• When should I consider risk-reducing surgery?
• What is breast reconstruction?
• Can I keep my nipples?
• What are the different types of reconstruction surgery available?
• What are the risks of complications following breast reconstruction?
Bilateral risk-reducing mastectomy is the removal of both breasts and lowers the risk of breast cancer in women at high risk to less than 5%.
When should I consider risk-reducing surgery?
It is not possible to tell you when you will develop breast cancer but we can estimate what the risk of breast cancer is at any given age and how that risk will change within the next five to ten years. It is important to consider the pattern of breast cancer in your family. If there are relatives who developed breast cancer before age 35 then there is a greater chance of you developing breast cancer at an earlier age.
Your decision will also be influenced by the impact breast cancer has had on close relatives, whether you are in a relationship, have children and how you feel about losing your breasts.
You will receive advice from medical professionals, friends and relatives but the decision is yours to make. You need to understand not only what your risk of breast cancer is but also what is involved in having surgery before making the decision. Take time to gather information, discuss your options with your breast surgeon and breast care nurses. The information booklet “understanding risk reducing breast surgery” available from Macmillan cancer support is very helpful.
What is breast reconstruction?
Risk reducing surgery involves removal of the breast tissue, known as mastectomy. Without reconstruction the chest wall will be flat and you would have the option of wearing breast prostheses in your bra.
Reconstruction surgery re-creates the breast mound below the skin and can be done at the time of the mastectomy or at a later date.
With immediate reconstruction it is possible to preserve more of the skin envelope and in many cases the nipples, which can give a more natural appearance.
Your decision may be influenced by your body size and shape, your general health, your lifestyle and relationships. Breast reconstruction should be viewed as a process, rather than as only one operation. It may take a number of operations to get the desired cosmetic result, or to treat complications that develop due to the effects of time and gravity (such as capsule thickening around an implant and increasing breast asymmetry).
The aim of breast reconstruction is to provide breast that will look natural when wearing a bra but the breasts will look and feel very different after surgery.
Can I keep my nipples?
Following breast risk reducing surgery the risk of breast cancer has been reduced to less than 5%. During surgery the surgeon aims to remove as much of the breast tissue as possible but clusters of breast tissue cells will remain beneath the skin. Over recent years with more experience in risk reducing surgery it is accepted that preserving the nipples does not significantly increase the risk of breast cancer.
A pathologist examines the breast tissue removed to determine whether there are any small breast cancers present in the tissue. If this is the case further surgery or treatment may be required.
When the nipples are preserved, it is only the coloured skin that remains. All the tissue behind the nipple is removed and this means the nipple will not respond to stimulation and often feels numb.
Your surgeon will advise you as to whether it will be possible to conserve the nipples and this will depend on the size and shape of your breasts and the type of reconstruction being considered. It is less likely to be suitable for women with large heavier breasts and for women who are smokers.
What are the different types of reconstruction surgery available?
There are two main types of reconstructive surgery. The majority of women now decide to have implants inserted to recreate the breast mound.
It is also possible to use muscle and or fatty tissue from another part of your body to recreate the breast, and this is referred to as autologous reconstruction.
Implant based reconstruction has the advantages of having a quicker recovery time with no additional scars to those on the breasts but it is more likely that you will require additional surgery in the future.
The implant is placed in a pocket formed by the muscle of the chest wall and more recently artificial tissue that acts as a fabric has been developed which can be used to make a larger pocket resulting in a more natural contour of the reconstructed breast.
LD Flap using the latissimus dorsi muscle from your back, with or without an implant may be recommended if you are having surgery on one breast after breast cancer and then 30 will have the other breast removed at a later date. It will give a softer more natural feel but will have an additional scar on the back and recovery will take longer.
TRAM flap reconstruction using the rectus muscle from your tummy gives a more natural feel and movement of the breast but means there is an additional scar across your lower tummy, and recovery from surgery is slower and may mean taking three months off work. The muscle that would have helped when doing a sit-up no longer works and the abdominal wall is weaker.
DIEP flap reconstruction uses the tummy fat without using the muscle, which gives a soft breast and does not interfere with the strength of the abdominal muscles.
Your surgical team will advise you as to which types of reconstruction would be best suited to you.
What are the risks of complications following breast reconstruction?
In about 10% of cases women may need to have the implant removed due to complications. It may take several months before further reconstruction surgery can be performed. With a tissue flap there can be problems with the blood supply to the flap and problems on the back or tummy where the flap has been taken from. After a TRAM flap operation there can be bulging of the abdominal wall and weakness of the tummy muscles.
Surveys have shown that 80% of patients were happy with their appearance when wearing a bra but this means that 20% of women were disappointed.
It is simply not possible to reconstruct a breast that is as good or as natural as one’s own breast. Surgeons aim to make a reconstructed breast that looks symmetrical with the other breast when wearing a bra.
However, out of a bra, it will be obvious that the breast has undergone major surgery and a reconstruction. In general, the reconstructed breast sits higher on the chest wall than a natural breast, is firmer to touch, the skin may feel numb and much less mobile. A reconstructed breast does not necessarily look, move or feel like a normal breast. Wome