BREAST RECONSTRUCTION

Your Journey, Your Choice

Woman wearing pink boxing gloves and a pink ribbon top, symbolizing breast cancer awareness. Breast Reconstruction.

Breast reconstruction aims to rebuild the breast following mastectomy. If you need to have a mastectomy for breast cancer, breast reconstruction can improve your body image and self-esteem, helping the process of recovery on a physical, emotional and psychological level. Breast reconstruction is now an integral component of breast cancer therapy and any woman undergoing mastectomy should have the opportunity to discuss her reconstructive options with her surgeon before the procedure, both in the public and the private sector. 

Breast reconstruction can be classified based on the composition as well as the timing relative to mastectomy, as summarised in the table below. 

Chart titled "Classification of Breast Reconstruction" with sections for composition and timing. Composition includes Autologous (tissue/flap), Prosthetic (implant), and Combined. Timing includes Immediate, Delayed, and Delayed immediate.

Implant or Tissue Breast Reconstruction?

Breast reconstruction may be done either with your own tissue that is relocated as a flap from another part of your body onto your chest (autologous reconstruction) or with the use of silicone implants (prosthetic reconstruction). Although falling out of favour, a combination of tissue and implant reconstruction may also be used as well when there is not enough tissue to achieve the desired projection with a full autologous reconstruction. However, in most of these cases addition of fat grafting can provide the extra volume required therefore avoiding using a prosthetic material all together.

Implant reconstruction is by far the most common type of breast reconstruction performed worldwide. This is due to multiple factors:

  1. Lack of suitable donor sites for tissue reconstruction

  2. Extra costs and skillsets required for tissue reconstruction

  3. Additional scars and complications associated with tissue reconstruction

Various silicone breast implant samples displayed on a table, with a hand touching one implant. Implant breast reconstruction.

The implant technology has significantly improved over the years, and we now have a wide range of safe silicone implants available to suit most patients’ anatomies and desires. Our improved understanding of the surgical oncology of the breast has allowed less invasive mastectomies with preservation of skin, nipple, underlying pectoral muscle and ligamentous boundaries of the breast which will serve as a perfect template to fill in a with suitable silicone implant avoiding the added operative time, complexity, and complications of tissue reconstruction. In addition, the availability of a wide range of synthetic meshes and allografts and fat grafting has significantly added to our armamentarium for a durable, appealing and safe implant reconstruction.

Having said that, autologous reconstruction offers some unique advantages over prosthetic reconstruction and if available should be offered to patients undergoing mastectomy. 

  • Long-term durability: Although breast implants don’t have an expiry date, the average shelf-life for breast implants is 15 years and more than 60% of women will need some sort of revision surgery within this time for rupture, capsular contracture or other complications. On the other hand, tissue reconstruction is rather a one-time, long-term investment. Your initial extra operating and recovery time is well spent for years of natural look and feel.

  • Avoid foreign materials: Infection is the biggest risk associated with the use of any foreign body material and occurs in about 10% of implant reconstructions. In addition, other risks associated with the use of breast implants include implant rupture, rotation, migration, rippling, capsular contracture and Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).

  • More natural feel and appearance: Despite the advancement in implant technology and reconstruction techniques, still tissue reconstruction offers the most natural look and feel to the reconstructed breast. In addition, it is more congruent with the rest of the body as it goes through aging and weight fluctuations. This can be particularly important for women who desire a more organic look and feel. However, some women may prefer the augmented breast look that is offered by implants.

  • Better symmetry: Tissue reconstruction may allow for a more symmetrical outcome, particularly when combined with procedures like fat grafting or breast reduction of the unaffected side to match the reconstructed breast. Matching an implant reconstruction with the contralateral breast is particularly challenging and often needs a smaller implant placed in the unaffected side to achieve symmetry.

  • Improved outcome with radiotherapy: Implant reconstruction and radiotherapy don’t go well together. This is due to increase skin shrinkage and capsular contracture associated with radiotherapy. Although implant reconstruction is not contraindicated, tissue reconstruction is the preferred form of reconstruction if post mastectomy radiotherapy is planned. 

Advantages of Tissue Reconstruction

Immediate or Delayed Breast Reconstruction?

Clearly from an aesthetic and psychosocial point of view, immediate reconstruction is preferred. By undergoing immediate reconstruction your surgeon will be able to preserve skin and the anatomical landmarks of your breast which will allow for a better aesthetic outcome, and you don’t have to go through the emotions of waking up from the general anaesthetics with a flat chest. However, in certain situations you may prefer a delayed reconstruction. There is often a lot to be considered and discussed if you are having breast reconstruction which you may find overwhelming. In particularly advanced cases delayed reconstruction may allow for a quicker progression through surgery and adjuvant therapy with less potential for delay.

Delayed immediate reconstruction is an alternative approach often employed in the setting of post-mastectomy radiotherapy. As mentioned before, implant reconstruction and radiotherapy don’t go well together. However instead of doing an immediate tissue reconstruction and then radiating the new reconstructed breast, in delayed immediate reconstruction a tissue expander is placed to preserve the skin and the anatomical landmarks in the first stage. The adjuvant therapies including radiation are then delivered, followed by second stage autologous reconstruction. With this approach the potential damaging effect of radiation on the reconstructed breast is avoided. In addition, a complex lengthy tissue reconstruction is reserved for a more convenient time following delivery of more urgent adjuvant therapies. Moreover, the patient may feel less pressured with many decision makings required in relation to both cancer therapy and breast reconstruction.

Breast implant expander with syringe illustration. Tissue expander.

Additional Resources