels in the mastectomy area by microsurgery

  • Pedicled TRAM flap

Moving lower abdominal tissue into the breast area still attached to its original blood supply

  • Unipedicled TRAM flap

Breast reconstruction using one of your two rectus abdominus muscles and tissue from your abdominal wall

See Skin flap

TUG flap (transverse upper gracilis flap)

Breast reconstruction using free muscle flaps from the inner aspects of your thighs

See Skin flap

Unipedicled TRAM flap

Breast reconstruction using one of your two rectus abdominus muscles and tissue from your abdominal wall

See TRAM flap

Urinary catheter

A small tube placed into your bladder to drain urine

Venous congestion

When the veins draining a flap get blocked, trapping the blood in the flap, causing the flap to become swollen and congested with purplish blood. Eventually pressure builds up, and new (oxygen-carrying) blood cannot get into the flap. Unless the blockage is cleared fairly quickly, the flap will be in danger of dying off

Volume displacement

Replacing tissue that has been removed with tissue borrowed from another part of the same breast

Volume replacement

Replacing tissue that has been removed with tissue borrowed from another part of your body

Index

Numbers in italics denote illustrations.

  • gap filling in the breast 111–112
  • genetic susceptibility to breast cancer 165–167
  • golf, playing 65, 195
  • ‘gracilis’ muscle 106
  • Graves’ disease 208
  • jackets 11
  • ‘jumping’ of muscle in breast 117
  • keloid scars 155
  • obesity/overweight 65, 80, 142
  • oncoplastic breast surgeons 139
  • oncoplastic surgeons 110
  • ovarian cancer 166, 170
  • over-expansion 38
  • questions, asking 3, 23, 63
  • umbilical cord 88
  • unaffected breast 7
  • upper pole fullness 53, 53