Breast Reconstruction

There is not one reconstruction method that will be suitable for every patient. The best outcome will vary depending on your body habitus, your general health, the characteristics of the disease being treating, previous treatments you have had, future treatments you will have and your own preferences.

Dr Teh has experience in all the procedures listed below. 

Breast implants after mastectomy is very different from cosmetic breast augmentation. In the latter, the implant is placed under a thick layer of breast gland which serves to not only hide the implant but also shields the implant from the external environment. The surgery involved in a mastectomy is also far more extensive with much more disruption to the blood and nerve supply of the breast skin and consequently, how it heals. 

As a result of this, post mastectomy breast implant surgery is characterised by a much lower aesthetic satisfaction and increased complications compared to a primary cosmetic breast augmentation. Furthermore, in a unilateral implant only reconstruction, symmetry with the normal side is very difficult to achieve as the tissue behaviour and the feel of both breasts are widely dissimilar. A chest wall that has or will be irradiated is also a less than ideal environment for an implant based reconstruction. Autologous reconstructions are generally preferred in this setting

The most ideal candidate for an implant only reconstruction is someone who is relatively slim with not a lot breast droop(ptosis), and is in need of a bilateral prophylactic mastectomy where both skin and nipple can be spared. In instances where the breasts are quite droopy, Dr Teh may recommend for the breasts to be lifted first prior to the mastectomy. This allows for a ‘delay’ phenomenon which helps to reduce the risk of nipple and skin necrosis whilst achieving better aesthetic outcomes.

Implant only reconstructions is only really suitable when done in the immediate setting. In a delayed reconstruction, there isn’t enough skin available to create an aesthetic breast mound. Tissue expanders do not work well in this setting. Also widely marketed are the use of ‘internal bras’ (synthetic meshes used to drape and hold the implant) as well as ‘slings (acellular sheets of human or animal skin) to create anchorage and coverage of the breast implants. Although good as an anchor, they are foreign in nature and do not provide an adequate barrier to infection (unlike vascularised tissue like a lat dorsi flap). According to several studies, they may in fact increase the risk of swelling and infection. Dr Teh prefers to use these devices only in very selected patients.  

Unless you want to be reconstructed to a larger size than your native breasts, Dr Teh prefers to perform a one stage reconstruction by placing permanent silicone implants at the time of your mastectomy.  These are placed either above or below your pectoralis muscle depending on how much soft tissue cover is left after your mastectomy. Should you wish to be a larger size, then you may have to have a 2 stage procedure. A tissue expander is placed during the mastectomy operation, and the expander is then filled gradually over the course of a few weeks. A second operation is performed some months later, and the expander is exchanged for a silicone implant. 

In the past, textured teardrop implants were commonly used for breast reconstruction. Due to the emerging recognition of anaplastic large cell lymphoma and its relation to macro textured implants, Dr Teh prefers to use only smooth or nano/micro textured implants now. Increasingly there is a move away from implant based solutions in breast reconstruction towards tissue only techniques for this reason. 

What does the surgery involve?

The latissimus dorsi flap is a tissue flap that takes the lat dorsi muscle from the back together with the overlying skin to reconstruct the breast. The muscle is divided from most if not all of its attachment and swung round to the front of the chest leaving its dominant blood supply in the axilla intact. In most cases, there is insufficient volume generated by the flap and a breast implant will need to be used. The muscle is used as coverage over the implant to reduce the risk of post mastectomy implant problems. Dr Teh does a horizontal skin island to try and place the back scar along the bra strap. In instances where skin isn’t required, a ‘scarless’ lat dorsi flap can be performed harvesting the muscle through the mastectomy scar. 

The reconstruction can be done in the same operation as the mastectomy or as a delayed procedure. The operation takes about 4 hours for a unilateral reconstruction and 6 hours for a bilateral.The downsides of this procedure is that you will have to sacrifice one of the largest muscles in the body. Shoulder pain and stiffness is not an uncommon side effect. In the longer term, you may have partial loss of strength or function that makes it hard to lift things and twist. This can affect your ability to perform certain swimming, golf, or tennis strokes, or turn and manipulate objects. So it’s generally not a great choice for bilateral reconstructions. Secondly a breast implant is usually required. Furthermore the fat layer around the latissimus muscle is much thinner than fat that comes from the belly area, so some women say that their latissimus dorsi reconstructed breast feels “tighter” and harder than their other breast. Dr Teh prefers to keep this technique as a fallback option should other techniques not be available or have already been attempted.


How is the recovery?

When you are back from surgery, you will have 2 drains in your back and 1 in your chest. There will be a urinary catheter in your bladder. The nurses will help you to get up 1 or 2 days after surgery. You will generally stay in hospital for about a week. It can take about 4 weeks to recover from latissimus dorsi reconstruction surgery. Because you’ve had surgery at two sites on your body (your chest and your back), you might feel worse than someone who had mastectomy alone and it will probably take you longer to recover. You’ll have to take care of two incisions: on your breast and your back. You may need to arrange for help to take care of the incision on your back. You also may be healing from axillary node dissection (an incision under your arm where lymph nodes were removed) if your breast oncologic surgeon recommended it. Physiotherapy is often required to help mobilise the shoulder and to prevent lymphoedema. You usually have to avoid lifting anything heavy, strenuous sports, and sexual activity for about 4 weeks after latissimus dorsi flap reconstruction. 

 

DIEP stands for the blood vessel (Deep Inferior Epigastric Artery Perforator flap) that supplies the tissue from the abdomen that is used to reconstructed the breast. It is widely considered to be the current gold standard for breast reconstruction as it provides in most cases, adequate volume for the reconstruction and the donor site scar is relatively well hidden. There is also the added advantage of a tummy tuck.

 

What are the Indications?

Following mastectomy (for breast cancer or prophylaxis against breast cancer), congenital absence or severe deficiency of breast tissue (Polands syndrome).

Provided sufficient abdominal skin and fat is present, one or two breasts can be reconstructed from the abdomen. Ideal candidates usually have a body mass index of 25-35 and have had previous pregnancies (ie abdominal skin has been stretched).

Are there any Contraindications?

Morbid obesity (BMI>40), moderate to severe organ disease (ie chronic obstructive lung disease, renal failure, liver failure or ischaemic heart disease) and previous abdominoplasty. It is usually possible to perform the procedure despite previous laparotomies, appendectomies and cesarian sections.

Relative contraindications include advanced age (>75), unstable metastatic disease , severe coagulation disorders, current smoker

How is the surgery performed?

Technical details of the surgery can be found here. Dr Teh worked with the pioneers of the DIEP procedure during his fellowship in Europe. He undertook his first DIEP flap in his first year of consultancy in 2007, and was one of the first surgeons in WA to undertake this procedure. He performed the first bilateral DIEP reconstruction in Western Australia in 2009. Since then he has done several hundred flap reconstructions of the breast and is one of the most experienced surgeons of this procedure in WA.

 

Are there any Alternatives?

If you prefer to use your own tissues, other areas of the body may be suitable as a donor site including the inner and posterior thighs (PAP flap) and upper buttock (SGAP flap) when the abdomen is not suitable.
Implant only reconstructions is a viable alternative as long as the chest wall has not had previous irradiation. This can be combined with a flap such as the latissimus dorsi muscle flap from the back to provide additional soft tissue to cover over and protect the implant where radiation has occurred or is anticipated to be needed following the mastectomy

 

What is the optimal timing for Reconstruction?

The reconstruction is normally best done at the same time as the mastectomy (immediate reconstruction). The aesthetic outcome is nearly always superior to a delayed reconstruction. The only exception is if radiotherapy is required post mastectomy. In this case, it may be better to insert a temporary implant or tissue expander during the mastectomy and then to have the definitive reconstruction with the DIEP flap after the radiotherapy has been completed. The surgery can be performed at earliest 6 weeks following radiotherapy.

Where can the procedure be performed?

Dr Teh performs breast reconstructions in private and in his public session at Sir Charles Gairdner Hospital. While there are no fees associated with surgery in the public, there are surgical gaps involved with having the surgery in private. Do contact his rooms to discuss these fees.

How long is the operation and how long do I stay in hospital?

Single sided reconstructions generally take about 4-6 hours. With bilateral (double sided) reconstructions, a second plastic surgeon is engaged in order to help reduce operative time. Operating alone would take him over 16 hours to complete the procedure. This time can be reduced to an average of 9 hours with 2 surgeons. Reducing operative time has the huge benefit of reducing bleeding and the need for transfusions in addition to a reduced risk of perioperative complications resulting from the prolonged anaesthetic.

Most patients will be bed-ridden for the first 48 hours in a warm single room. On the third day post surgery, you will generally be helped up by the nurses to begin to mobilise. The majority of patients are discharged by Day 7 post surgery.

What measures do I have to take before surgery?

If you smoke, stop! Unless instructed otherwise, try to maintain your body weight. Depending on your body habitus, you may even be advised to gain some weight.

Tamoxifen is generally withheld 2 weeks prior to surgery as this can sometimes cause blood clots. Do check with Dr Teh if you take blood thinners or have a known bleeding disorder. Ensure that you are eating a well balanced healthy diet and that your iron stores are normal. Check with your GP if you suspect that you might have a low blood count (anemia). Make sure that if you have any chronic illnesses like high blood pressure, diabetes or asthma, that these are well controlled. 

Dr Teh will generally see you at least twice before your surgery. A CT Angiogram Scan of the chest and abdomen is performed to examine your vasculature for surgical planning. Blood tests are performed a week prior to surgery.

More details about the post operative recovery can be found here

PAP stands for the blood vessel (Profunda Artery Perforator flap) that supplies the tissue from the back and inside part of the upper thigh that is used to reconstructed the breast. It is generally considered where the abdomen is not an option to reconstruct the breast.  It can be used after a single sided or double mastectomy. Unlike the abdomen, it often only gives a modest volume reconstruction.  It tends to work better for women with small to medium-sized breasts (A to B cup).

Are there any Contraindications?

Because of the duration and nature of surgery, contraindications will include morbid obesity (BMI>35), moderate to severe organ disease (ie chronic obstructive lung disease, renal failure, liver failure or ischaemic heart disease) and peripheral vascular disease. Relative contraindications include advanced age (>75), unstable metastatic disease , severe coagulation disorders, current smoker

Tell me about the surgery and the recovery

The surgery for one side takes about 6-8 hours and a bilateral procedure 10-12 hours. Because of the technical complexities involved in raising and anastomosing this flap, a two surgeon approach is generally recommended both for one sided and bilateral reconstructions. Technical details of the surgery can be found here. You will return to the ward with a drain in your thigh and one in the breast. you will have a urinary catheter. During this time , you are asked to avoid bending the hips more than 30degrees of flexion, and this includes when going to the toilet. This is to avoid overly stretching the scar which is placed in your lower buttock crease. If everything goes well, you will be suitable for discharge 7-10 days after surgery. Waterproof dressings are used so you are able to take quick showers until the sutures are removed. You will see Dr Teh a week post discharge for suture removal. 

 

Are there any Alternatives?

In most centres around the world, the DIEP flap from the abdomen is still the go to procedure. The PAP flap is often reserved for when the DIEP flap is not suitable.  SGAP flap from the buttock is another option. Implant only reconstructions is a viable alternative as long as the chest wall has not had previous irradiation. This can be combined with a flap such as the latissimus dorsi muscle flap from the back to provide additional soft tissue to cover over and protect the implant where radiation has occurred or is anticipated to be needed following the mastectomy

What is the optimal timing for Reconstruction?

The reconstruction is normally best done at the same time as the mastectomy (immediate reconstruction). The aesthetic outcome is nearly always superior to a delayed reconstruction. The only exception is if radiotherapy is required post mastectomy. In this case, it may be better to insert a temporary implant or tissue expanded during the mastectomy and then to have the definitive reconstruction with the PAP flap after the radiotherapy has been completed. The surgery can be performed at earliest 6 weeks following radiotherapy.

Where can the procedure be performed?

Dr Teh performs breast reconstructions in both private hospitals and in his public session at Sir Charles Gairdner Hospital. While there are no fees associated with surgery in the public, there are surgical gaps involved with having the surgery in private. Do contact his rooms to discuss these fees.

How long do I have to stay in hospital?

Single sided reconstructions generally take about 4-6 hours. With bilateral (double sided) reconstructions, a second plastic surgeon is engaged in order to help reduce operative time. Operating alone would take him over 16 hours to complete the procedure. This time can be reduced to an average of 9 hours with 2 surgeons. Reducing operative time has the huge benefit of reducing bleeding and the need for transfusions in addition to a reduced risk of perioperative complications resulting from the prolonged anaesthetic.

What measures do I have to take before surgery?

If you smoke, stop! Unless instructed otherwise, try to maintain or even gain body weight. 

Tamoxifen is generally withheld 2 weeks prior to surgery as this can sometimes cause blood clots. Do check with Dr Teh if you take blood thinners or have a known bleeding disorder. Ensure that you are eating a well balanced healthy diet and that your iron stores are normal. Check with your GP if you suspect that you might have a low blood count (anemia). Make sure that if you have any chronic illnesses like high blood pressure, diabetes or asthma, that these are well controlled. 

Dr Teh will generally see you at least twice before your surgery. A CT Angiogram Scan of the chest and thigh  is performed to examine your vasculature for surgical planning. Blood tests are performed a week prior to surgery.

The SGAP (Superior Gluteal Artery Perforator) flap is not a commonly used flap in WA largely because of the complexities involved with the surgery. The skin and fat flap is harvested from the top of the buttocks with the dissection performed through the gluteal muscles to harvest the blood vessels. In a single sided reconstruction, it can lead to a lop sided buttock appearance. 

 It is harvested with the patient lying on the side and then the wound has to be closed and the patient turned to lie on her back before the microsurgery to join the flap to the chest can be performed. In women requiring bilateral reconstructions, Dr Teh will perform this procedure over two sittings, only operating on one side at a time. This is due to the multiple turns that has to be done when doing both sides at once, with the potential to irretrievably damage the flaps during the turning procedure.

The procedure takes 8 hours to perform and stay in hospital is approximately a week. Sutures are removed after 2 weeks and mild exercise is recommended for 4 weeks. Full recovery is usually at the 4-6 week mark.