Breast Reconstruction Sydney

When considering Breast Reconstruction it is important to consider what defines the desirable breast. There are four important parameters that define the beauty of a breast:

  1. Location on the chest wall,
  2. Proportions of the breast in relation to the torso,
  3. Aesthetically pleasing shape, and
  4. Symmetry of both breasts in volume and shape.

Technique

Reconstruction of a breast that has been removed due to cancer or other disease is one of the more complex yet rewarding surgical procedures. Selecting the most appropriate technique and timing for the reconstruction involves complex decision making, dependent on the patient’s preference, their body habitus, prior exposure to radiotherapy and previous surgery.

Breast reconstruction is a multi-staged process requiring many physiological variables but consistent amongst all techniques are the interaction of 3 key anatomical features;

  1. Breast platform,
  2. Volume substitution and
  3. Skin envelope.

The final shape of the breast is never determined by the platform, the volume, or the envelope independently. It is the combined action of these three elements that will result in a pleasing and natural-appearing breast that maintains a stable shape over years.

Breast Platform

This is the footprint that the breast makes on the chest wall, analogous to the outline a house makes on a parcel of land. The platform forms the basis or foundation of the overlying three-dimensional structure of the breast. This platform may vary individually in height and width. Also, the position of the platform on the chest wall may vary slightly from one woman to another.

Breast Mound

This refers to the three-dimensional shape, projection, and volume of the tissue (or implant) on top of the breast platform. In building terms, this is analogous to the size of a building taking into account the number of floors their distribution and external shape. In brief there are 3 options available for mimicking breast volume;

  1. Autologous tissue (patient’s own tissue),
  2. Alloplastic (breast implants) or
  3. Combination of the two.

The decision to choose one technique over the other is highly patient dependent reliant on many factors but primarily on body habitus, prior radiotherapy and the patient’s wishes to return to regular activity.

The autologous options available to patients include lower abdominal tissue (DIEP, SIEA or TRAM flaps), buttock tissue (superior and inferior gluteal artery perforator flaps), groin tissue (transverse upper myocutaneous gracilis flap) and back tissue (latissimus dorsi myocutaneous flap). As the breast is reconstructed from natural tissue, the results have a natural feel and appearance and are longer lasting than an implant based reconstruction. However, this technique is more complex and recovery time is usually longer.

The gold standard when all options are available is a DIEP (deep inferior epigastric artery perforator) flap. This is my flap of choice, as unlike the traditional TRAM (transverse rectus abdominus myocutaneous) flap the rectus abdominus muscle and it’s fascia are not violated in the harvest of this flap. This leads to lower abdominal morbidity in the long term such as abdominal weakness and hernia rates plus it has the added bonus of being a tummy tuck.

Should you not have adequate tummy tissue, then my next flap of choice, is the TUG flap (Transverse Upper Gracilis). This utilises the upper inner thigh tissue which is the tissue that is excised in an inner thigh lift.

Implant based reconstruction can sometimes be performed in one operation with or without the use of a muscle flap from the back (latissimus dorsi flap). However, usually multiple small operations are required. At the first operation an expander is placed under the skin and muscle at the site of the new breast. This is inflated with saline injections over a period of weeks. This act of inflating the balloon acts to recruit soft tissue for future coverage of the implant. At the second operation, usually 3 months later, the expander is replaced with a permanent silicone implant.

Skin Envelope

The quantity and quality of the skin envelope has a major influence on breast aesthetics. A skin envelope of appropriate quantity functions like a well-fitted bra, holding the breast mound, or implant, in an appropriate position. This is the case in immediate breast reconstruction following mastectomy where one only needs to replace the breast platform and breast volume.

Both the quantity and quality of the envelope are severely affected by previous radiotherapy or a delayed reconstruction, and in these cases tissue and volume needs to be important from elsewhere.

Surgery to the other breast is often required or requested by the patient to match the reconstructed breast. This can be in the form of an augmentation, breast lift or breast reduction.
Lastly, reconstruction of the nipple and areolar is usually performed some months later using part of the other nipple or the patient’s tissue from elsewhere.

Timing

Breast reconstruction can be performed at the same time as the breast cancer surgery if the breast surgeon and patient so wish. Some patients prefer this immediacy as they combine the breast cancer and reconstruction surgery in one hospital stay, wake up with a breast mound already in place and are spared the experience of having no breast at all. Otherwise breast reconstruction can be performed at any time after breast cancer treatment is completed.

What are the potential risks and complications?

Breast reconstruction surgery using implants has some inherent risks these include:

  • Infection around the implant
  • Capsular contracture, where firm scar tissue forms around the implant causing it to lose shape and softness. This is particularly pertinent if you have had radiotherapy
  • Implant rupture or failure
  • Leakage of the implant’s contents into the surrounding tissues
  • Asymmetry of the breasts
  • Lumps in local lymph node tissue formed by leaking silicone. These are not serious and don’t cause any health concerns
  • Movement of the implants from their original position
  • Further surgery to treat complications

Breast reconstruction surgery using flaps also has some inherent risks these include:

  • A clot in the blood vessels to the reconstructed breast. With modern microsurgical techniques this is rare, but should it occur can result in the flap tissue dying.
  • Small areas of hardness may develop in the new breast, these are a result of poor blood supply to the fat cells. This is called fat necrosis.
  • Fluid collection, which is called a seroma, under the new breast or where the flap was taken
  • Should you not be a candidate for a DIEP and have a TRAM flap, there is a risk of weakened abdominal muscle, which can result in a hernia.
  • Difference in size and shape between the natural and reconstructed breasts

Cost

Breast reconstruction surgery is a reconstructive procedure and is be covered by private health insurance. You will need to review your policy carefully to determine what is covered.

Should you not have private insurance, I provide a public breast reconstructive service at POW, Royal Hospital for Women’s and Westmead Hospitals at no cost to you.

My policy with all reconstructive cases is as follows:

  1. Private patient in a private hospital: This does incur a “gap-fee” which is dependent on the type of operation involved. This offers you the luxury of choosing your hospital and the date of the procedure. After our consultation my staff will give you an itemised account of the total cost.
  2. Private patient in a public hospital: I charge “no-gap” in these circumstances and I perform the operation. However, the waiting time is dependent on the availability of operating time at one of the public hospitals I work at.
  3. Public patient in a public hospital: In these circumstances you go on one of my public waiting lists . As you will operated on in a large teaching hospital there is a likelihood that an advanced plastic surgical trainee may perform the procedure. Should this be the case, I will directly supervise the operation and I am responsible for your care and your outcomes.

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