Dr Allen Rezai is the lead consultant plastic, aesthetic and reconstructive surgeon at Elite Plastic and Cosmetic Surgery Group in Dubai Healthcare City. He answers Friday’s question about post-mastectomy reconstruction.
What are the different types of breast reconstruction options available to a mastectomy patient?
There are many different options available for breast reconstruction, but these come under two main categories: Implant-based reconstruction and autologous or living, tissue reconstruction.
Implant breast reconstruction, using silicone implants, is good for patients who are not suitable for autologous tissue reconstruction, and of course it can also be used even for patients who specifically request it.
In autologous breast reconstruction, we use the patient’s own tissue from another part of their body, for example from the lower abdomen, to recreate the breast. This will enable nerve regeneration and a faster return of sensation to the reconstructed breast compared to an implant-based reconstruction. Another important and positive factor is that breasts reconstructed in this way will grow and shrink naturally as one’s weight changes, thereby keeping the reconstructed breast in proportion to the rest of the body.
I prefer to use the techniques of autologous tissue reconstruction, especially the Diep (Deep Inferior Epigastric Artery Perforator) Flap technique, when possible. I believe that this will produce breasts with the most natural look and feel, and they will remain with a woman for life, whereas synthetic implants will eventually need replacing. However, some patients do not have the right indications for this option or simply prefer the option of implant breast reconstruction.
Why are patients who have undergone radiation therapy before a mastectomy advised against having breast implants?
Radiotherapy is excellent for killing cancer cells, but at the same time it also affects the non-cancerous normal tissue, including the skin. Radiation makes the skin fragile and not strong enough to stretch to accommodate the implant. Furthermore, the risk of implant-related complications and the body rejecting the implant is high when a patient has undergone radiotherapy. The best reconstruction options in these cases would be natural tissue breast reconstruction, especially Diep flap reconstruction.
How complicated is the diep flap breast reconstruction surgery and why is it so complex?
There are two main types of autologous reconstruction techniques, muscle flap reconstruction, also known as pedicle flap, and those involving perforator ‘free’ flaps, the latter being the most advanced method of autologous reconstruction and requiring microsurgical expertise.
The diep flap is a perforator flap and uses the ‘free flap’ technique. This means that a diep flap consisting of skin, fatty tissue and tiny blood vessels that supply nutrients to the tissue is completely detached from the surrounding tissues at the lower abdomen (hence the name ‘free’ flap), transferred to the breast reconstruction site, and the blood vessels are then re-connected to vessels close to the breast using microsurgical techniques, ensuring that the flap receives the blood supply necessary for survival.
This procedure is generally performed by a team of at least two surgeons, and takes anywhere from six to eight hours to complete, being lengthy due to the precise nature of the micro-surgery. However, the effort is rewarded by excellent aesthetic results. The procedure is ideal for anyone who would also benefit from having abdominoplasty surgery [aka ‘tummy tuck’], since the resultant effect on the abdomen will be very similar to this.
With breast reconstructions, are all parts of the breast, such as the nipple, reconstructed too? What role does a 3D nipple tattoo have in the reconstruction?
Generally, the nipple and areola are removed during mastectomy as a precaution against leaving lingering cancer cells behind, unless the patient has nipple-sparing mastectomy and immediate reconstruction after which she will have her own natural nipples on her reconstructed breast but with possibly diminished sensation and response. In those cases where the nipples must be removed then nipple reconstruction can be performed during an immediate reconstruction, but is more commonly performed 4-6 months after the breast reconstruction is complete.
However, there are several factors to consider about the new nipple. The reconstructed nipple will not react in the same way to temperature changes or touch; it will not have the same sensation as a natural nipple; it will not grow and flatten as natural nipples do; and it will have no feeling. But in spite of these drawbacks, it makes a significant contribution to the overall naturalness of the new breast. Nipple reconstruction is certainly not a necessity, it is rather a choice. Some patients choose to not have their nipples reconstructed and are happy with how they are and opt for only a tattoo instead. The 3D tattooing will only give the appearance of a nipple and not the physical shape, whereas a combination of tattooing and surgical nipple reconstruction will produce nipple with an areola complex, very similar to a real nipple areola complex.
Are all breast reconstructions done immediately after the mastectomy in one go?
Breast reconstruction can be done at different times, depending on the patient’s circumstances and stage of cancer. It can either be performed at the same time as the mastectomy, or weeks, months, and even several years after the mastectomy.
Generally patients who choose to have prophylactic (preventative) mastectomy or those who are diagnosed with stage I or some stage II cancer are good candidates for this option. In some cases, this option may even be appropriate for stage III and IV cancer patients, but this is something that the patient needs to discuss with her oncologist and plastic surgeon.
Factors such as stage of breast cancer, patient’s medical condition, patient’s preference and lifestyle and whether or not additional therapies, such as radiation, are needed to treat breast cancer, are taken into consideration when determining the timing of reconstruction.
Can reconstructive surgery guarantee the feel and weight of natural breasts?
No, sadly not! It is important to understand that reconstructed breast will never feel 100 per cent like a real breast, but depending on the method of reconstruction it can be a close match to the natural breast.
Both implant and natural tissue breast reconstruction techniques recreate cleavage, projection, and the soft contours of a woman’s natural breast but many times, due to mastectomy and various cancer treatment therapies, the skin elasticity and sensation will be impaired. Still, the autologous tissue reconstruction produces breasts with the most natural look and feel, and the new breast will remain with a woman for life. I prefer to use this technique whenever possible but some women do not have the right indications for this option or simply prefer the option of implant breast reconstruction, in these cases a dermal mesh with or without fat transfer may be used to achieve a more natural feel.
What are the risks of breast implants? Are there chances of infections or leaks? How safe are implants for breast cancer patients?
The new generation of cohesive gel implants are generally quite safe, and if the patient has the right indications for implant breast reconstruction, and the procedure is performed by a skilled plastic surgeon, the risk of infection is very minimal. There are however, specific risks associated with breast implants, which again are rare but may occur. These include leakage and rupture of implant, which nowadays do not cause any health issues for the patient, and is treated by replacing the ruptured implant with a new implant. Then there is capsular contracture, which is hardness of the capsule surrounding the implant and the risk of this is very high if patient has had radiation. BIA-ALCL is another implant associated complication, which is quite new and extremely rare; it affects the immune system and lymph nodes.
What are the risks or side-effects for a diep flap breast reconstruction?
If the patient has the right indications for diep flap reconstruction and it is performed by a skilled surgical team, then the risks are minimal. There will however be some disadvantages, like longer surgery time and having more than one scar as there will be a scar at the donor site as well as the reconstruction site. But the benefits always outweigh the risks when it comes to diep flap reconstruction, especially when performed by a skilled and experienced team.
What if any are the psychological benefits of a breast reconstruction for mastectomy patients?
I strongly believe that breast reconstruction plays an important factor in a woman’s psychological and physical recovery after having mastectomy. But this is a highly personal decision. Some women may decide, for various reasons, that they are not yet ready to take this step, or they simply do not want to undergo any further surgeries. Whereas others feel the need to have this procedure in order to feel whole or like their ‘old self’ again.
How affordable are breast reconstructions in the UAE? Is the procedure covered by insurance if it is for a breast cancer survivor?
Understandably, the natural tissue breast reconstruction, especially diep flap reconstruction, costs more compared to implant based reconstruction, but I am happy to say that most insurance companies do provide cover for breast reconstruction to cancer survivors, however, the level of cover varies depending on the type of reconstruction, and sometimes patient may need to contribute financially towards the cost of their surgery.