Some personal views on breast reconstruction in 2001
Breast reconstruction is a misnomer. The female breast has a number of functions and attributes, and when I teach medical students I begin by asking what these are. Amazingly almost all of them come up with milk production as the main function of the breast. This ignores in a way that would have been unlikely when I was a student, the aesthetic function, the role in sexual definition, and the erogenous functions of the breast. In reconstruction of the breast we replace only the form of the breast, and we should remember this limited aim when we embark upon the procedures.
There has been a lot written recently about methods of reconstruction, and I am grateful to be able to put my own views in this area. In part this article aims to demystify some of the issues around breast reconstruction, and in part to point the way that I think we are going with attempts to improve matters for patients facing removal of the breast.
How to make a breast: 4 simple steps
When making a breast there are four main elements to consider and create.
First one has to create the bag of skin (sometimes called the “envelope”) that will contain the breast and form it’s surface.
Next we have to decide what to fill this bag or envelope with: for instance whether to fill it with an artificial implant or with the patient’s own fat? These two stages obviously depend upon each other to some degree, in that we cannot put the filling in without the envelope present, nor would we make and leave an empty envelope without filling. But more subtly, the proportions between the fill and the envelope determine the shape and droop of the breast: a larger fill in a smaller envelope giving a tauter breast, whilst less fill in a bigger envelope will allow more droop of the new breast.
Having created the envelope and fill, we must
next consider whether to create a nipple and areola,
finally whether any surgery to the opposite breast is needed to achieve symmetry: it is often more prudent to make a smaller less droopy breast than existed before and then to match the normal breast to the reconstructed side. Lets look at these options in more detail.
Making the envelope.
The bag of skin that will contain the breast is known sometimes as the envelope. How it is made and the size of it is very important for the final result. There are some simple options available and some obvious principles that determine the best way to go. The options are either to use the existing breast skin, or to place new skin from another part of the body or finally to stretch the skin around the breast scar to make new skin. Lets look at these options a little closer and discover some of the principles that should guide us.
If the reconstruction is planned to occur immediately at the same operation that the breast is removed, then it may be possible to use the existing breast skin by sparing some of the skin from removal and using it to refashion a breast shaped envelope. This is not always possible but when it is it does produce very good skin appearance, not surprisingly really since it is breast skin. However it is an important principle that if the mastectomy is for cancer no compromise on the removal of the cancer must be allowed and so in some cases it simply will not be possible safely to preserve this skin. This is a shame since although many do not realise it, skin varies in colour and texture from one part of the body to another, and breast skin makes the best replacement for breast skin.
However we can stretch the skin around the breast scar to make new skin by a technique known as tissue expansion. Here a silicone rubber balloon is temporarily placed beneath the skin around the breast scar at one operation. It is then gradually inflated over many weeks to form a bulge beneath the skin and the body responds by actually creating new skin. The inflation is done by progressive injection through the skin into a special port on the balloon (also known as “the expander”) and the inflation proceeds at a rate slow enough to be comfortable and to allow the body time to make the new skin required. This is a very effective way of creating the envelope for a breast reconstruction but of course it suffers from the disadvantage of requiring a separate stage of surgery before the filling is finalised (because we rarely use the balloon - or expander - as the filling also: they tend to be poor rather globular shapes and quite hard and unwobbly). It is thought by many surgeons that this technique of tissue expansion cannot safely be used for patients who have had radiotherapy after their mastectomy, because radiation severely diminishes the ability of skin to heal and repair itself. My own experience is quite different. I have used this technique may times in patients who have had radiotherapy and found excellent results with no more complications than for any other patient, provided the filling of the breast is subsequently made from the patients living fat (see below).
This question of the filling is important when deciding whether to use the expansion technique for creating skin. If the filling is going to be an implant then the expansion technique should only be used on patients who have not had radiotherapy, who have enough padding (whether by fat or muscle) to allow the implant not to show every little wrinkle and crease beneath the skin, and when the patient is not expecting much in the way of droop in the new breast (since implants are not very good at producing droop). If however the filling is going to be the patient’s own fat, then the expansion method can be used even in radiotherapy patients, it can produce droop and has the great benefit of creating breast skin with the right colour and texture matches since it is breast skin that has been expanded. It still of course has the disadvantage of requiring two stages for completion.
A single stage reconstruction is possible after mastectomy only by placing skin from another part of the body. In effect this involves putting in a patch (or as plastic surgeons call it, a "flap") of skin and the common places to get the patch from are the back (combined with muscle in the form of a latissimus dorsi flap) or the abdomen (combined with a TRAM or DIEP flap - see below). As we observed above, skin from other parts of the body never matches breast skin perfectly, and furthermore such a patch must have a scar going all around it (whereas if the existing skin next to the scar is stretched by an expander there is still only one scar line). For this reason patches or flaps of skin represent a compromise but they do have the great benefit of allowing the envelope and the filling to be created at one single stage. They also suffer from the disadvantage that they leave a scar where they come from (chest wall or abdomen).
Making the filling
Having created the envelope of the breast we then have to fill it, and as discussed above, the proportion between the filling volume and the envelope size will determine the shape and droop of the breast. There are two main options for the filling, namely synthetic implants or the patient’s own living tissue (usually fat).
Synthetic implants are now almost exclusively silicone rubber shells with silicone gel filling. Following the almost hysterical and unsubstantiated scare stories about silicone and health hazards in the early 1990s, this material has been exhaustively tested and investigated without any significant adverse health hazard being found. It is therefore concluded by independent government instructed organisations (e.g. the Medical Devices Agency in the UK) that silicone gel filled implants are suitable and safe for the purpose of breast reconstruction. Similar findings and policies have now been implemented around the world, but during the period when doubt existed some other implant materials found their way onto the market and into patients. Some of these have now been discredited as less safe than silicone, and my own belief is that silicone represents a well tested and very satisfactory material.
However there are some advantages and disadvantages to the use of synthetic implants as filling that should be understood. The advantages are obvious: they are easily available, do not require separate surgery to a donor site elsewhere on the body, and their size ands shape and consistency can be varied by choice. They do have disadvantages also. They are not generally suitable for long term use under skin that has had radiation treatment, as there is in the long term a risk of hardening and extrusion of the implant. They don’t reproduce droop well and they can harden as a tight capsule of scar forms around them inside the body and then shrinks, squeezing the implant into a hard sphere. As a result of new implant design this complication (called capsular contracture) is less common than it was, but still can occur. Because of the implants scares of the past most manufacturers now recommend (with little scientific basis) that their implants be exchanged for new ones every ten years, which is a further disadvantage. One other more minor problem they may exhibit is that they can feel cold, since they do not have a warming blood supply like normal breast. Nonetheless implants are important tools for breast reconstruction and can be used in conjunction with tissue expansion, flaps, or immediate reconstructions.
The patient’s own living tissue may be transplanted from another part of the body to the breast. In practice this tissue is usually fat and most often nowadays comes from the abdomen. Two notable exceptions are that some surgeons will transplant muscle from the back in conjunction with the latissimus dorsi skin flap (a technique I do not often use because the muscle wastes away and so the bulk benefit is in the long term very little) and some may transplant fat from the buttocks (which is a more difficult site to use but which can produce good results in some patients).
Such transfers are known as autogenous reconstructions because the material is from the same body. An important principle here is that the fat transferred must be alive and remain alive: dead fat soon goes hard (fat necrosis) and can become infected. For this reason if any significant volume of fat dies it should be removed. To maintain the fat alive its blood supply must either remain intact (in which case the fat tissue remains attached to the body throughout by a stalk or pedicle that contains the blood supply, for example in a “pedicled TRAM flap”) or be immediately restored (for example in a “free TRAM flap” where the fat is completely removed in one lump from the abdomen and then the blood vessels nourishing it are rejoined to similar vessels on the chest wall to immediately restore vitality. This requires a complicated microsurgical procedure.
Why do some surgeons prefer free microsurgical procedures over the pedicled procedure, especially since the rejoining of the blood vessels can fail and the fat die and have to be removed? Well although the pedicled technique may seem safer in that the blood vessels remain intact throughout, it does involve a very extensive exposure between the abdomen and the breast in order to transfer the fat, and the stalk (or pedicle) that contains the blood vessels may become long, and attenuated. As a result others and I have found that whilst it was unusual for all of the fat to die it was common for some of it to die, and when combined with the complications of the additional exposure the overall risk of adverse complications was quite high. By contrast the “free” microsurgical procedure usually results in all the fat being well nourished and surviving, although on rare occasions all of it can die if the joining of the blood vessels fails. In other words there are fewer complications but the ones that do occur are more serious. It is also a less extensive procedure than the pedicled technique but it does require microsurgical expertise that is not universally available.
Having chosen a free autogenous reconstruction from the abdomen there is yet another choice to be made. The original fat transplant was the TRAM flap (Transverse Rectus Abdominis Myocutaneous) in which fat with or without skin also (to recreate the envelope at the same time as the filling) was lifted with underlying muscle and fascia through which the blood vessels nourishing the fat passed (fascia is the important tough layer that holds the muscle in place). This produced a very secure blood supply for the new breast but left a potential deficit in this important layer of the abdomen that required implanting of polypropylene mesh to repair it lest a hernia or weakness develop. This was not such a severe problem if only one breast was being reconstructed but if two breast were needed the damage to both sides of the abdomen was significant and some surgeons were reluctant to inflict this on their patients. I was one of those surgeons concerned about the damage, and for my practice it was particularly important since I was seeing a fair number of young women testing positive for genes associated with breast cancer and requiring removal of both breasts. For these healthy women the trade off of an abdominal weakness was a high price to pay in conjunction with the loss of their natural breasts.
A new technique emerged: the DIEP flap (Deep Inferior Epigastric Perforator flap). In fact this technique is very similar to the TRAM but differs in that the essential but tiny blood vessels are painstakingly dissected out from the muscle and fascia, leaving these important structural elements behind but preserving the nourishment of the fat for transfer. This has several consequences. Firstly the disadvantages: the operation requires a skillful and meticulous technique and takes longer than the TRAM (about an hour longer per breast in many hands). Despite a skilled approach the blood supply to the fat for transfer is inevitably more precarious and so fat necrosis is a little commoner than with a TRAM. But against these there is the advantage that the abdominal wall is secure, no fascia or muscle is lost and no mesh is required for reconstruction.
So, we have a new technique that preserves a strong abdominal wall at the cost of a longer operation and slightly higher fat necrosis rate in the new breast. In both techniques minor complications are common (and this is now emerging from series elsewhere including Glasgow). In fact the two techniques merge into one another as we can take TRAM flaps with less and less muscle eventually reaching the point where they are essentially DIEP flaps and mesh repair of the abdomen is not required. Sometimes the pattern of blood vessels in the abdominal muscles makes raising a DIEP flap difficult and TRAM is the only option. Based on my own experience of these two microsurgical techniques over 10 years I now try wherever possible to use a DIEP flap, but if only one breast is being reconstructed I am prepared to err on the side of safety of the flap and if necessary taking some muscle and fascia rather than risking fat necrosis. On the other hand, if both breasts are to be reconstructed then I will do everything possible to preserve muscle and use two DIEP flaps because the resulting abdominal strength is so important.
Either autogenous technique has some real advantages. Leaving aside the welcome removal of abdominal excess, they create permanent breast fill with no need for revision once they are healed, and with a normal consistency and warmth (because of the arming blood supply). They also create very natural droop. They can be combined with any technique of envelope creation, and they can bring a skin patch from the abdomen with them. We have discovered that they can particularly be used with tissue expanded post-radiation skin envelopes when the blood vessels of the flap have a nourishing and beneficial effect on the irradiated skin envelope. For the irradiated breast this is now definitely the way forward in my opinion, and indeed the two stage technique of tissue expansion and Autogenous fill with a DIEP flap represents in my view the premiere technique for breast reconstruction producing a good skin match with minimal scarring and a natural filling.
Nipple and areola reconstruction is also a misnomer, since we cannot pretend to create more than the appearance of a nipple and areola, and not the erogenous sensibility and erectile qualities of that organ. There are a number of techniques available for reconstruction of the nipple and areola using grafts from other parts to produce the brown dimpled skin of the areola. The most satisfactory of these is by sharing the skin of the opposite areola, particularly suitable if the opposite breast is having surgery for adjustment. Sometimes this option is not available, and skin form the inner thigh or genital area can produce a very satisfactory substitute in terms of pigmentation. Skilled tattooing may augment any deficit in pigment
An important principle in reconstruction of the nipple areola complex (NAC) is that it should be deferred until the breast has achieved its final shape that may be many months after reconstruction. If performed earlier the relative position of the NAC may change and eventually be inappropriate. Moving its position later is difficult if not impossible. For this reason I have favoured using artificial stick on NACs. These are commercially available but are of rather poor quality so that I and others in the area in which I work are very fortunate to have available the prosthetic expertise of the Material Sciences Laboratory in Bradford where Professor Roberts designs and replicates the size shape and tone of the patients own normal NAC in a silicone stick on prosthesis. From this we have learnt that many patients only use the prosthetic NACs occasionally and indeed once provided with a prosthetic NAC of this quality very few go forward with permanent reconstructions the other advantage is that the NAC can be repositioned each time it is worn to take account of the gradual maturation in shape of the new breast.
Surgery to adjust the opposite breast is often required. This is because if the opposite breast has a lot of droop or is excessively large it makes sense to reconstruct a less droopy breast or a smaller breast and then adjust the normal breast to match the new one. The act of reduction or lifting a breast is a simple and infinitely adjustable one and much more predictable than the act of recreating a breast. For this reason I often try to persuade patients to defer these adjustments until the new breast is finally completed and then size and shape can be accurately matched. At the same time if the breast is reduced it may be appropriate to reduce the NAC size and so some areola skin may become available for a NAC reconstruction if wished.
I have tried to set out how my own practice in breast reconstruction has evolved over the last 10 to 15 years. There is much left unsaid, particularly about patient selection and the issues of prophylactic mastectomy and immediate reconstruction: that is mastectomy for someone is likely to develop breast cancer but has not yet done so. In this group of patients and in immediate reconstructions after mastectomy for cancer, the expectation of the patient is very high. They expect to go to sleep with a breast and wake up with a comparable breast, and as I have discussed this is difficult to achieve. These new technique bring us much nearer to that goal, especially the Autogenous methods of filling, but it is still a conceit to think we can reproduce the complexity and subtlety of the female breast and not all patients are suitable for autogenous reconstruction (by reasons of general health or simply inadequate abdominal resources!). These patients must therefore be very carefully counselled to know what to expect realistically and to make their own decision about the risks and benefits of surgery. For the patient with an existing mastectomy, I believe we have seen some great improvements in the quality of reconstruction. The best results in my opinion come from tissue expansion to create the envelope and autogenous fill using DIEP flaps to create the fill. An important discovery in our unit and some others is that this technique can equally well be applied to patients who have been irradiated, allowing them the same benefits of minimal scarring, good skin colour and texture match, and normal living fill. But we should not be complacent: there is still much to do and even when that is done, “breast reconstruction” will still be a misnomer I think.
Professor Simon Kay, Consultant Plastic Surgeon