Breast reconstruction and the role of the plastic surgeon

Breast cancer is now the most common cancer in the UK, with almost 55,200 new cases per year. That equates to almost 150 cases diagnosed per day. It accounts for 15% of all new cases in the UK and can occur in males also. The risk of male breast cancer is far lower, with approximately 390 cases per year, according to Cancer Research UK in 2014. Because of this, breast revision surgery is becoming more and more popular.

Following a diagnosis of breast cancer, if the resultant treatment involves a mastectomy then there are several options available for reconstruction. The recent NICE guidelines have incorporated breast reconstruction as an integral pathway in the treatment of breast cancer and it is here where plastic surgeons are involved.

Most breast surgeons who perform the mastectomy can perform certain aspects of the reconstruction such as using implants for example, but more complicated reconstructions often involve the plastic surgeon. Oncoplastic breast surgeons are general surgeons who have been trained in breast surgery and perform all the mastectomies and varying degrees of reconstruction dependent on their training and ability. Plastic surgeons do not perform the mastectomies but can perform all aspects of reconstruction.

What are the reconstructive modalities available?

Following the decision for a mastectomy – the reconstruction can in simple terms be carried out as immediate (at the time of mastectomy) or delayed (after a period of time following mastectomy) reconstructions. The reasons for a delayed reconstruction include patient choice; the need for radiotherapy; or other treatment modalities necessitating a delay. In these instances, commonly an expander implant is placed to maintain the skin integrity and elasticity such that it can be used at a later date for reconstruction.

Consultant marking areas for breast augmentation

For both delayed and immediate reconstructions, the breast reconstruction options are:

  1. Do nothing – some patients do not want any form of reconstruction
  2. Implant based reconstruction
  3. Implant reconstruction with Acellular Dermal Matrix
  4. Using your own tissue (latissimus dorsi flap) +/- implant
  5. Using your own tissue as a free tissue transfer (DIEP flap/ TRAM flap/ TUG flap/SGAP flaps for example)
  6. Following breast reconstruction, the nipple can be reconstructed –this can either be through 3D tattooing or more commonly using your own tissue to reconstruct the nipple, and subsequent tattooing to complete the reconstruction

The type of reconstruction will be discussed with you in detail and it will depend on your treatment options/ overall health and body type as to which form of reconstruction will be carried out.

What is free flap surgery?

Flaps are blocks of tissue that have been moved from one area, maintaining their blood supply and transfer the whole volume of tissue en-bloc to another region. In the case of the latissimus dorsi, this is the largest muscle in the body and is on your back. It is dissected as an ellipse of skin on the back and the whole muscle is freed. This is then dissected up to the armpit and then the whole block is passed through the arm pit into the chest area to be used as the new breast. The donor site on the back is closed as a horizontal straight line scar and usually based such that the scar would be hidden by the bra strap. The main disadvantage of this procedure is that you are sacrificing a muscle flap and can see some loss of function. Although, the body compensates very well and unless you are a professional athlete, will probably not notice much difference.

In contrast, a free flap is where the whole block is disconnected with its blood vessels and this whole block is then reattached in another area. This involves microsurgery with re-connection of the blood vessels under microscope. The gold standard in free flap reconstruction of the breast is the Deep Inferior Epigastric Artery Flap, otherwise known as the DIEP flap. This involves the tissue that of the lower belly – all the tissue that would normally be removed during a tummy tuck. The advantages of this procedure is that no implant is used; the feel of the breast is more natural as it the the transfer of skin and fat that mimics the breast tissue that has been removed; and that a tummy tuck is carried out in the same instance.

Surgeon holding silicone breast implants

The role of plastic surgeons and breast reconstruction

Plastic surgeons and breast surgeons will generally be discussing your cases together and determine the best course of treatment. This will then be discussed with you quite extensively prior to your procedure being carried out.

If free flap surgery is indicated, the plastic surgeons will arrange scans to assess the blood vessels in the belly to identify the feasibility of using this tissue in the micro-surgical reconstruction. During this surgery, following the mastectomy, the rib cage will then be dissected and the blood vessels here will be isolated. The belly tissue will then be carefully dissected and then removed and the DIEP vessels will be connected to the rib vessels (internal mammary vessels) under microscopic guidance using stitches finer than your hair to complete the connections of the vessels (anastomoses).

The abdomen will be closed with a resultant scar from hip joint to hip joint along the bikini line to remain hidden. This surgery can take anywhere from 6 – 10 hours and if enough belly tissue is available can be used to reconstruct both breasts if required.

The role of plastic surgeons is that they form an integral part of the decision making process in breast cancer patients.