Dr Garry Buckland – Plastic and Reconstructive Surgeon

What types of reconstruction techniques are available?

Breast reconstruction techniques range from using silicone gel prostheses through to using your own tissue in the form of Tram flap type reconstructions from the abdomen.  Alternatively a combination of both your own tissue and prosthesis can be used using the Latissimus Dorsi muscle from the back.  Each technique has its own advantages and disadvantages and it is important to tailor the reconstructive technique to the patients’ physical and psychological state.

What type of reconstruction is the most common?

The type of reconstruction depends very much on the patients’ physical and psychological state.  In a preventative or prophylactic setting, implant type reconstructions are commonly used because these give a very youthful breast reconstruction and obtain very good symmetry between sides.  It has to be remembered that preventative mastectomy is most common in a younger patient group and as such symmetry and youthful appearance is important.  It is possible to use Latissimus Dorsi and implant reconstructions bilaterally as is it possible to perform bilateral Tram flaps. 

How long are the first and second operations for expander / implant type reconstructions? What is the recovery time?

The process of two stage expander and implant reconstruction is a relatively short operation compared to using your own tissue.  The first stage of inserting the tissue expander can be done either at the time of mastectomy or sometime after mastectomy.  The operation itself takes approximately 90 minutes and involves the placement of the tissue expander underneath the pectoralis and / or the serratus anterior muscles.  This is done under a general anaesthetic and time in hospital varies from an overnight stay in a delayed reconstruction to somewhere between 4 and 7 days when done at the time of mastectomy. 
           
The second stage of the operation of removing the expander and placing a definitive implant is done at some time after 3 months from the first procedure.  This again is done under a general anaesthetic and can be done either as day surgery or as an overnight stay procedure.  This type of reconstruction is done commonly in the prophylactic setting as it gives a youthful appearance and good volume and position symmetry.  Pre operatively the process involves 2 consultations with your Plastic Surgeon during which time the whole process of the reconstructive journey is discussed.  The pre and post operative restrictions are also discussed so that the patient has a full understanding of what is required during this process.  Pre operatively it is important that all Aspirin and anti-inflammatory drugs and Fish oil are ceased 10 days prior to surgery in order to minimise bruising and swelling and in the post operative period the main restriction is to avoid any heavy lifting or straining as the expander and implant are placed in the sub-pectoral position and as such the pectoralis muscle has to be split in order to allow access.  This is sutured at the time of surgery but does require approximately 4 weeks before healing in complete and allows you to lift again with this muscle.  In terms of recovery after this form of surgery we like to limit the amount of heavy lifting and straining to approximately 5 kilograms or a ladies small handbag / one light shopping bag, this should be for a 4 week period after which time gradual reintroduction of all normal activities is undertaken.   This applies for both the insertion of the expander and also the subsequent insertion of the implant.

How many drains will I have and how long will they be in place for?

Drains are placed at the time of immediate reconstruction when done in combination with mastectomy and or axillary surgery.  There is usually one drain placed in this scenario and it is secured in the axilla in order to minimise any associated scar from the drains.  The drains stay in place until they stop draining.  This is in general terms until they are draining approximately 30ml over a 24 hour period, when they are less than this amount of volume the body is able to absorb this without difficulty and therefore prevent the formation of seromas.  If a seroma is to occur it needs to be drained as it is associated with an increased risk of infection. 

How long before the scars heal?

In general terms wounds heal within a 2 week period and after this time require no dressings.  The scars themselves mature over a much longer period.  This is usually at least 12 months.  This reflects the change in colour of the scar as the body delivers the building blocks for wound healing.  In order to deliver these building blocks it is necessary for there to be more blood vessels provided to the area and as such explains why the initial scar is red.  The scar progresses from being red to pink to purple and back to skin colour white over a 6 to 12 month period.  The rate at which this occurs depends on the background skin type.  If your skin type is pale you tend to restore your scar to a normal colour more quickly than should you have an olive complexion in which case the process is more prolonged.  During this time it is important to moisturise and massage the area regularly and should there be any evidence of hypertrophic (raised or thickened / keloid) scar formation then the application of silicone gel sheeting certainly accelerates this process. 

Will the numbness in my reconstructed breast go away?

The numbness after breast surgery is total initially.  Over a 2 to 3 year period there is certainly an increase in sensation to the reconstructed breast but it never returns to normal. The initial numbness is actually advantageous as it allows the expansion process to occur in a relatively pain free environment.  There is some return of sensation such that the sensation of the expansion process changes over a 3 month period.  There is obviously no return of erogenous sensation to the breast. 

How long are the bandages on after my initial surgery?

I place the wound dressings on at the time of surgery and leave these intact for 7 to 10 days.  These are changed at the first post operative visit.  We endeavour to place waterproof dressings so that the patient is able to shower in the post operative period once the drains are removed.  Once the initial wounds are healed no dressing is required.  This allows regular massaging and moisturising to accelerate scar maturation. 

When can I go back to the gym and return to normal activities?

I like to restrict any upper body exertion or exercise for a 4 to 6 week period after expander and implant type reconstruction.  After this period it is possible to progressively return to normal activities.  It is important to listen to your body during this period of resuming all activities and modify any activities based on how you are feeling.  By waiting for 4 to 6 weeks you allow the muscles to recover and to return to normal function.

I have children, will I need some help and for how long?

There is no doubt that in the initial period help with the family is most important.  Especially with young children who like to be lifted and cuddled, this can be very difficult and obviously they weigh more than 5kg and this activity needs to be avoided during the first 4 week period in order to allow healing to occur in an unremarkable fashion.  Any family support and help is certainly much appreciated and makes the recovery period that much easier. 

Can I see photographs of before and after surgery? 

Your Plastic Surgeon will be happy to show you photos of people both before and after and during the reconstructive journey.  It is important to see a wide range of photos so that you can get an appreciation of the wide range of results that are potentially obtained. 

What is the risk of cancer occurrence after preventative mastectomy? 

Preventative mastectomy removes approximately 97% of the underlying breast tissue.  It is not possible to
remove it in entirety as there are small breast cells that are not visible to the eye which can occur at the margins of the mastectomy excision.  This dramatically reduces your risk of developing cancer in the future but does not remove it entirely.  As such it is very important to continue to have regular follow-up with your breast surgeon and G.P. in order to have regular examinations and detect any anomaly that may occur. 

Is it easy to detect a lump after a reconstruction / mastectomy?  

After a mastectomy and a reconstruction with implants a lump is easily detected as it would occur in the immediate subcutaneous position.  That is the position between the skin and implant. As such it is readily examinable and detectable.  It is important that you are educated on how to examine your breasts yourself and then have regular yearly reviews by your doctor.  There is no role for mammograms in this scenario as clinical examination is able to detect any anomaly. 

Should I donate blood before surgery? 

It is unusual to require blood transfusion after any mastectomy or reconstructive procedure.  Certainly for a mastectomy and implant type reconstruction the incidence of requiring blood transfusion is miniscule.  Should you be undergoing bilateral free tram flap reconstruction after bilateral preventative mastectomy then the incidence of you requiring blood transfusion is slightly elevated and this is something that you should discuss with your surgeon should you be going down this route. 

How do I recognise signs of infection?

The most common timing of infection is between 3 and 7 days post operatively.  The initial signs include redness and swelling around the wound with or without associated fevers.  You can feel systemically unwell with some nausea and headaches.  Should you develop any of these signs or symptoms it is important to contact your surgeon directly and be reviewed at the earliest possible time. 

What are the possible complications from the surgery? 

All surgery has potential complications.  The role of the surgeon is to try and minimise these complications by changing the technique in order to modify risks.  There are risks associated with having an anaesthetic but these are small especially when performed on fit and healthy young women.  The risks of the surgery are the same as any surgery.  These include infection, bleeding, bruising, delayed wound healing, poor scars and infection of the underlying expander or implant.  Whilst it is not possible to eliminate these risks, it is certainly possible to reduce them.  By using a diathermy you are able to minimise the risk of bruising and bleeding as this technique coagulates tissue and blood vessels as it is cut and therefore modifies the amount of bruising.  We use antibiotics at the time of surgery to minimise the risk of both wound infection and infection around the expander or implant.  This is coupled by the use of diligent sterile technique and antisepsis.  Antibiotics are continued in the post operative period in order to minimise this risk. We use internal dissolvable stitches in order to get the best possible scars.  Wound healing is optimised by ceasing all smoking for a minimum of 4 weeks pre and post operatively.  Complications specific to the implants relate to infection in the short to intermediate term and capsular contraction in the long term.  The importance of reducing infection to the implants cannot be underestimated.  It is important that the patients comply with the surgeons’ management regime in order to minimise this risk.  Capsular contraction or hardening around an implant has certainly reduced significantly over the last 10 to 15 years as a result of significant improvements in implant quality.  This process of capsule formation is exacerbated by the potential need for radiotherapy and as such the use of prosthesis in an irradiated woman needs to be considered carefully before making such a decision.  Should capsule formation occur the use of polyurethane coated implants has been shown to significantly reduce the incidence of further capsular formations. 

When should I start wearing a bra and can I wear underwire?

Post operative support bras are important and certainly minimise the amount of bruising and swelling. They also give the patient confidence and support in the early post operative period.  I do not like to use an underwire bra during the first 3 months as I find that these are a little uncomfortable and certainly prevent the implant settling into their normal positions.  That said there are instances where an underwire bra is important for support especially if you have an undesired descent of the implant.  You should discuss this with your surgeon so as to modify the use of post operative support according to your individual circumstances.  Your surgeon should also be able to give you advice as to the type of bra that is most appropriate during your recovery period. 

When do I wear prosthesis if I decide not to have a reconstruction straight away? 

Your Breast Care Nurse will be able to advise you with regard to the wearing of external prosthesis and bras in the post operative period.  This usually comes down to a comfort level and should be able to be undertaken within the first 2 weeks of healing your mastectomy wounds.

What should I expect pain wise? 

Whilst there is always pain after surgery it is always controllable.  It is important that the anaesthetist and surgeon work as a team, and have a recognised regime in order to deal with your pain in the post operative period.  The pain will be dealt on a multi modality basis using a combination of local anaesthetic, oral anti-inflammatory drugs and pain killers.  The pain killers can be initially used through a Patient Controlled Analgesia (PCA) situation whereby you are able to control the amount of pain relief that you receive through your drip.  Subsequent to this you will get oral analgesia which should be given on a regular basis in order to prevent peaks and troughs of pain.  The surgeon will ensure that your pain is well managed.  There is no need for you to suffer from pain, pain can always be controlled. 

How long is the hospital stay for? 

The hospital stay for an immediate reconstruction at the time of mastectomy is usually somewhere between 4 and 7 days for a prosthetic type reconstruction.  When this reconstruction is done with a tram flap it is more like 7 days whilst the latissimus dorsi reconstruction with an implant is more like 5 days.  These obviously change according to individual circumstances but these are ball park figures. 

Expander / Implant Reconstructions

Will I wake up with breasts?

My personal preference when placing an expander in is not to expand the expander at the initial surgery.  This allows the wounds to heal without tension and therefore reduces the risk of potential wound breakdown and post operative infection.  I prefer not to place an immediate implant at the time of surgery as I feel that the position of the reconstructed breast and the end result in terms of breast form is better achieved through a two stage process using an expander to stretch the underlying musculature and skin and then getting the definitive result with an implant in the longer term. 

When do in fills start and how many will I need? 

The expansion process is started between 3 and 4 weeks post operatively.  We fill 100ml per week until we achieve the desired volume.  The amount able to be filled is also dependent on the volume of the expander inserted.

How long will it take between expander surgery and exchange for implant?

I like to wait a minimum of 3 months between the initial insertion of the expander before removing the expander and replacing with an implant.  This allows the issues to mould and stretch over this period and be ready to accept a definitive implant.  At the time of exchanging an expander for an implant, the incision is placed through the previous incisions so that there are no new scars.  The expander is removed, any pocket modification for positioning is undertaken and an implant placed.  I do not use drains at this time.  This procedure can be performed either as day surgery or an overnight stay.  The surgery for exchange takes usually 1 to 1.5 hours per breast. 

Can I pick the size of my implant?

Prior to the exchange process it is important to sit down with your Plastic Surgeon and discuss implant size and shape.  There are many different sizes and shapes depending on your underlying body habitus and your desires in terms of volume.  It is important that the implant matches your torso width and also consideration is undertaken in terms of your height.  These are issues that it is worth spending time with your Plastic Surgeon in order to get right so that you are happy with the end result. 

What kinds of implants are used?

The implants that I use are silicone cohesive gel implants.  They have a silicone shell and a cohesive gel centre.  These are safe and have been subject to extensive testing in order to document this.  I do use polyurethane coated silicone gel implants in patients that have a propensity for capsular formation.  At this stage the variation in implant size and shape in the polyurethane range is a little restricted compared to the other providers but certainly this is a very good technique for this small group of patients that suffer from repeated capsule formation.

Tram Flap Reconstruction

What is the recovery time for this type of surgery?

Tram flaps are long and complicated surgery.  They usually require a period of 7 days in hospital and a 3 to 4 month of recovery before one is able to return to totally normal activities.

What will the scars look like?

With a tram flap there are scars both on the breasts and on the abdomen.  The abdominal scar is the same as an abdominoplasty or tummy tuck operation and extends from hip to hip.  The scar is kept low so it is within the line of the underwear but it is long and little unpredictable in terms of the quality.  This is because it is in a mobile area and obviously there are lots of day to day stresses and strains on this are and such a widened scar can result.  That said tram flap reconstructions provide a very natural soft and supple reconstruction that is permanent and does not require modification at any time in the future.  The reconstruction is warm when you are warm and cold when you are cold and the breasts do fall in a very natural fashion. 

What kind of complications can occur with this kind of surgery?

This said the surgery is long and complicated.  In bilateral circumstances the procedure is done as a free micro-vascular flap whereas in unilateral circumstances it can be done as a either a free micro-vascular flap or a pedicled flap.  The complications of such surgery are the same as any surgery, that being bruising, bleeding , delayed wound healing, infection, poor scars.  These again can be modified by a diligent surgical technique but cannot be eliminated.  The biggest potential complication with tram flap reconstruction relates to the circulation to the breast.  Should the circulation to the breast be inadequate or compromised in the post operative period then this can result in flap death or partial flap death requiring debridement and certainly compromising the post operative cosmetic result.  Again there are techniques in order to minimise the risk for compromised circulation to your flap but it cannot be totally eliminated. The other issue with regard to tram flaps is the potential laxity or weakness in the abdominal region.  There are various techniques to repair the abdomen where the flap has been removed.  It is important during the 3 month post operatively that the abdomen is protected in order to minimise the potential for hernia formation.  Your surgeon will discuss the restrictions with you in the post operative period and it is important that you are very compliant with this in order to minimise the potential risks of such an occurrence.