BREAST RECONSTRUCTION OPTIONS
There are two main types of breast reconstruction procedures:
- Implant reconstruction, whereby a breast implant is surgically inserted as either a single operation, or a two-stage procedure using an expander and then implant.
- Flap - or autologous - reconstruction, whereby a portion of tissue, skin and often muscle from another part of the body is transferred to the chest. There are three main types of autologous reconstructions offered at our clinic:
- TRAM flap
- DIEP flap
- Latissimus dorsi flap
Click on the buttons below for more information about each reconstructive option, or scroll down to read frequently asked questions about breast reconstruction.
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FREQUENTLY ASKED QUESTIONS ABOUT BREAST RECONSTRUCTION
What are the different types of breast reconstruction?
1. Implant reconstruction
This can be performed as a single stage or two stage procedure, with the end result being the placement of a silicone or saline implant to recreate the breast. If your reconstruction is unilateral (one breast), you may also choose to have your natural breast lifted or reduced to create symmetry with the reconstructed breast. Read more about implant reconstruction with Dr Sharp here.
2. Pedicled transverse rectus abdominus myocutaneous (TRAM) flap
In this this procedure, your plastic surgeon will ‘harvest’ the rectus muscle, lower abdominal skin and fat, which is known as a ‘flap’. A tunnel is made under the skin between the abdomen and chest, and the flap is passed through this tunnel and relocated to the chest, and positioned to form the shape of a breast. Because it is still connected to its original blood supply via the ‘pedicle’, the transferred tissues survive in their new position. Read more about TRAM flap reconstruction with Dr Sharp here.
3. Deep inferior epigastric perforator (DIEP) flap reconstruction
The DIEP flap is an evolution from the pedicled TRAM flap, but it is a ‘free flap’ in that it is not attached to the body by a pedicle - that is, part of the flap is not left attached to the body’s blood stream. DIEP flaps are only performed by plastic surgeons who are skilled in microsurgery, and in select hospitals with microsurgical expertise and monitoring. As the lower abdominal tissue must be completely detached from the body and transferred to the chest, microsurgery is required to restore circulation to the transplanted skin and fat. Read more about DIEP flap reconstruction with Dr Sharp here.
4. Latissimus dorsi flap reconstruction
This flap borrows muscle and skin from the upper back, leaving the tissue partially attached to the body via a pedicle. The flap is tunnelled underneath the skin from the back, through to the chest while still attached to its blood supply, which keeps the tissues alive during and after transplantation.
What is the best type of breast reconstruction?
There are many ways of using your own body’s tissue to recreate the breast; one is not better than the other, as it is dependent entirely on the individual patient’s body type, tissues and remaining natural breast. Scarring, radiotherapy and the patient’s desired outcome all need to be taken into account. A combination of techniques may used for some women. Your plastic surgeon can advise on the best types of reconstruction for you. They may take into consideration the following factors:
- how much of the breast tissue was removed
- tissue health at the planned operation site
- whether or not a patient has had radiotherapy to the breast area or chest wall
- patient’s general health and body build
- patient’s personal preferences and desired outcome
Breast reconstruction is not for everyone; after investigating their options, some patients decide that they don’t want to have a breast reconstruction. Some are willing to live with their post mastectomy shape, while others use an external breast prosthesis to recreate breast shape.
Do I have to decide whether I want a breast reconstruction straight away after mastectomy surgery?
No, you don’t have to make a decision about breast reconstruction straight away. The procedure can be performed immediately, or delayed until months or years after surgery. If you know you want an immediate reconstruction, it’s important to discuss this with your breast surgeon so a plan can be put in place to make this happen.
How many women choose reconstructive surgery?
Currently, about half of all women how undergo mastectomy surgery choose to have a reconstruction, either at the time of their mastectomy or after. But the rates of breast reconstruction are growing, as more GP’s and surgeons are more aware of modern techniques available and able to refer onto a plastic surgeon who is trained and experienced in the microsurgical techniques required to perform the full spectrum of reconstruction. Increased public awareness of the options available, thanks to celebrities such as Angelina Jolie, who spoke publicly about her breast reconstruction following preventative mastectomy surgery.
What costs are involved in breast reconstruction surgery?
Breast reconstruction surgery is offered through the public health system in Australia at no cost. If you would like to consider this option, your breast surgeon or breast care nurse can refer you to a public hospital that offers reconstruction surgery. Not all public hospitals are able to provide reconstruction surgery and waiting times will vary from hospital to hospital. Talk to your treating team about what’s available. If you are considering an immediate reconstruction and would like to have your surgery in a public hospital, it is important that you talk to your breast surgeon about this as soon as possible. If you choose to have delayed reconstruction at a public hospital, you will be put on the hospital’s elective surgery waiting list.
If you have applicable private health insurance, your private hospital fee should be covered by your fund. You will also receive a rebate for a portion of your surgeon’s and anaesthetist’s fees. You can choose to pay for treatment as a private patient even if you don’t have private health insurance; your major out of pocket expenses will include your hospital fee, surgeon’s fee, implants (if you choose an implant reconstruction) and anaesthetist’s fee. Medicare will provide a rebate on a portion of some of these costs, depending on the item numbers assigned to your surgery after you have selected your chosen reconstructive procedure.
It’s important to ask your surgeon for a written quote before committing to any surgery. Your surgeon’s fee does not just cover the time spent in theatre on the day of surgery; this fee also takes into account all surgical consultations in hospital (if you have the procedure as an inpatient) or their clinic, breast expander appointments - and ordinary post operative care for the 6 weeks following your surgery.
If you have private health insurance, once you have indicative item numbers and costs from your surgeon for the reconstructive procedure you are having, you may like to ask your fund what is covered by your insurance, and what the gap will be between how much you are charged - and how much is paid by your fund. There can be a substantial gap between the cost of surgery and the amount you receive from your insurance fund that is not covered by Medicare.
Can I have a nipple and areola reconstruction?
It is preferable to allow your reconstructed breast to settle for 3 to 6 months after your surgery, so that the nipple and areola can be placed in the proper position. This aspect of the reconstruction is done as day surgery and usually involves very little discomfort. The nipple may be made from the tissue and fat of the reconstructed breast. If the nipple of your natural breast is prominent, then a portion of it can be used as a graft to make a new nipple for the reconstructed breast in a procedure called nipple share. The finishing touch is a tattoo procedure to match the colour of your natural nipple and areola. This can be done by a medical tattoo artist several months following the nipple reconstruction.
If I’m having a unilateral mastectomy (one breast removed) will I need rebalancing surgery?
The objective of breast reconstruction is to create a breast that looks natural and balances the body, and although every effort is made to make them match as closely as possible, reconstructed breasts rarely match perfectly. Surgery to correct the shape and size of the other breast is often done to help match the new breast. This type of surgery can also be performed on women who had only a part of their breast removed (lumpectomy, partial mastectomy) to improve the shape of the partial breast defect, and can include breast lift, or mastopexy surgery - or breast reduction surgery.
In a breast lift, the nipple and breast tissue are placed in a higher position with some skin removal to match the reconstructed breast. The overall effect is a higher and firmer breast mound. Fat and breast tissue are not removed; therefore there’s very little change in size. In a breast reduction - through the same incisions as a lift - skin, fat, and breast tissue are removed in order to better match the size of the other reconstructed breast. Alternatively, in women with small breasts, placing an implant in the other breast can help to create balance.
Are breast implants safe?
Both saline and silicone gel implants are safe and available for use in Australia. Saline implants are plastic shells made of silicone externally and filled with salt water. Reconstructions using permanent saline implants tend to result in a less natural appearance and feel than reconstructions using silicone gel filled implants. Other than a few limited indications, saline implants are not recommended for use as the permanent breast prosthesis for reconstruction.
The newer generation silicone implants contain thicker silicone gel that is more cohesive and in turn have the advantage of being more form-stable. The most common complication for implant reconstruction is the gradual hardening of the breast due to capsular contracture. While breast implants themselves never harden, the body can form a capsule or layer of scar tissue around the breast implant. In most women, the scar tissue capsule remains soft and pliable, but in some women the capsule can be unusually thick resulting in a firm and painful breast. In these cases, surgery may be needed to remove and replace the implant. In general, an implant reconstructed breast will feel firmer than the natural breast, and will always feel different from the natural breast. Click here to read more about the breast implants that Dr Sharp uses.
What is alloplastic dermal matrix and how is it used for breast reconstruction?
Alloplastic dermal matrix (ADM) is donated human skin, which has been put through a process to create a sterile support sling that can be used to support and cradle the breast implant in breast reconstruction surgery - where mastectomy has removed some of the internal tissues that would usually support a breast implant. Dr Sharp offers the use of ADM technology in appropriate breast reconstruction cases, in both Brisbane and Ipswich. Read more about this advancement in breast reconstruction technology, and how Dr Sharp uses it here.
What are the psychological benefits of breast reconstruction surgery?
A number of state of art surgical techniques now exist to reconstruct breasts after mastectomy or lumpectomy. Knowing about these options - and having confidence in your surgeon’s training and experience in performing them – is crucial in decreasing the anxiety and uncertainty that can come with the news that a mastectomy is required. Anecdotally, patients often report that breast reconstruction has helped mitigate the emotional, social and sexual impact of breast cancer treatment, improving their body image and general state of mind around their breast cancer diagnosis. That said, the reconstructive process - in some cases - can be lengthy and challenging. Tissue flaps can fail and the body can reject breast implants. While breast reconstruction can have significant psychological benefits, the process can also be traumatic and stressful in an already-difficult time. It’s important to discuss these positives - and drawbacks - with your surgeon prior to surgery, as part of making an informed decision about what is best for you.
What are the potential complications of breast reconstruction surgery?
The risks and complications of breast reconstruction surgery include infection, blood clots, fat necrosis, flap failure, capsular contracture, implant malposition or rupture, seroma, muscle weakness at the flap harvest site, scarring, asymmetry and the harmful effects of radiation therapy if it is required later. It’s important to weigh the benefits of the procedure against the risks; you should not undergo breast reconstruction until you fully understand the potential outcomes and complications. If you are not sure that the benefits outweigh the risks, remember that you can delay the decision to have a reconstruction, and choose to proceed with one in the future if your feelings change.
FREQUENTLY ASKED QUESTIONS ABOUT BREAST CANCER
What is breast cancer?
Breast cancer occurs when abnormal cells in the breast grow in an uncontrolled way.
What are the risk factors for breast cancer?
A risk factor is any factor that is associated with an increased chance of developing a particular health condition. There are different types of risk factors for breast cancer, some which can be changed or reduced - and some that cannot.
Having one or more risk factor does not mean a person will develop breast cancer; most people have at least one risk factor but will never develop breast cancer, while others with breast cancer may have none of these risk factors, but still develop cancer. While the causes of breast cancer are not yet fully understood, there are a number of factors associated with the risk of developing the disease, which include:
- being a female
- increasing age
- having a family history of breast cancer (immediate relative)
- having a personal history of breast cancer, DCIS or LCIS
- hormonal factors
- child-bearing history
- being overweight
- high alcohol intake
Are there different types of breast cancer?
Yes, the different types of breast cancer include:
- Ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS) are non-invasive breast cancers that are confined to the ducts or lobules of the breast.
- Invasive ductal or lobular carcinoma is an invasive breast cancer that starts in the ducts or lobules of the breast and can spread into the breast tissue. Invasive breast cancer may be confined to the breast and lymph nodes in the armpit (early breast cancer) or may have spread outside the breast to other parts of the body (secondary breast cancer).
- Paget’s disease of the nipple is a rare form of breast cancer that affects the nipple and the area around the nipple (the areola) and is commonly associated with an invasive cancer elsewhere in the breast.
- Inflammatory breast cancer is a rare form of invasive breast cancer that affects the lymphatic vessels in the skin of the breast, causing the breast to become red and inflamed.
How common is breast cancer in Australia?
Breast cancer will affect all of us at some time in our lives; whether it be a loved one, colleague, friend – or ourselves – diagnosed with this common form of cancer. The chance of a woman developing breast cancer up to the age of 85 is 1 in 8. When breast cancer is detected early, women have a much greater chance of being treated successfully and for most, the cancer will not return after treatment.
What are the signs of breast cancer?
Early detection is the best chance you can give yourself for a positive prognosis. And a defined lump is not always the first sign of breast cancer. Breast cancer symptoms can include:
- Thickening of the breast tissue
- Nipple discharge
- Redness of scaling of the nipple
- A nipple that becomes inverted (turned inwards)
- Unexplained redness, swelling, skin irritation, itchniness or rash on the breast.
There are a number of conditions that may cause these symptoms, not just breast cancer. If any of these symptoms are experienced, it is important that they are discussed with a doctor. Women of all ages should be familiar with the normal look and feel of their breasts. If you notice any of the following changes please see your doctor immediately:
- a lump, lumpiness or thickening of the breast
- changes in the skin of a breast, such as puckering,dimpling or a rash
- persistent or unusual breast pain
- a change in the shape or size of a breast
- discharge from a nipple, a nipple rash or a change in its shape.
The signs of breast cancer can look like this – or not at all. It’s important to remember that the best defense you have is you own ‘gut instinct’. If you feel your breasts have changed unexpectedly – or just something isn’t right – listen to your inner alarm bell. When it comes to breast cancer, it is far better to have a screening ‘just in case’ than live with the regret of knowing you missed the signs. Clear here for the Cancer Council’s breast cancer fact sheet.
How is breast cancer diagnosed?
Diagnosis of breast cancer involves the ‘triple test’, which includes:
- a clinical breast examination
- imaging tests (mammogram and/or ultrasound)
- taking a sample of tissue (called a biopsy) from the breast, for examination under a microscope by a pathologist
Other tests may also be utilised, such as blood tests or bone scans. Magnetic resonance imaging (MRI) may also be used in some cases.
What is a mammogram?
Mammograms are X rays of a woman’s breasts. Screening mammograms are performed on women without any symptoms of breast cancer. Mammograms may find a breast cancer which is too small to feel by touch. There are over 500 screening locations across Australia - to contact your local BreastScreen service, call 13 20 50.
Can I have a mammogram if I have had a breast augmentation?
In most cases, it is safe to have a mammogram after having a breast augmentation, as long as you advise your clinician that you have have implants. However, many women with breast implants find ultrasounds are more comfortable.
Who should have a regular screening mammogram?
The biggest risk factors for developing breast cancer are being a female, and getting older. BreastScreen predominantly services women aged 50 to 74 years, because 75% of all breast cancers occur in women over the age of 50. Screening mammograms are actually often less reliable for women under 40 years of age, due to the density of breast tissue in younger women. All women aged 40 to 49 years who have no breast symptoms also have free access to the BreastScreen Australia program should they choose to a have a screening mammogram. All women aged 50 to 74 years are encouraged to have a free mammogram every two years through BreastScreen Australia. BreastScreen recommends that women aged 75 and over who have no breast symptoms should discuss whether to have a mammogram with their doctor - they can access free mammograms through BreastScreen.
Breast cancer treatment options
Treatment and care of people with breast cancer is usually provided by a team of health professionals, called a multidisciplinary team. Treatment for breast cancer can depend on the type and stage of the disease’s development, the severity of symptoms and the patient’s age and general health. This usually involves surgery to remove part or all of the affected breast, and removal of one or more lymph nodes from the armpit. Radiotherapy, chemotherapy, hormonal therapies or targeted therapies may be used. Breast reconstruction options should be discussed as part of the treatment plan, if the patient wishes to investigate the potential reconstructive procedures available to them.
As research continues into the diagnosis and treatment of cancer, some people may be offered the option of participation in a clinical trial to test new ways of treating breast cancer.
Can men also get breast cancer?
Breast cancer is often thought of as a woman’s disease, but it also occurs in male glandular chest tissues as well.
What can I do to reduce the risk of developing breast cancer?
- stop smoking
- maintain a healthy body weight
- be physically active on a daily basis
- choose a nutritious and varied diet with plenty of fruit and vegetables, and low on takeaway or packaged foods
- limit your alcohol intake
If you need support with making lifestyle changes to help reduce your risk of cancer, talk to your GP about the proactive steps you can take on a daily basis.
What is a preventative mastectomy?
You may consider having a preventative mastectomy if you have a strong family history of breast cancer and/or if genetic testing suggests a strong likelihood that you may be diagnosed with breast cancer in future. Preventative mastectomy is a big decision. It involves much consideration, consultation with healthcare professionals and genetic counselling. Click here to read more about preventative mastectomy surgery.
Other helpful resources:
Cancer Council 13 11 20 About breast cancer
BreastScreen Australia 13 20 50 www.cancerscreening.gov.au
Cancer Australia www.canceraustralia.gov.au
Watch women talk about their breast reconstruction surgery experience
7 questions to ask your surgeon if you are considering breast reconstruction…
If you are considering breast reconstruction following partial or complete mastectomy, your doctor should ensure you are fully informed of all surgical options available. Your final choice will depend upon your own wishes, desired result and your surgeon’s clinical recommendations. Asking these questions will help you begin your reconstructive journey well informed.
- What are my reconstruction options, and of these, which do you most highly recommend for me?
- What are the short and long term ‘pros’ and ‘cons’ for each reconstruction?
- When I can have a reconstruction; immediately, or later – and why?
- How many procedures will I require, over what period of time; and what is the average hospitalisation/recovery period for each of these steps?
- How will my breast look and feel after reconstruction. If you require reconstruction on only one breast, how will it compare to the other – and will further surgery be required to restore symmetry?
- What are your qualifications and experience in microsurgical breast reconstruction? Check your surgeon’s credentials with the Royal Australasian College of Surgeons’ website here.
- How much will this cost? Your written estimate of fees document should outline all expected major costs, item numbers and potential rebate on your hospital and surgeon’s fees. Depending on whether you have health insurance or not, and the type of insurance you hold, you may find part or all of your hospital fees are covered.
- What if I don’t want a breast reconstruction; what are my options?
And after your breast reconstruction, make sure you know:
What kind of screening do I have after mastectomy, and how often should I have it?
In addition to screening, what signs of breast cancer recurrence should I be looking for?