Breast Reconstruction

Breast reconstruction is a physically and emotionally rewarding procedure for a woman who has lost their breast or breasts due to cancer or other conditions.

Breast reconstruction is achieved through several plastic surgery techniques that attempt to restore a breast to near normal shape, appearance and size following mastectomy.

The creation of a new breast can improve self-confidence and quality of life. Although surgery can recreate a relatively natural-looking breast, a reconstructed breast will never look or feel exactly the same as the breast that was removed.

Is a Breast Reconstruction right for you?

Breast reconstruction is a highly individualised procedure. You should do it for yourself, not to fulfil someone else’s desires or to try to fit any sort of ideal image. Breast reconstruction is a good option for you if:

You have the ability to cope (physically and mentally) with your diagnosis and treatment
You do not have additional medical conditions or other illnesses that may impair healing
You have a positive outlook and realistic goals for restoring your breast and body image
You are not a smoker
Your BMI is less than 32 and your weight is stable

Breast reconstruction typically involves several procedures performed in multiple stages. It can:

Begin at the same time as mastectomy (immediate reconstruction), or
Be delayed until you heal from mastectomy and recover from any additional cancer treatments such as chemotherapy or radiotherapy

Immediate breast reconstruction is most suitable for women:

With non-invasive cancer
Having prophylactic mastectomy
Not expecting postoperative adjuvant radiotherapy

Don’t forget, breast reconstruction may be offered to many patients, but it may not be suitable for everyone. At your consultation, your surgeon will discuss with you:

Whether breast reconstruction (immediate or delayed) is suitable for you;
Which type of breast reconstruction is suitable for you;
Risks associated with each option offered;
The recovery involved with each option;
Realistic results that can be expected from breast reconstruction;
Possible long-term consequences or long-term care commitment required for the reconstruction option offered.

Questions are welcome during the consultation, and the options, results and expectation are explored. It’s important that you feel ready for the emotional adjustment involved in breast reconstruction. It may take some time to accept the results of breast reconstruction. It is also important that you are prepared to undertake the recovery process involved with your procedure.

What is a breast reconstruction?

Breast reconstruction is achieved through several plastic surgery techniques that attempt to restore a breast to near normal shape, appearance and size following mastectomy. Although breast reconstruction can rebuild your breast, the results are highly variable:

A reconstructed breast will not have the same sensation and feel as the breast it replaces.
Visible incision lines will always be present on the breast, whether from reconstruction or mastectomy.
Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the back, abdomen or buttocks.

A note about symmetry: If only one breast is affected, it alone may be reconstructed. In addition, a breast lift, breast reduction or breast augmentation may be recommended for the opposite breast to improve symmetry of the size and position of both breasts.

Risks of Breast Reconstruction

The decision to have breast reconstruction surgery is extremely personal. You’ll have to decide if the benefits will achieve your goals and if the risks and potential complications are acceptable.

Your surgeon will explain in detail the risks associated with surgery. You will be asked to sign consent forms to ensure that you fully understand the procedures you will undergo and any risks or potential complications.

The possible risks of breast reconstruction include, but are not limited to, bleeding, infection, poor healing of incisions, unfavourable scarring and anaesthesia risks. You should also know that:

Flap surgery includes the risk of partial or complete loss of the flap and a loss of sensation at both the donor and reconstruction site.
The use of implants carries the risk of breast firmness (capsular contracture), implant rupture, implant mal-position and implant infection.
If you require postoperative adjuvant therapy such as chemotherapy and radiotherapy, unexpected complications from breast reconstruction may delay these treatments.
If you require postoperative radiotherapy, this treatment may damage your reconstruction, altering the shape, volume and appearance of the newly reconstructed breast. Results are often suboptimal and may require revision or repeat reconstruction after you have completed your treatment.

Breast implants do not impair breast health. Careful review of scientific research conducted by independent groups such as the Institute of Medicine has found no proven link between breast implants and autoimmune or other systemic diseases. However, there are rare cancers which are associated with breast implants. To find out more about breast implants, read All About Implants for more information.

Although breast reconstruction surgery can be an effective procedure where the benefits significantly outweigh the risks, like everything in the practice of medicine and surgery, it is not an exact science. The degree of surgical success can be altered by how each individual’s body responds to surgery and healing. Although good results are expected, there is no guarantee. In some situations, it may not be possible to achieve optimal results with a single surgical procedure; revision surgery may be necessary.

Be sure to ask questions: It’s very important to ask questions about your procedure. It’s natural to feel some anxiety, whether it’s excitement or preoperative stress. Don’t be shy about discussing these feelings and any specific concerns with your surgeon or any of our staff members.

Options for Breast Reconstruction

Surgery for your breast reconstruction is performed in a hospital setting, including hospital stay of 5-10 days. Your procedure will require general anaesthesia.

The TRAM/MSTRAM/DIEP Flap

This is where abdominal tissue is transplanted to the chest to recreate the breast mound. TRAM flap stands for Transverse Rectus Abdominus Musculocutaneous flap. A TRAM flap uses donor muscle, fat and skin from a woman’s abdomen to reconstruct the breast. The TRAM flap is based on the deep inferior epigastric artery (DIEA) and veins (DIEV). The MS TRAM is a muscle-sparing TRAM where not all of the rectus abdominus muscle is harvested. The DIEP (deep inferior epigastric perforator) flap is where the rectus muscle is not harvested as part of the flap and the flap only contains the abdominal skin and fat (more details below).

The flap may be transferred to your chest wall in two different ways:

It can remain attached to the original blood supply and then tunnelled up through the chest wall (also known as pedicle flap).
Or it can be completely detached with its artery and vein (DIEA and DIEV), transposed to the chest wall and these blood vessels then rejoined to blood vessels behind the ribs using microvascular technique. (This is also known as the free flap).

The abdominal tissue is then shaped and inset into the chest wall to create a breast mound.

A variation to the TRAM flap is the DIEP flap. DIEP stands for Deep Inferior Epigastric Perforators. This is where the abdominal tissue (just fat and skin) is taken without the rectus abdominus muscle based on branches of the DIEA and DIEV; whether this is a better alternative than TRAM remains debatable. There are various pros and cons, including different risk profiles of TRAM vs MS TRAM vs DIEP. DIEP flaps are also not suitable for everyone, its viability is heavily dependent on the anatomy of your blood supply and branching pattern of DIEA and DIEV to the abdominal wall - this can be variable between different individuals.

TRAM flap reconstruction can be done as an immediate reconstruction (at the same time as your mastectomy) or delayed reconstruction (after your mastectomy and other treatments such as chemotherapy or radiotherapy). It can also be used to reconstruction for one side (unilateral) or both sides concurrently (bilateral).

Free TRAM flap surgery can take up to 6 hours. Recovery includes hospitalisation for 5-10 days, no driving for up to 4 weeks, and no lifting or straining for 8 weeks. A garment will need to be worn for minimum of 12 weeks postoperatively for both abdominal and breast support. (To find out more about postoperative instructions for this procedure, check out our patient resources page).

Specific risks associated with TRAM flap reconstruction are:

Abdominal bulge or hernia
Bleeding and haematoma in both breast and abdominal donor site
Infection
Risks of a long general anaesthetic (it can take up to 6-8 hours for unilateral and 8-12 hours for bilateral)
Flap loss, partial or complete
Unplanned re-operation, and revision surgery
Seromas (collections of fluid under the flap or in the abdomen)
Fat necrosis
Breast asymmetry in shape and size

Most of the risks are very uncommon, and some people (with particular health problems or risk factors), may be at higher risk for specific complications. Your surgeon will discuss this with you during your consultation if any of these risks are specifically pertinent to you.

TRAM flap may not be suitable for you if:

You have had extensive or multiple surgeries on your abdomen
You have had previous open heart surgery
You are a smoker
You are diabetic
You have poor general health
You have history of Deep Vein Thrombosis, clotting or bleeding disorders
Your body mass index is >32
Your weight is not stable and fluctuates regularly (>8-10kg)
You do not have enough excess abdominal tissue to recreate a breast
Postoperative Radiotherapy is planned for you after your mastectomy

The main advantages of a TRAM flap include:

One-stage reconstruction to re-create the breast to its full volume
Utilises your own natural tissues
Permanent and long lasting reconstruction - does not require change or replacement compared to implants
Looks and feels natural
Moves and age with your body
Provides best symmetry with a natural breast on the other side

TRAM flap reconstruction is a very rewarding procedure for both the surgeon and the patient. It will provide you with a very natural looking breast and offers great symmetry for the remaining breast on the opposite side. Although the operating time and recovery period is longer than other forms of reconstruction, it is a one-stage reconstruction that gives you an instant permanent result with your own natural tissue.

Tissue Expander and Implant Reconstruction

Reconstruction with tissue expansion allows an easier recovery than flap procedures, but it is a lengthier reconstruction process because it is done in two stages. Firstly, a tissue expander (an empty silicone bag) is placed under your muscles in the initial operation. This can be done as an immediate reconstruction (at the same setting as the mastectomy) or as a delayed procedure (well after your mastectomy and postoperative therapies).

After the placement of the tissue expander and the wound has healed. You will be required to visit us 4-5 times to slowly expand the prosthesis. This is done in our office once a week or once a fortnight, where sterile saline is injected through an internal valve. The skin and muscle expand with this process, and eventually, a pocket is created under the skin and muscle for the permanent implant. The expansion process itself is usually painless, but some simple analgesia such as paracetamol may be required for minor discomfort for 24 hours.

A second surgical procedure will then be needed to replace the expander as it is not designed to serve as a permanent implant. This second procedure is often 8-12 weeks after the final expansion, to allow the scars around the expander to soften and the pocket to settle into its final position. The expanders once fully expanded may sit high on the chest wall, however, this is often corrected at the second operation, where an implant is used and dropped lower to the natural inframammary crease, to re-create the natural shape and position of a breast.

Sometimes, if your natural breast is B cup or less in size, an implant can be used to reconstruct the breast as a one-stage procedure. Expansion is often not required in this case as we can rely on natural tissue stretch to accommodate the small implant.

Tissue Expander/Implant reconstruction can produce good symmetry in clothes, as it provides good matching volume to the chest wall. However, it is always much ‘perkier’ than the natural breast, thus frequently a lift or reduction is required for the opposite breast to produce better symmetry. Surgery for the opposite breast is often done concurrently, at the same time as the second stage expander-implant exchange. An implant-reconstructed breast always feels firmer than natural breast.

Tissue expander/Implant reconstruction can be performed as an immediate or delayed reconstruction. It may also be done for one or both breasts. Bilateral reconstructions with expander/implant often give excellent symmetry and cosmetic result.

Surgical time for each stage is approximately 60 to 90 minutes, hospitalisation can range from 5-7 days for the first stage and is usually only 2-3 nights for the second stage. Recovery from the first stage is often longer, with two weeks of no driving and 4 weeks of no lifting or straining. Muscle ache and pains around the expander can also be prolonged for 6-8 weeks. The second surgery requires less recovery, unless significant revision of the implant pocket is required.

Specific risks associated with a tissue expander/implant reconstruction are:

Infection of the tissue expander or implant
Bleeding or haematoma
Recurrent Seroma (fluid collection under the skin and around the expander/implant)
Migration/malpositioning of the tissue expander or implant
Implant complications such as rupture or capsular contracture
Extrusion of the implant

Expander/Implant Reconstruction may not be suitable for everyone:

If you have had radiotherapy to your chest wall
If radiotherapy is planned for your chest wall after the mastectomy
If you are a smoker
If you want a natural look for your reconstructed breast
If you want the best possible symmetry to match your natural breast
If you do not want any implant or foreign material in your body

The advantages of an expander-implant reconstruction are:

Shorter operation
Shorter recovery period after surgery
No donor site scars or problems as surgery is limited to the breast and chest wall only.

CLICK HERE to read the patient pamphlet about Tissue Expanders.

Latissimus Dorsi Flap & Expander/Implant Reconstruction

Radiation therapy often leaves insufficient tissue on the chest wall to cover and support a breast expander or implant. In these cases, the prosthesis almost always requires coverage and protection from the latissimus dorsi muscle.

A latissimus dorsi flap uses muscle, fat and skin from the back tunneled to the mastectomy site to cover an expander or implant. The muscle remains attached to its donor site, leaving its blood supply intact.

Very occasionally, the flap itself may have enough volume to reconstruct a complete breast mound, but more often than not it is used to provide the muscle and tissue necessary to cover and support a breast implant. The donor site (back) is often closed with a straight-line scar, which can be orientated to suit your clothing preference. Latissimus dorsi flap reconstruction can be done as immediate or delayed reconstruction. It can also be done for unilateral or bilateral mastectomies.

Operating time ranges from 3-5 hours, and postoperative recovery include 5-7 days stay in hospital, limited arm movement above your head for 2 weeks, no driving for 3 weeks and no lifting or straining for 8 weeks. A garment is often required for at least 2-3 weeks, after which soft cup, non-underwire bras are adequate. To find out more about postoperative recovery, visit our Patient Resourcespage.

If reconstruction is with an expander under the latissimus dorsi muscle - 3 to 4 visits to the office after surgery is required for weekly or fortnightly expansions. Once fully expanded, second stage expander-implant exchange surgery will be required and is often done at least 2-3 months after the final expansion.

Specific risks associated with Latissimus dorsi reconstruction

Bleeding and haematoma
Seromas (both in the back where the muscle was harvested, as well as under flap around the expander/implant)
Expander/implant - associated complications (see above)
Asymmetry to the natural breast
Flap loss (partial or complete)

Loss of the latissimus dorsi muscle minimally affects the function of your arm, unless you are a swimmer or your occupation requires heavy manual activity above your head (e.g. painters, sailors, boat workers). It has been described, however, that some women find it difficult to do heavy chores above their head, such as hanging up the laundry or getting a jar off the top shelf. Some find any upper arm activity above the shoulders fatigue easily. Physiotherapy may be required postoperatively to increase the range of movement as well strengthening of surrounding muscles to help with daily limitations. Majority of women have noticed minimal difference in their daily functions and only minor adjustments are necessary for certain activities.

This technique of reconstruction can also be used as a salvage operation, where previous expander/implant-only reconstruction has failed or a TRAM flap has been lost due to unforeseen complications.

Advantages of a Latissimus Dorsi Reconstruction:

Gives implant reconstruction a more natural feel and look
Provides soft tissue cover in radiation damaged chest wall
Minimise risks of implant extrusion, infection and other complications
Does not rely on microsurgery (does not require special instruments/equipment and facilities which may not be available in some hospitals)

Surgery for the Contralateral (opposite) Breast

Sometimes surgery for the contralateral breast is required to achieve symmetry between the reconstructed breast and the remaining natural breast. This may be to correct the size difference or to correct breast shape and overall position.

Contralateral breast surgery may be:

Breast reduction
Breast lift
Breast augmentation

Often the cost of contralateral breast surgery is claimable with your private health insurance, except for breast augmentation. Breast augmentation in patients with a recurrent history of breast cancer is often not recommended, as implants under the breast tissue can affect future mammogram screening of the remaining breast, with up to 3-5% of cancers missed even with special mammography views and techniques.

Breast tissue removed from contralateral breast reduction is always sent to the pathology laboratory to check for the presence of breast cancer. Breast reduction or lift does not affect mammography screening.

Contralateral breast surgery is often done either at the second stage of expander-implant exchange or at a later setting to the reconstruction. It is not a necessity and the decision to proceed with any surgery on the opposite breast is very much as a personal choice.

Nipple Reconstruction

Breast reconstruction is completed with reconstruction of the nipple and areola. These can take three forms:

Stick on Nipples (these are available for purchase online or at specialty stores)
3D Nipple Tattoos where a tattoo can create the illusion of nipple projection and areolar texture
Surgical nipple reconstruction where a nubbin is made to give the projection and shape of the nipple. Once this has healed and the final shape has settled, the colour of the areola will be created via tattooing to match the natural side.

To read more about Nipple Reconstruction, please click here.

Postoperative Recovery

Following your surgery for flap techniques and/or the insertion of an implant, gauze and elastic foamy tape be applied to your breast, chest wall and donor sites. This will minimize swelling and support the reconstructed breast. A small, thin tube may be temporarily placed under the skin to drain any excess blood or fluid.

You may have a pain button linked to pain killers in the first few days of surgery, to ensure that you are comfortable. Postoperative physiotherapy is often commenced in hospital if required. You will be reviewed by your surgeon during your stay in hospital and specific care plan for your type of reconstruction will be discussed with you.

Results and outlook

The final results of breast reconstruction following mastectomy can help lessen the physical and emotional impact of mastectomy. Over time, some breast sensation may return, and scar lines will improve, although they’ll never disappear completely.

There are trade-offs in the reconstruction process, but most women feel these are small compared to the large improvement in their quality of life and the ability to look and feel whole. Careful monitoring of breast health through self-exam, mammography and other diagnostic techniques is essential to your long-term health.

Vocabulary to know:

Areola: Pigmented skin surrounding the nipple. Plural is Areolae.
Breast augmentation: Also known as augmentation mammaplasty; breast enlargement by surgery.
Breast lift: Also known as mastopexy; surgery to lift the breasts.
Breast reduction: Reduction of breast size and breast lift by surgery.
Capsular contracture: A complication of breast implant surgery which occurs when scar tissue that normally forms around the implant tightens and squeezes the implant and becomes firm.
DIEP flap: Deep Inferior Epigastric perforator flap which takes tissue from the abdomen without the rectus abdominus muscle.
Donor site: An area of your body where the surgeon harvests skin, muscle and fat to reconstruct your breast - commonly located in less exposed areas of the body such as the back or abdomen.
Flap techniques: Surgical techniques used to reposition your own skin, muscle and fat to reconstruct or cover your breast.
General anaesthesia: Drugs and/or gases used during an operation to relieve pain and alter consciousness.
Haematoma: Blood pooling beneath the skin.
Latissimus dorsi flap technique: A surgical technique that uses muscle, fat and skin tunnelled under the skin and tissue of a woman’s back to the reconstructed breast and remains attached to its donor site, leaving blood supply intact.
Mastectomy: The removal of the whole breast, typically to rid the body of cancer.
Tissue expansion: A surgical technique to stretch your own healthy tissue and create new skin to provide coverage for a breast implant.
TRAM flap: Also known as transverse rectus abdominus musculocutaneous flap, a surgical technique that uses muscle, fat and skin from your own abdomen to reconstruct the breast.
(Some Information & Illustrations are courtesy of the American Society of Plastic Surgeons)