With advances in breast cancer treatment, the prognosis for breast cancer has improved dramatically over the years. For example, the 5-year relative survival rate for localized breast cancer is now 99% and even when there is spread to nearby lymph nodes, the relative breast cancer survival rate is 86%1. The focus has thus shifted to restoring a high quality of life and enabling patients to resume the work and activities they previously enjoyed without hindrance.
Wide excision and radiotherapy is indicated in localized breast disease. Removal of the whole breast (mastectomy) is recommended in extensive disease or when breast preservation is not ideal. Loss of breast tissue in both instances can negatively impact one’s way of life (such as clothes-wearing/wearing swimsuit) and a patient’s confidence.
Breast reconstruction is thus an integral part of the treatment of breast cancer. It is a medical procedure in itself and not a cosmetic procedure — nor is it about vanity. It has been shown to improve the patients’ quality of life by restoring the sense of self and body image. It does not hinder the treatment of the cancer or hide any recurrences. In fact, breast reconstruction aims to help in the total recovery of the breast cancer patient through physical and mental rehabilitation.
1. Surveillance Research Program, National Cancer Institute. SEER*Explorer. Breast Cancer – SEER 5-year relative survival rates, 2013-2019, by stage at diagnosis, female, all races/ethnicities, all ages. https://seer.cancer.gov/explorer/
The overall goals of breast reconstruction are to create a breast mound and achieve a natural silhouette while avoiding the need for an external prosthesis. Breast reconstruction is often carried out immediately or as a delayed procedure. Immediate reconstruction in the same surgery as the mastectomy is usually preferable. This is because the aesthetic results are improved when the breast skin has not shrunken and stuck down to the chest wall and the breast boundaries are still present. However, if immediate reconstruction is not possible, delayed reconstruction can still be undertaken months to years later.
The methods can be divided into two broad categories: implants or using one’s own tissue. We perform all types of breast reconstruction and these options will be discussed during consultation before making an individualized decision together with the patient.
Areas such as the abdomen, thighs or back, usually accumulate excess skin and fat tissue. Even in slim patients, enough tissue can usually be obtained for one-stage reconstruction. Fat grafting can be performed later to add more volume in cases of residual volume or contour deficit.
Such autologous (own tissue) reconstruction has innate advantages such as a softness, natural appearance/feel and life-long result. The tissue that has been transferred cannot turn into breast cancer, as they are composed of fat cells, not breast cells. Yearly screening mammogram is thus not done on the reconstructed side and only self-monitoring and clinical monitoring performed.
The overall goals of breast reconstruction are to create a breast mound and achieve a natural silhouette while avoiding the need for an external prosthesis. Breast reconstruction is often carried out immediately or as a delayed procedure. Immediate reconstruction in the same surgery as the mastectomy is usually preferable. This is because the aesthetic results are improved when the breast skin has not shrunken and stuck down to the chest wall and the breast boundaries are still present. However, if immediate reconstruction is not possible, delayed reconstruction can still be undertaken months to years later.
A flap is a piece of skin and fat supplied by a blood vessel. The Deep Inferior Epigastric Perforator flap (DIEP flap) is a common method of breast reconstruction as many women have excess skin and fat at the lower tummy area. This is the same skin and fat that is removed during a tummy tuck procedure and instead of throwing it away, it is borrowed to reconstruct the breast. The final scar can be easily hidden within underwear and the abdominal contour is improved, with results resembling a tummy tuck.
The blood vessels supplying the skin and fat are preserved by separating them out from the abdominal wall muscles they pass through. The piece of skin and fat is then brought up to the chest and the blood vessels reattached under a microscope to small supplying vessels at the breast. This is termed microsurgery.
Unlike conventional pedicled or free TRAM (Transverse Rectus Abdominis Muscle) flap where the rectus abdominis muscle is also removed, DIEP flap aims to preserve the integrity of the abdominal wall muscles as far as possible. This greatly reduces post-operative abdominal muscle weakness as well as the risk of abdominal hernia or bulge. This fat and skin is then surgically transformed into a new breast mound.
In a select group of patients (<10%), the abdominal tissue is supplied by a large Superficial Inferior Epigastric Artery (SIEA) which lies under the skin. There is no need to enter the abdominal wall muscles. The procedure is otherwise the same as the DIEP flap, resulting in a low abdominal incision much like a tummy tuck.
In contrast to the DIEP and SIEA flaps, in some situations, a portion of the rectus muscle must be taken with the abdominal skin and fat. This is termed the Transverse Rectus Abdominis (TRAM) Flap. The decision to remove some muscle is based solely on the blood vessel anatomy of the patient. Preoperative imaging helps to evaluate if this will be required, but ultimately this is decided during the surgery itself. An small abdominal mesh is then placed to prevent postoperative bulge. This mesh is a netting made of suture material and integrates well into one's own body without any long term issues. The TRAM flap otherwise offers similar results in the breast. In our practice it is rare that we use TRAM flap as we almost always can use a DIEP or SIEA flap.
The nerves to the breast skin are interrupted during mastectomy, resulting in varying degrees of numbness over the breast. With ingrowth of surrounding nerves, partial recovery of sensation can happen over 6 months to 2 years. If suitable sensory nerves can be found at the abdominal flap, these can be joined to those at the chest, to potentially improve sensory recovery of the breast.
The recovery is similar to after a tummy-tuck procedure. Due to advanced pain management techniques including continuous pain pump/nerve blocks and patient-controlled analgesia, almost all patients can experience a comfortable recovery. The incisions typically heal by 2 weeks and the patient walks slightly flexed at the waist until then to ease tension on the abdominal closure. Drains are placed at the breast and abdomen to aid with drainage of fluid and internal healing and removed in 5 to 9 days. These can be easily managed outpatient if the patient is keen for home. Patients wear an abdominal binder for the first 2-3 months, similar to what is worn after childbirth.
We have extensive experience with the DIEP Flap and have performed hundreds of these procedures with very high success rates. Our approach is focused on achieving flap success, producing superior aesthetic results, limiting abdominal morbidity, and increasing operative efficiency leading to quicker recovery.
As in all procedures, there can be complications associated with microsurgical breast reconstruction. The potential adverse outcomes are total flap failure or partial flap failure. Monitoring of the flap circulation is carried out postoperatively and if there are signs of blockage of the artery or vein into the flap tissue, flap re-exploration is carried out to attempt to salvage (save) the flap by re-joining the blood vessels. The rate of flap re-exploration is 5%. This only happens within the first week (usually first 3 days) when the vessel flow can be affected by factors such as kinking or pressure. Thereafter, the new “breast” becomes just another part of your body and will not die.
Total flap failure, the most feared complication, typically occurs due to an irreversible venous or arterial thrombosis of the vessels supplying the flap. With improved operative technique, in experienced hands this risk is extremely low (<1% in our personal series). In these rare instances, other reconstructive options (whether implant-based or autologous) are still available.
Partial flap insufficiency (<5%) can result in fat necrosis which manifests as localized flap hardening. This improves over 1 -2 years with massage, even if it remains firm, removal is usually not required.
With the DIEP flap, there is no risk of abdominal hernia. A slight bulge can occur in 5% of patients due to abdominal laxity, this does not cause any functional impairment. A small mesh made of suture material can be placed during abdominal closure or as a secondary procedure.
Hematomas/seromas are rare (<1%). Wound healing issues/cellulitis (5%) at donor or breast site are treated with antibiotics and dressings. These usually occur in patients with neo-adjuvant chemo, poorly-controlled diabetes or obesity; other patients typically heal very well.
The skin and fat from the posterior inner thighs are often redundant and can be used for breast reconstruction. This is termed the Profunda Artery Perforator flap (PAP Flap), named after the blood vessels supplying the flap. The posterior thigh is an excellent donor site for breast reconstruction, for example in patients who have had previous abdominal surgery or who are very slim. There are also some young women that prefer this donor site given the desire for future pregnancy. To minimise asymmetry of the thigh donor site, harvest of both thighs is preferable, thus it is especially useful in bilateral breast reconstruction (when both breasts need to be removed). In some bigger breasted patients, we can perform a double stacked PAP flap using both thighs for one breast reconstruction.
There are many advantages of the PAP flap. The scar is typically inconspicuous and hidden in the buttock crease. The fat is this area is firmer and thus produces a more projected and youthful breast shape. As it is an autologous (own tissue) reconstruction, the result is natural and is meant to last a lifetime.
The PAP flap is a perforator flap, meaning blood vessels are dissected free from the surrounding thigh muscles. Depending on the individual patient’s vascular anatomy, sometimes a TUG flap is performed instead, wherein the gracilis muscle is also included in the flap. This does not result in any functional impact on the patient. Using microsurgical techniques, the PAP flap is transplanted to the breast and the thigh area is stitched closed.
Thigh incisions typically heal by two weeks; it is advisable to walk with smaller steps until then. A thigh drain helps remove fluid and aids internal healing. This is usually removed by 6-10 days and can be easily managed outpatient if the patient is keen to go home.
Although uncommon, these are similar to other methods of microsurgical breast reconstruction (See link to DIEP flap complications).
Using excess tissue from the mid back is a good option for many patients. The scar is hidden in the bra line and not visible to patients from the front. The skin and fat is supplied by blood vessels arising from the underlying latissimus dorsi (LD) muscle. This muscle is brought from behind to the breast pocket as a pedicled flap, keeping its blood supply intact. There is no need to join blood vessels and thus there is no risk of microsurgical failure.
In some patients, there is sufficient volume for breast reconstruction with the LD alone. In others, LD flap can be combined with an implant placed below the flap for further projection and volume. An increasingly common technique involves augmenting the LD flap with fat from elsewhere (LIFT technique). We harvest excess fat from the thighs using liposuction with mini- incisions, process the fat and inject it into the LD muscle flap, all at the primary surgery. This allows a predictable one-stage autologous breast reconstruction. The scar can be shorter than in a conventional LD flap as we do not need to rely on the skin paddle for volume. In a few patients, repeat fat grafting can be carried out to address residual volume or contour deficiency. Conversely, in select small-breasted patients, the latissimus dorsi flap can be harvested endoscopically and fat injected into it. Endoscopic harvest obviates the need for a horizontal back incision to elevate the LD muscle.
The LD muscle is one of the muscles that move the arm inwards and backwards. There are other muscles that perform a similar function so using the LD muscle for breast reconstruction does not impair day-to-day activities or exercise for most patients. However this technique is not recommended for patients who require alot of upper arm/shoulder strength in sports such as rock-climbing or competitive swimming. In addition patients who play tennis/racquet sports on the affected side may find their strength affected. In these patients, the TAP (thoracodorsal perforator flap) can be an option, whereby only the skin and back soft tissue is transferred, leaving the muscle behind.
Recovery after LD flap breast reconstruction is usually rapid as patients can walk well immediately after surgery. Incisions heal in 2 weeks. Patients should limit shoulder movement until drains come out, thereafter frequent mobilisation is emphasized. The most common complication (<5%) is a back seroma after the drains are removed, which may need needle aspiration in clinic.
Some patients may not be suitable for reconstruction with their own tissue due to health issues or lack of available donor tissue. Others may prefer implant-based reconstruction as surgery time is shorter without need for an additional donor site. In contrast to own tissue (autologous) reconstruction which is meant to last a lifetime, implants do not last forever and may need removal or replacement years later. This may be due to reasons such as silicone leakage or capsular contracture.
Implant reconstruction was typically carried out in two stages in the past, with an expander (hollow implant) first inserted, then serially inflated over a few months before change to final implant. Now one-stage reconstruction at the time of mastectomy can be carried out with the addition of acellular dermal matrix (ADM) as an additional layer over the implant. Fat grafting can also be added at the same time to help improve the result. More often, the fat is added in a second-stage surgery.
Drainage tubings are placed in the breast and usually removed after 1 to 2 weeks. Although the chance is low, early risks include implant exposure or infection which necessitate removal. Autologous options or repeat insertion of expander are then considered for breast reconstruction.
Although implants are considered an “expedient” and “convenient” technique, it may be harder to match the natural shape or ptosis (droop) of the contralateral breast. It is easier to match symmetry in bilateral breast reconstruction with implants. Some patients also feedback that the implant feels colder within the body and “stiffer”, being less mobile than a normal breast.
Depending on the location and type of tumour, the breast surgeon will determine if the nipple and areola can be preserved (nipple-sparing mastectomy). If it needs to be removed, there are ways we can reconstruct a nipple. Small local flaps can be raised and folded into a 3-D shape. Alternatively a nipple graft can be harvested from the other side nipple, especially if it is relatively big. This is typically done as a day surgery procedure under local anaesthetic . Nipple-areolar tattooing can then be carried out 3 months later to restore the native colour.
Depending of the size and location of the wide-excision required, the defect may be obvious and further exacerbated after radiotherapy. Improving breast symmetry and appearance can be possible using methods such as breast reduction, breast lift, local tissue rearrangement or fat grafting. This can be performed at the time of the wide excision or as a delayed procedure.
Removal of the axillary (armpit) lymph nodes may sometimes be necessary to ensure surgical clearance. The risk of lymphedema is estimated to be 25% after axillary clearance. Lymph nodes drain lymphatic fluid (waste fluid) from the arm, thus their removal can result in accumulation of protein-rich fluid and cholesterol. Complex decongestive therapy including custom-made pressure garments are required life-long to keep the swelling under control. (Link to lymphedema section).
New research developments in recent years have explored strategies to reduce lymphedema at the time of axillary clearance. These include bypassing lymphatic flow into veins by microsurgical anastomosis (joining) when these are available. Alternatively placement of vascularized tissue including abdominal lymphatic tracks can reduce axillary scarring and provide a pathway for spontaneous regeneration.