Although breast reconstruction is normally done after a mastectomy, it can be worthwhile for women with significant distortion or asymmetry of the breast following a segmentectomy or lumpectomy. Surgical reconstruction of the breast is an option being taken up by increasing numbers of women.
Each of the many possible techniques for breast reconstruction has its own merits and disadvantages, and any one of several may be suitable for a particular woman. However, what is most appropriate for one woman may not be appropriate for another, and it is important that before undergoing any type of breast reconstruction, you discuss your options with your reconstructive surgeon so that, between you, you can choose the most suitable one.
Breast reconstruction can involve using only the woman’s tissues, imported to the chest from another part of her body, or implanting an artificial prosthesis with or without the use of the woman’s own tissues.
Prosthetic reconstruction
Reconstruction of the breast with a prosthesis, or implant, can usually be done immediately after a mastectomy, thus making use of the existing mastectomy incision, and requiring very little additional operative time. However, reconstructing a breast to match a normal ‘droopy’ breast is difficult with prosthesis alone.
The prosthesis itself consists of a silicone envelope which can be filled with various liquids or gels to mimic the consistency of normal breast tissue beneath the skin.
The recent controversy about the long-term safety of silicone gel as a filling for breast implants has led to the current restrictions on its use in the USA. The Health Department in the UK does not consider there is sufficient evidence to warrant such restrictions, and therefore this type of prosthesis is still widely used in the UK. You should discuss with your reconstructive surgeon the advantages and disadvantages of each of the different fluid fillings before you make a decision.
If there is not enough skin remaining on your chest after a mastectomy to allow the simple placement of a prosthesis beneath it, skin may have to be imported from another part of the body, usually the back or upper abdomen, to create a space for the prosthesis.
A possible alternative to importing skin is to expand the existing skin of the chest by inserting a special balloon beneath it, which is then gradually inflated with a salt solution over a period of weeks or months until the correct size of breast is achieved. Once the skin has been stretched sufficiently, the balloon can be removed and replaced by a soft, permanent prosthesis. To recreate the natural droop (ptosis) of the breast, the skin is over-expanded before the implant is inserted.
There are several special ’tissue expanders’ which can be used which already contain the permanent prosthesis and which do not therefore need to be removed once expansion of the skin is completed, although a minor surgical procedure may be necessary to remove the filling valve.
For women whose pectoralis major muscle is still intact, the tissue expanders can be placed in a pocket underneath this muscle rather than directly under the skin. This helps to reduce the risk of complications occurring in the future, particularly for women who have had radiotherapy, which damages the blood vessels in the skin, and may weaken it and make it more likely to allow protrusion of a breast prosthesis.
Although good cosmetic results can be obtained by tissue expansion, and an artificial nipple can be created with a skin graft, it should be understood that, as with all methods of reconstruction, a perfect breast cannot be refashioned in this way.
Side-effects of prosthetic reconstruction
If an infection develops following prosthetic reconstruction, the implant may have to be removed, at least temporarily. Protrusion of the implant may occur if the skin has been weakened for any reason, e.g. by radiotherapy or an infection.
Although the body generally tolerates the foreign material of a prosthesis, a capsule of fibrous tissue forms around it as the body walls it off. In some women, the fibrous tissue becomes thick, and the capsule it has formed around the implant contracts, thus altering the shape of the prosthesis and causing a marked firming in the texture of the reconstructed breast. When this complication – known as capsular contracture – does occur, it is most likely to do so within the first year or two after the implant has been inserted, although it is possible many years later. The breast may become hard and painful, and sometimes further surgery is necessary to regain the desired breast shape or to remove the implant.
Other possible complications of prosthetic reconstruction include the implant moving from its original position, or leaking or deflating. Surgery may be necessary in these cases to reposition or replace the prosthesis.
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