R is for… Reconstruction

When I was diagnosed and found out I had to have a mastectomy, I thought I was going to end up with horrible, scarred Frankenboobs. However, as I researched my options and sneaked a peak at as many reconstructions as I could (many girls are so pleased with their recon that they are happy to share and, quite frankly, some of them are fantastic and wouldn’t have looked out of place on Page 3 of the Sun! ) I soon realised that the reconstruction options these days can give AMAZING results.

I had immediate reconstruction using expanders (as I had to have radiotherapy) and am off at the end of January for an implant exchange! The expanders have given me a great shape, but are quite hard and uncomfortable. I’ll let you know how the implants are once they’ve settled in a bit.

It is, however, a personal decision involving major surgery and about a quarter of women choose not to have any reconstruction. For those of you who do want reconstruction, there are quite a few different options, either using implants or your own tissue to form a new boob, and all with different pros and cons.

I have done LOADS of research about reconstruction options and have been swamped with booklets and websites. BY FAR the best one I came across is this one. It covers all of the different surgeries with pros and cons, patients’ experiences and pictures. They are now charging to download it…but it’s still free to read online.

I’ve briefly described the main  methods below – but not all of them will be suitable for everyone. Your surgeon or plastic surgeon will look at your body and talk you through the different options (there may only be one) that would work best for you depending on factors specific to you such as:

• Your body shape and how much tissue you have. For example, if you are of a very slim build you may not have enough tissue on your back, tummy, bum or thighs to have recon using your own tissue, in which case implants might be the only option.
• Your general health. Some options involve major surgery and will only be performed on healthy individuals.
• Your lifestyle. Be sure to let your surgeon know about the sports you enjoy, whether you have young children you need to be able to pick up and carry or if you have a very hands on job etc. For example, I work in the ski industry and am a keen skier, so although I have enough tissue for an LD flap, my surgeon advised against it as I need those muscles for skiing! Your lifestyle may also affect how long you would be prepared to be off work or unable to drive
• What size breasts you would like to have. There is a limit on size – it depends on how much muscle and flesh you have and implants are only made to a certain size, so the size you want to be could have a bearing on the reconstruction options available to achieve it.
• What treatment you are having. If you have to have radiotherapy, most surgeons like to delay reconstruction with your own tissue as it can affect the results and once that tissue has been used, there’s no other tissue as a back-up. Some will perform the reconstruction but make it larger, knowing it will probably tighten and shrink following radiotherapy.
• Your expectations. Explain what your expectations are so the surgeon can give you the best option to meet them and, if they are unrealistic, realign your expectations so you are not disappointed.
• Unlilateral or bilateral surgery. If you carry one of the breast cancer genes (BRCA1 or BRCA2) or have a very strong family history you may opt to have a bilateral mastectomy which will also affect the type of recon you could have. For example, you may have enough tummy tissue for one recon, but not two.

They should also explain why other methods would not be suitable for you. If they don’t, push them on this as it may be that they don’t perform some of the procedures, in which case it would be best to ask to be referred to an oncoplastic surgeon or plastic surgeon who does, so you are given all options and can therefore make an informed decision. Also ask about their experience and whether you are able to see pictures of past patients to give you an idea of their work. You are also entitled to a second opinion. I had my chemo before my surgery so had plenty of time to see different surgeons and research the different options, but for those of you having surgery prior to treatment, you may feel very overwhelmed and rushed – which makes it even more important to have a surgeon who explains it to you so you understand your options and come to a decision with which you are happy.

Make sure you understand which options are available to you, whether you should have immediate or delayed reconstruction, what to expect from each option, the pros and cons particular to you, where you will have scars, the shape and size you will be, how long the recovery time is (including time in hospital, time off work and when you will be able to drive), whether they would expect many subsequent operations, the possible risks and complications, whether it will delay treatment and get advice on post-surgery bras, clothes and physio.

A very, very brief overview of the most commonly used types of recon are below:

Tissue Expander or Implant

A tissue expander is a deflated implant that is slowly inflated over time with saline to stretch the skin or muscle, and is used if you want to be bigger than you were before, if you had to have skin removed or as a temporary reconstruction if you are having radiotherapy. The port sits under your skin and is accessed with a needle and they just inject the saline in which makes the implant grow in size and stretch your muscle and skin.

Implants can be made of a silicone outer shell, filled with saline or silicone or a kind of silicone jelly.

Both expanders and implants are placed under the muscle in your upper chest which holds it in place. There are lots of types, shapes and sizes to choose from. The main shapes are round or teardrop and they come in different sizes with different projections. Your surgeon will be able to discuss which will be best for you.

Pros:

• simplest and shortest op
• shortest hospital stay
• quickest recovery
• no additional scarring on other parts of your body

Cons:

• can feel cold and unnatural
• small risk of infection
• small risk  of rejecting implant
• tissue expanders involve regular hospital appointments for inflation
• difficult to get symmetry with natural breast as it doesn’t “droop” (not so much of an issue with bilateral recon and can lift other breast to match)
• less fleshy than reconstruction using your own tissue
• risk of capsular contracture where scar tissue can form and distort the shape of the implant
• further ops required to replace implant as they have a limited lifespan

LD flap 

The LD flap (latissimus dorsi) uses muscle from your back which they kind of poke round your side(s) to form the new breast(s). It can either be made with a large amount of muscle, or a smaller amount of muscle in conjunction with an implant or expander, depending on what size you want to achieve. You can have it either as an immediate or delayed reconstruction and it gives a very natural result with a medium-sized scar on your back that should be hidden by a bra.

Pros:

• natural shape and movement
• fleshy, warm and lifelike
• matures like your other breast
• if using implants, capsular contracture is  less obvious as it is hidden under flesh
• changes with your weight

Cons:

• major op with longer recovery time
• higher chance of not working than implants as more complications possible
• you are left with scars on your back as well as your breast
• not suitable if you play certain sports as the muscle is removed from your back
• if using implants, may need to be changed

TRAM flap

The TRAM flap (transverse rectus abdominus myocutaneous flap) op takes excess tissue, including muscle, from the lower part of your tummy which is then used to form your new breast(s). It can also be done immediately or after treatment. As with the DIEP, it is major surgery with the longest recovery, but gives the most natural result. You also get a bonus tummy tuck – but this does involve a large scar from hip to hip that they try to hide under your knickerline.

Pros:

• Most natural shape, weight and movement as all your own tissue.
• Will change with your weight.
• Feel soft and warm.
• Tummy tuck
• Shouldn’t need further ops.

Cons:

• Longest op and longest recovery time.
• higher risk of flap not taking than LD.
• Long scar on tummy from hip to hip
• Risk of hernias and tummy muscle weakness.

DIEP flap

The DIEP (deep inferior epigastric perforator) flap is similar to the TRAM flap but it is just the skin and tissue taken – no muscle – which is taken to form your new breast(s), so reduces the risk of hernias and tummy muscle weakness. It can be done immediately or delayed. Again, it is major surgery with the longest recovery, but gives the most natural result. As with the TRAM, you get a bonus tummy tuck – but this does involve a large scar from hip to hip that they try to hide under your knickerline.

Pros:

• Most natural shape, weight and movement as all your own tissue.
• Will change with your weight.
• Feel soft and warm.
• Tummy tuck
• Shouldn’t need further ops.

Cons:

• Longest op and longest recovery time.
• higher risk of flap not taking than LD.
• Long scar on tummy from hip to hip.

TUG, SGAP, IGAP and LTT flaps 

These are similar processes to the DIEP flap procedure, but using tissue from around your bum – the SGAP flap (superior gluteal artery perforator) and IGAP flap (inferiorgluteal artery perforator) – or your thighs – the TUG flap (transverse upper gracilis – the inner part of your thighs) and LTT flap (lateral transverse thigh – the outer part of your thigh). These are used if you carry your weight more around your bottom or thighs as opposed to your tummy. The pros and cons are similar to the DIEP, but with the scars being on your bottom or thighs.

Nipple reconstruction

Some surgeons do nipple reconstruction at the same time as your actual reconstruction, but most will wait for the recon to settle and for the swelling to go down which I guess would give better results in terms of placement etc. If you are having one side done to match the other side, they will place and size it accordingly. If you are having both done, you can choose what you want! Nipple-sharing and skin-grafting is performed under a general anaesthetic, but the skin-twisting boob-origami is often performed under a local and as day surgery.

Symmetry

Occasionally some people need subsequent ops to match the breasts up. Tweaking the reconstructed breast could involve lifting it, reduction, increasing size with an implant or lipo-filling (transferring fat from elsewhere to smooth out irregularities or to increase size). Or they may decide to tweak the healthy breast by lifting it, inserting an implant, or reducing the size.

Tags: Breast Cancer, breast reconstruction, DIEP, LD Flap