Delayed Breast Reconstruction

What is Breast Reconstruction?

Breast reconstruction is a surgery performed to restore the normal shape, size, symmetry, and appearance of one or both breasts after Mastectomy.  

What are the benefits of Breast Reconstruction? 

• Reduces the Psychological impact of Mastectomy
• Helps patients with their body-image, self-esteem, and confidence
• Improves quality of life
• Eliminate the need for the external prosthesis

What is Delayed Breast Reconstruction?

Breast reconstruction can be performed at different times, depending upon what works best for your case. Delayed breast reconstruction is a surgery that is performed many weeks, months, or years after a mastectomy. The decision to perform a reconstruction surgery immediately or at a later time may depend upon several factors, such as:

• Your medical condition
• Your breast cancer stage
• Your lifestyle and preference
• Additional treatment measures, such as chemotherapy or radiation required to treat breast cancer

Although immediate breast reconstruction is the preferred method of reconstruction, it might not be possible or available at the time of Mastectomy. Some surgeons recommend patients to hold off on reconstructive surgery until after chemotherapy and radiation therapy are completed prior to having breast reconstruction as these therapies can cause the reconstructed breast to change in appearance, texture, colour, and to lose volume. Specifically, radiation therapy has been known to cause unpleasant changes to implant reconstruction. Cancers that are greater than 5 centimetres in size and that have advanced to the lymph nodes are more likely to require radiation therapy post-surgery.

Advantages and Disadvantages of Delayed Breast Reconstruction

Some of the merits and demerits of delayed breast reconstruction include:

Advantages

• Additional cancer therapy such as radiation therapy post-mastectomy does not trigger any issues at the site of reconstruction
• Provides ample time for patients to consider various options of breast reconstruction

Disadvantages

• Less ideal cosmetic results
• Mastectomy scar on the chest wall
• More challenging to reconstruct after scar formation
• Need for supplementary surgery and recovery time

Methods of Breast Reconstruction

The two main methods of breast reconstruction include:

• Implant Reconstruction: Inserting an implant which is filled with silicone gel or under the skin and muscle of the chest to create a new breast mound is the most commonly performed technique.
• Flap or Autologous Reconstruction: The patient’s own skin tissue taken from another section of the body, such as the stomach, thigh, or buttocks is used to create a new breast mound.

As an experienced Oncoplastic Surgeon Dr Meybodi performs prosthetic delayed breast reconstruction. He works closely with a team of skilled plastic surgeons who perform tissue-based breast reconstruction

Can patients with mastectomy and radiotherapy still undergo implant-based breast reconstruction? 

Radiation exposure can induce stiffness and atrophy of the skin subcutaneous tissue and chest muscle. This can make prosthetic reconstruction challenging and less successful. In the past radiation exposure was considered a contraindication for implant-based breast reconstruction. Nowadays, although Autologous reconstruction is regarded as an ideal method when it's not possible or the patient is not suitable or does not want, then the combination of fat grafting with prosthesis reconstruction can be considered.

Fat grafting can reverse the side effects of radiotherapy by creating more even chest contour and enhancing the thickness and padding of the skin. After one to three sessions of fat grafting, prosthetic-based breast reconstruction will be performed.

Preparation for Delayed Breast Reconstruction

In general, preparation for delayed breast reconstruction may involve the following:

On the day of consultation:

• A thorough history taking and examination by Dr Meybodi is performed to check for any physical, medical and social circumstance. Address issues that need to be addressed prior to the procedure.
• Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and more imaging to help detect any abnormalities that could threaten the safety of the procedure.
• You will be asked if you have allergies to medications, anaesthesia, or latex.
• Inform us of any medications, vitamins, or supplements that you are taking.
• You will review before and after surgery pictures of patients who had delayed breast reconstruction.
• You will have a 3D photo to measure your other breast volume and shape to match with the reconstructed breast.
• In some scenarios, the other breast also might need some procedures like a reduction or lift to achieve better symmetry. That will be discussed in the initial consultation.
•  A written consent will be obtained from you after the procedure has been explained in detail, and you made your mind to proceed.

Preparation for the surgery:

• Refrain from smoking pre- and post-procedure for a specific period of time, as this may hamper proper healing and increase your chances of areolar or nipple damage, tissue necrosis, and other complications.
• Maintain a moderated level of physical activity to enhance your physical and mental fitness in preparation for your surgery.
• You can find out more about how you prepare yourself and your home environment before surgery here. 

On the day of surgery:

• You may be instructed to shower with an antibacterial soap in the morning of your surgery.
• You should not consume any solids and liquids 8 and 4 hours prior to surgery.
• Please bring all your images to the operating theatre.

Procedure Involved in Delayed Breast Reconstruction with prosthesis

Delayed breast reconstruction is usually performed under general anaesthesia either in an outpatient or hospital setting. The surgery may take a couple of hours or more based on the size and composition of the breasts.
In general, Dr Meybodi will undertake the following steps:

• Use a marker to draw guidelines on the chest wall to carry out the incisions.
• Make an incision accordingly around the previous surgery scar lines.
• Develop a pocket above or under the chest wall muscle to insert the breast prosthesis.
• The Tissue expander is carefully inserted within the pocket to form a new breast mound.
• The prosthesis is then supported with a mesh, which acts as an internal bra to hold the device in place.
• A drainage tube may be placed under each arm to drain excess fluid or blood.
• Close the incisions with sutures and wrap the breasts with a waterproof dressing.

Post-Procedure Care and Recovery

Most people can go home in one or two days after surgery if no complications are noted. In general, postoperative care instructions and recovery involve the following:

• You may notice sensitivity, tenderness, swelling, and bruises over the reconstructed breast. Pain and anti-inflammatory medications are provided as needed.
• The drains are usually removed in about a week or two from the surgery. You will be instructed how to look after your drain. You can watch this video from MyHealth.Alberta.ca as a guide.
• You will be able to have a shower from the first day after surgery. A waterproof dressing will protect your surgical scar.
• You may experience constipation post-surgery try to add fibre to your diet and drink enough water. You can use simple laxatives to help your bowel motion. 
• Refrain from using anything too cold or too hot on your reconstructed breast skin as your breasts will lack normal sensation.
• You will be able to resume normal activities within a couple of weeks, but may have certain activity restrictions. You can find out about exercises after breast reconstruction surgery here.
• A periodic follow-up will be scheduled to monitor your overall progress.
• In follow up appointments’ Dr Farid will perform an ultrasound to check the health of your reconstructed breast. 
• When a tissue expander used for reconstruction, it needs expansion to stretch the overlying muscle and skin. In your post-operative appointment, more saline (saltwater)  will be injected to the device to achieve the appropriate size.
• In the next operation, the tissue expander will be removed and replaced with the permanent implant. This surgery will be performed as a day only or single night stay in the hospital and majority of time doesn't require drain insertion. As the breast pocket already matured the limitation after the surgery, is much less than the first operation.
• Some patients prefer to proceed with the nipple reconstruction which will be explained in another page.

Risks and Complications of Delayed Breast Reconstruction

Delayed breast reconstruction is a relatively safe procedure; however, as with any breast reconstruction surgery, some risks and complications may occur, such as:

· Bleeding
· Poor healing of surgical cuts
· Infection at the surgery site and around the prosthesis
· Anaesthetic risks
· Blood clots
· Necrosis or tissue death
· Uneven breasts
· Accumulation of fluids around the prosthesis
· Need for revision surgery

What happens if I develop infection around the tissue expander? 

With all the advances, implant reconstruction, including proper case selection, reduced operating time, meticulous tissue handling and enhanced recovery protocols, the chance of implant infection has decreased significantly. Unfortunately, the possibility of implant complication and in particular Infection, also known as periprosthetic Infection is not zero. Implant infection can be managed conservatively with antibiotic an ultrasound-guided aspiration of fluid collecting around the implant. With severe infections, the treatment is a bit more complicated. In the past treatment of severe Infection was implant removal, which can cause significant morbidity for the patient. Dr Farid, with the team in Westmead Breast Cancer Institute, has been in the frontline of developing a new technique for salvaging infected breast implants with a high success rate. You can find out more about this technique here.