Knowledge about the timing of reconstruction is also important as several options are available.
Immediate or primary reconstruction is associated with a much lower psychological morbidity than delayed reconstruction. There are fewer operative procedures and anesthetics, together with a reduced hospital stay. This makes immediate breast reconstruction more tolerable for the patient and significantly less expensive. Several recent studies have indicated that there is no risk of delaying subsequent adjuvant therapy.
Delayed or secondary reconstruction is performed at least 6 months following the final adjuvant treatment (i.e. chemo- or radiotherapy). During this period, detailed information about the type of tumor, staging and prognosis are available and the patient has an opportunity to select her plastic surgeon, type of reconstruction and plan the procedure.
Tertiary reconstruction or reconstruction after previous failed attempts can be performed at any time depending on the condition of the local tissues.
Number of procedures
Regardless of the indications, technique or timing of breast reconstruction, the final result invariably involves more than one surgery.
Traditionally, transfer of some local or distant tissue is performed at the first operation to achieve as close a match as possible, in terms of both shape and volume, to the contra-lateral breast. We like to follow the classical principles of sculpture: a block of material, in this instance fat, is placed on a platform, the chest wall. The first operation is intended to create a “basic” shape by transferring a large piece of tissue. The tissue resembles a breast but the final shape and volume have not yet been established. An additional 10-15% of tissue is transferred to allow removal of smaller amounts of fat at a second procedure.
The second operation takes place approximately six months following the initial surgery. The transferred tissue has experienced the effects of gravity, acquired a new, more natural shape and is at its final resting position on the chest wall. Under local or general anesthesia, the second operation is then performed to improve the symmetry between both breasts. The majority of patients do need a second surgical intervention, as it is virtually impossible to obtain a perfect result after only one procedure. However, it is still sometimes possible to achieve a satisfactory result at one sitting. Symmetry is our main goal after the second procedure: it can be achieved by adjusting the reconstructed breast, adjusting the contralateral breast or a combination of both alternatives.
Alterations to the reconstructed breast include nipple reconstruction, scar revision (if required) and shape or volume adjustments. To adjust the volume, again following the classical principles of sculpture, we prefer to remove small amounts of fat and skin excess by relatively simple techniques, such as direct excision and/or liposuction, in preference to adding more tissue. The latter involves more complex techniques, such as local tissue transfer or lipofilling.
Adjusting the shape can be achieved by repositioning and/or rotating the flap. Skin resection and correction of the infra-mammary fold or other borders of the reconstruction, can also help achieve a more aesthetically pleasing result. More and more, small changes in shape can be achieved by less invasive techniques. For example, removing fat by liposuction at one place and adding that same fat to another area by lipofilling. This less invasive surgery also enables a patient to recover more quickly.
The other, natural breast can also be adjusted by augmentation, reduction or a breast-lift (mastopexy). A prophylactic mastectomy with or without reconstruction may also be required.
In reality, it is not always easy to obtain perfect symmetry between both breasts and it may be necessary to repeat flap corrections or adjustments of the contralateral breast. These small “nip and tuck” procedures are tailored to each individual and can almost always be done under local anesthesia. They may need to be repeated until the patient is happy with the result, although their expectations must be realistic. The thoughts and opinion of the surgeon are obviously important but secondary to the wishes of the patient.
At a third operation, 3 months following the last corrective procedure, tattooing of the new nipple and areola is performed. Reconstruction of the areola with skin grafts is no longer done as the results are no better than following simple tattooing. As our eyes are very sensitive to colour differences, bilateral tattooing, even over the normal contralateral nipple-areola complex, provides the most natural results. Unfortunately though tattoos fade over time and may need to be repeated.