breast aesthetics

This leaflet is for anyone having a breast reconstruction operation; it will help you to understand your breast reconstruction options following mastectomy. It should give you an overview of the different types of breast reconstruction that are available and may help you to decide on which is the most suitable method of reconstruction for yourself.

It is important that you read and understand this leaflet before agreeing to have a reconstruction operation.

What is a breast reconstruction?
The aim of breast reconstruction surgery is, where possible, to restore breast shape by replacing most of the breast tissue that has been lost during mastectomy or lumpectomy. It is not possible to reconstruct an exact match with the remaining breast, however your plastic surgeon will aim to achieve a result that gives you a balanced appearance when you are wearing a bra.

Breast reconstruction is usually a major operation and is performed under a general anaesthetic. It may be performed at the same time as your mastectomy or some months afterwards, depending on when you are ready. There are a number of methods that are commonly used for breast reconstruction:

Silicone Implant

Simple implant or prosthesis made of silicone, which is inserted under the chest wall muscles to create a breast mound.

Tissue Expansion and Implant

Tissue expansion, which is the insertion of an inflatable implant under the chest wall muscles.

A tissue expander is an inflatable silicone bag, rather like a balloon. It is filled by injecting sterile fluid into a valve located under the skin beside the expander.

The expander is inflated over a period of weeks to stretch the skin and muscle, and in some cases may be replaced with a breast implant.

Skin and Muscle Flaps
A muscle and skin flap can be used to build a breast shape. The flap may be taken from one of two areas:

LD flap (Latissimus Dorsi flap)

The most common flap reconstruction uses a piece of skin and muscle from the back, directly behind the mastectomy site, which is tunnelled below the armpit and stitched onto the chest wall. This reconstruction often requires the use of a silicone implant or tissue expander. As well as a scar on the chest wall, there will be a long scar on your back.

TRAM flap (Transverse rectus abdominus muscle flap) or DIEP Flap

The second method uses a flap of skin and muscle from the abdomen, which is tunnelled upwards to the breast area and stitched to your chest wall.

There is often enough tissue here to avoid the use of a silicone implant.

As well as a scar on your chest wall, there will be a scar on your abdomen, which may extend beyond the bikini line.

A variation of this operation involves completely detaching the flap of skin and muscle from your abdomen and reconnecting it to blood vessels in your chest wall, and then stitching the flap to your chest wall as mentioned earlier.

The advantage of this variation means that the skin and muscle flap does not need to be tunnelled up to your chest wall; however it is a more complex and time consuming procedure, which may take 6-8 hours to perform.

Your plastic surgeon will discuss all the above options with you; the choice of method of reconstruction will depend on your particular circumstances as each method has its advantages and disadvantages.

What are the limitations of breast reconstruction surgery?
It is important that you are well informed about what breast reconstruction surgery can achieve before making a decision to proceed with the operation. You need to have realistic expectations about the possible result and be aware of the limitations, some of which are listed below.

You should be aware that a breast reconstruction will not restore the same breast appearance or shape that you had before your mastectomy. To achieve the same volume, shape and size is not possible.

This operation may not involve a nipple reconstruction.

Your new breast will not be as sensitive as your natural breast.

Your expectations may be higher than can be achieved.

What are the benefits of having a breast reconstruction?

A breast reconstruction operation may help you to come to terms with your physical appearance following a mastectomy. In clothes your appearance may be similar to what it was before your mastectomy; and even without clothes you may feel better with a permanent breast mound restoring your natural shape.
The formation of a breast mound may also help to restore your self-confidence and feelings of femininity, attractiveness and sexuality.

What are the risks, consequences and alternatives associated with breast reconstruction?

Most operations are straightforward, however as with any surgical procedure there is a small chance of side effects or complications. This list of complications is not intended to put you off having the operation, however you need to be aware of any potential risks or complications before you consent to having surgery.

Bleeding. There is a risk that you may experience bleeding from the site of the operation; this could result in a collection of blood beneath the stitch line. If bleeding occurs you could experience pain and swelling in the area, the collection of blood may need to be removed, this may necessitate another operation.

Wound infection. There is a risk of wound infection, which can occur at any time following surgery. Symptoms of infection may include increased swelling, redness, fluid leakage and increased pain at the site of the operation. If your wound becomes infected you may need treatment with antibiotics, occasionally this may mean admission to hospital for antibiotics to be given through a drip. After a wound infection, healing may be delayed and you may need dressings for a longer period than normal.

Wound breakdown. There is a risk that your wound may break down following surgery. Wound breakdown can happen if the stitch line does not heal properly and the wound gapes, or if the blood supply to the skin becomes interrupted. If this happens you will require dressings for a longer period of time than usual, rarely, a further operation may be needed. After wound breakdown your scar may not have as good a cosmetic result than if your wound had healed without problems.

Scarring. You will have permanent visible scars on your skin; scars tend to improve over a period of 18 months following surgery. In some patients, for unknown reasons, scars can become raised, red and lumpy; unfortunately this is largely beyond surgical control. The way a scar develops depends as much on how your body heals as it does on your surgeon's skills.

Risks, complications and consequences associated with silicone breast implants:

The formation of a fibrous capsule around a silicone breast implant. If you have a reconstruction using a silicone implant, over time, your body may form a wall of scar tissue known as a fibrous capsule around the implant. If this happens you may need a further operation to remove the capsule or release the scar tissue.
Possible infection around a silicone implant. Infection may occur with any surgical implant. Symptoms of this could include tiredness, weakness, and intermittent periods of high temperatures. Infection around an implant may necessitate another operation to remove the implant.
Possible rupture of a silicone implant or failure of a tissue expander. Rupture means the development of a split or a hole in the implant. Breast implants are thought to have a life expectancy of 7 -10 years, however this is only a guide, your implant may not need to be replaced at this time. If your implant ruptures you may need a simple operation to remove or exchange it. If your tissue expander fails you may need another operation to replace it.

Possible failure of a muscle and skin flap. If your reconstruction involves a muscle and skin flap, there is a risk that this flap may fail. A muscle and skin flap relies on a good blood supply for its survival. Occasionally the blood supply to the flap becomes inadequate and some, or all of the flap may die (known as flap necrosis). If this happens healing may be delayed and you may need dressings for a prolonged period of time. In more severe cases you may need another operation to remove the flap and further breast reconstruction surgery at a later date.

Loss of skin around your mastectomy site. If your mastectomy and reconstruction operations are performed at the same time using an implant or expander, there is a small risk that the mastectomy skin may not survive. This may lead to a longer recovery period needing dressings. As long as the implant remains covered, no immediate surgery is warranted but you may need another procedure such as a skin graft at a later date. This complication tends to occur more with radiotherapy treated skin and may lead to a less pleasing cosmetic result than originally planned.

Difference in size or shape of the reconstructed 'breast' compared to the other (asymmetry). After a reconstruction, some degree of asymmetry of shape and size of the breasts will be evident. A corrective procedure may be needed to achieve a better match, this may involve another operation to adjust your natural breast; your surgeon will discuss this with you if necessary.

Failure to achieve expectations. It is important to remember that after breast reconstruction surgery there is a risk that the end results may not meet your expectations.

Chest Infection. A chest infection can occur following any general anaesthetic. You can reduce the risk of this happening by taking regular, deep breaths in and out following surgery and getting up and sitting out of bed as soon as you are well enough. If you smoke you can reduce the risk of a chest infection by stopping smoking for at least a month prior to your surgery.

Deep vein thrombosis. Deep vein thrombosis (DVT) is a blood clot that can arise in the deep veins of the leg or pelvis. A DVT can happen if your mobility is restricted or you are inactive for a time following your operation. You can reduce the risk of deep vein thrombosis by wearing the elastic stockings supplied, during and after your operation, and moving your legs about whilst you are in bed. A deep vein thrombosis may lead to a blood clot in the lungs in certain cases.

Anaesthetic risks and complications. You will need a general anaesthetic. Your anaesthetist will give you more information about your anaesthetic and will discuss specific anaesthetic risks and complications with you prior to your surgery.

Other complications. Depending on the method of breast reconstruction to be used, you may be at risk of other complications associated with your operation. Your surgeon will discuss any risks and complications specific to your individual case with you.

The alternative to having a breast reconstruction is not to have it performed; if you do not have a reconstruction you may still achieve a balanced appearance when wearing a bra if you wear an external artificial breast prosthesis.

If you are concerned about any of these risks, or have any further queries, please speak to your consultant or a member of his medical team.

What preparation will you need?

If your own doctor prescribes aspirin, ibuprofen or other medications, which may cause bruising or bleeding, such as clopidogrel, you may be asked to stop taking these for a period of time before your operation. These medications may increase the risk of bleeding during and after your operation. Your surgeon will advise you about this when you see him / her in clinic. If you do not hear from the hospital, please continue to take your medication as normal.

If you normally take warfarin tablets you may be asked to stop taking these 3 days before your operation. You may also be asked to have a blood test on the day of your operation.

If you take the oral contraceptive pill or HRT you may be contacted by the hospital and asked to stop taking them. If you do stop taking the contraceptive pill remember to use some other method of contraception to avoid pregnancy. If you do not hear from the hospital, then continue to take your medication as normal.

If you take prescribed medication other than those previously mentioned, please continue to take these as normal. Please also bring all your tablets, inhalers or sprays into hospital with you.

You may be asked to attend a pre assessment clinic at the hospital.

If you are not asked to attend this clinic you will have pre-operative investigations carried out on your admission to hospital. These investigations will include a blood test.

What happens when you arrive in Hospital?

A resident doctor along with the nursing staff would admit you and your consultant would take you through the informed consent form and perform any necessary preoperative photographs and markings. You will also see the anesthetist.

On the day of your operation you will need to stop eating and drinking for a period of six hours before the surgery.

Please have a bath or shower before your operation

If you have any questions or concerns about your operation, please ask your surgeon or a member of the nursing staff for assistance.

Your surgeon or another doctor will make sure that you informed about the nature of your surgery and the possible complications. He or she will ask you to sign a consent form agreeing to the surgery.

On the day of your operation you will need to stop eating and drinking for a period of time, the nursing staff will advise you of when this will be.

It is advisable to have a bath or shower before your operation.

What can you expect after the operation?

The operation may take as little as one and a half hours to as long as eight hours to complete, depending on the type of reconstruction performed.

After the operation is finished and you are awake and comfortable, you will normally return to the ward.

If you have been in theatre for a long time, you may be taken to the High Dependency Unit for closer monitoring overnight.

The nurse looking after you will regularly check your wound, your drains and your blood pressure and pulse after you return; this is routine procedure.

If you have a reconstruction using a skin and muscle flap, your nurses will monitor the blood supply to your flap regularly. Keeping warm may improve the blood supply to your flap; you may be looked after in a private room that is kept very warm when you come back from theatre.

You may have stitches and are likely to have a dressing over the wound.

You may have one or more drain tubes coming from your wound areas; these will allow any excess blood to drain into a bottle attached to each tube. The drains will be removed when there is only a minimal amount of drainage. This may take several days.

You may have a drip, either in your hand, arm, foot or occasionally in your neck, to replace any fluid lost during your operation. You may lose blood at your operation; very rarely you may need a blood transfusion to replace this. Alternatively, you may be prescribed iron tablets to correct any associated problems.

There will be bruising, swelling and discomfort following your operation, and you will be offered pain relief either by injections or tablets.

You will generally be encouraged to get up the day after your operation, but at first you should limit your activities to routine tasks such as eating, brushing your teeth and walking short distances. You should also take care not to dislodge your drains.

You may see a physiotherapist after your operation; a physiotherapist can advise you about exercises that may help your recovery after the operation.

Going home

You will normally be allowed to go home after your drains are removed, this may take several days depending on the method of reconstruction used. If you do not have drains you may be able to go home the day after your operation.

You may be prescribed a weeks supply of painkillers to take home. If you need a further supply you should contact your own doctor.

You do not need any special care at home, however if you have small children it may be advisable to arrange for someone to help you to care for them.

Please keep your dressings dry. Avoid touching your wound as this could cause an infection.

Follow up care

You will normally be given an appointment to return to the plastic surgery dressing clinic within 10 days of your operation, for a wound check and removal of stitches if you have any.

You will need dressings until your wound has healed, these may be done at the plastic surgery dressing clinic or you may have a district nurse or practice nurse to redress your wound.

You will need to wear a well fitting, supportive bra without wires such as a sports bra, after the dressings are first removed. This bra can be worn over dressings if necessary and should be worn day and night for three months.

If you have had a reconstruction with a tissue expander, you will need to attend the outpatients' department or dressing clinic at approximately 1-2 weekly intervals to have more fluid injected into the expander.

If you have had a different method of breast reconstruction, an appointment in the out patients department will be arranged, usually within 4- 6 weeks of your operation.

What can go wrong?

It is normal to have some bruising, swelling and tenderness around your wound following the operation.

However, if you suffer from any of the following symptoms after your discharge from hospital you should telephone the plastic surgery department for advice.

Persistent or increasing levels of pain

Fever

Redness or excessive swelling around your wound/s

A feeling of heat or burning in your wound/s.

Leaking, or a feeling of wetness around your wound/s

A feeling of tiredness or fatigue that lasts longer than three weeks.

Shortness of breath or pain when you breathe in deeply.

When can you start your normal activities again?

You should not drive until you can wear a seat belt comfortably and feel able to perform an emergency stop. Your insurance company may refuse to meet a claim if they feel you have driven too soon. It is also advisable to contact your insurance company with regards to cover following a general anaesthetic.

You should not go back to work until instructed by your surgeon. This could be 4-6 weeks depending on your job.

You should not do any heavy lifting for 4-6 weeks. This includes vacuuming and carrying bags of shopping or laundry.

Please ask if you require a doctors' certificate for your work.

You may resume sporting activities approximately 6 weeks after your surgery, unless your surgeon advises otherwise; however you should stop if you experience pain or discomfort during the activity. You should wear a well fitting sports bra during any sporting activity.

Useful contact numbers

Depends on hospital or BAAPS Other contacts.

Cancer BACUP - British Association of Cancer United Patients (An information service staffed by cancer nurses. They also provide free information booklets on coping with cancer.) Free telephone number 0808 800 1234.

Cancer Research UK - www.cancerhelp.org.uk

Department of Health publication: Breast Implants; Information for women considering breast implants. Copies are available free by writing to: Department of Health, PO Box 777, London SE1 6XH.

The report of the Independent Review Group: Silicone Gel Breast Implants (1998). Available from: Silicone Gel Breast Implants IRG. Tel: 020 7972 8077,

Website: www.silicone-review.gov.uk

Leaflet information
This information leaflet has been devised by:
Mr. A.M. Juma, Consultant Plastic & Reconstructive Surgeon

Protection of health care workers
In accordance with the Department of Health Guidelines for Clinical Health Care Workers 1998 (Protection Against Infection with Blood-borne Viruses), you may be required to provide a blood sample if a member of staff sustains an injury involving a used needle, sharp instrument and/ or contamination with your body fluids.
Your co-operation would be greatly appreciated.