Breast reconstruction and mastectomy

Treatment for early breast cancer aims to remove the cancer and reduce the risk of it spreading or coming back. One of the main treatments is surgery.

Types of breast cancer surgery#

There are two main types of surgery:

• Breast-conserving surgery (also called wide local excision, lumpectomy or partial mastectomy) – only part of the breast is removed.
• Mastectomy – the whole breast is removed.

Breast-conserving treatment, followed by radiotherapy, is just as effective for surviving breast cancer as a mastectomy, and you may be able to choose between the two.

Sometimes the size and location of the cancer mean that mastectomy offers the best chance of removing all of it, for example if the cancer is large compared with the size of the breast, or is in more than one area. Women undergoing mastectomy should be offered a choice about whether or not to have breast reconstruction.

Women who choose not to have reconstruction have a mastectomy with an aesthetic flat closure, sometimes called “going flat” or “living flat”. There are several reasons for this choice, including personal preference, health issues that make further surgery inadvisable, and concerns about cost.

For women who choose reconstruction, it can be done at the same time as the mastectomy or in a separate operation later. Reasons for choosing reconstruction include achieving a similar appearance to the original breast when wearing normal clothes, and managing the emotional aspects of the experience.

Your doctor should discuss your situation in detail, including the options of having or not having reconstruction, before you make any decisions. You might also like to speak with a specialist breast care nurse about your options.

Breast-conserving treatment#

During breast-conserving treatment, the tumor, some of the surrounding breast tissue (the margin) and nearby lymph nodes in the armpit are removed. Most of the breast remains, although it may be smaller and a different shape to the other breast.

A follow-up operation is sometimes needed to make sure the margin of tissue around where the tumor was removed is free of cancer. After breast-conserving surgery, most people are advised to have radiotherapy, which uses high-energy X-rays to kill any remaining cancer cells in the breast or armpit.

Some studies suggest women may have fewer body image and sexuality concerns after breast-conserving treatment than after mastectomy.

Mastectomy#

Mastectomy removes the entire breast. Usually the underlying chest muscles remain intact.

In most cases, breast cancer surgery also involves removing one or more lymph nodes from the armpit (axilla). Lymph nodes are found throughout the body and help protect against disease and infection. The lymph nodes near the arm are often the first place breast cancer cells spread to outside the breast. They may be checked using a sentinel lymph node biopsy or an axillary lymph node dissection.

Recovery from mastectomy may include a hospital stay of between two and seven days. In some cases, radiotherapy and chemotherapy are used after the operation.

Risks and side effects of surgery#

All types of surgery carry risks. Before your operation, talk with your doctor so you understand what to expect in terms of recovery time, the care available to you, and the side effects that may occur. Possible complications include infection, death of tissue along the edges of the incision, and post-mastectomy pain syndrome (sharp pain on the chest wall).

Side effects that can occur in the first few months after surgery include:

• Numbness or pins and needles – surgery may damage nerves, causing numbness across the chest or in the armpit and arm. This can improve but may not go away completely.
• Seroma – fluid may collect in or around the scar and can last up to six weeks. Your doctor or breast nurse can drain it if needed.
• Shoulder stiffness – exercises can help prevent or manage this. A physiotherapist or occupational therapist can advise you.
• Cording – caused by hardened lymph vessels, this feels like a tight cord running from your armpit down the inside of the arm, sometimes to the palm.
• Lymphoedema – swelling of the arm if lymph nodes in the armpit have been removed.
• Breast pain, changes in balance, fatigue, depression and anxiety.

There is a lot that can be done to improve many of these side effects, so it is important to discuss any concerns with your specialist or breast care nurse. Talking to a counselor or psychologist may also help. For most women, breast surgery brings up difficult emotions, and feelings of sadness, anxiety and low self-esteem are very natural. Knowing where to get the right help will help you cope better.

Breast forms (prostheses)#

After breast surgery you may be given a temporary “soft form”, a soft breast-shaped cushion that you pin inside your bra. After around two months, once you are no longer sore and your wound has healed, you can be fitted for a permanent “breast form” or external prosthesis.

A permanent prosthesis is generally made of medical-grade silicone gel and worn inside your bra. It is weighted to restore your balance and moves and looks like your other breast under normal clothes. It is best fitted by an accredited breast prosthesis fitter to make sure the size is right. Your breast care nurse can advise you on services in your area.

Breast reconstruction#

If you decide reconstruction is your preferred option, you can discuss the timing with your surgeon. Reconstruction can be done at the same time as the mastectomy (immediate reconstruction) or later (delayed reconstruction).

A reconstructed breast will not look or feel the same as your original breast, but in normal clothes you may look similar to before. Depending on the type of reconstruction, you may have scars on your breast and on other parts of your body. There is no single method suitable for all women. The type recommended depends on your body shape, general health and personal preference. Reconstruction is a significant operation and needs substantial recovery time, so ask your treating team any questions you have.

There are two major types of reconstruction: implant reconstruction and flap reconstruction.

Implant reconstruction#

An implant is a sac filled with silicone gel or saline that creates a breast shape. It is placed under the skin and muscle.

You may have implant reconstruction as a one-stage or two-stage operation. In the one-stage operation, the surgeon places a permanent implant during the mastectomy. In the two-stage operation, a tissue expander is first used to inflate and stretch the skin so there is room for the implant. Afterwards you will have a scar on the breast, the type depending on the incision your surgeons choose.

Silicone gel implants are used in almost all implant reconstructions. They are filled with a soft, semi-solid cohesive gel that is quite firm and holds its shape. The surface can be smooth (micro textured) or rough (macro textured); textured implants grip tissue better and are less likely to move. Saline implants are no longer commonly used, as they are more prone to deflation and may need a further operation to replace. The main drawback of implants is that they may not look or feel like natural breasts, particularly after aging or weight changes.

Flap reconstruction#

If you have larger breasts, do not have enough skin to cover an implant, or prefer not to have one, a flap method may be used. In flap reconstruction, skin, fat and sometimes muscle are taken from elsewhere on the body to make the new breast. The methods are often named after the muscles or blood vessels used.

• TRAM flap – particularly suitable for women with loose abdominal skin. A section of skin and fat from the tummy is removed (similar to a “tummy tuck”) and transferred, along with a tag of abdominal muscle and two blood vessels, to the chest. The flap’s blood vessels are connected to vessels of the armpit or beneath the ribs, then the flap is shaped into a breast. This offers a more natural-looking breast with normal “hang” than an implant, but leaves a large scar across the abdomen. The reconstructed breast will change size if you gain or lose weight.
• DIEP flap – uses only skin and fat to reconstruct the breast. Unlike the TRAM flap, the abdominal muscle is not used, so supporting mesh is not required and you can maintain your core strength long-term. It allows a quicker return to normal activities and a smaller risk of hernia, and is now often the preferred flap method because of fewer complications and faster recovery.
• Latissimus dorsi (LD) flap – muscle from the back and the overlying skin are used to form a breast shape, often filled out with an implant. The back is left with a visible scar and slight hollowing near the shoulder blade.
• Buttock flap – a small flap from the gluteus muscle is sometimes taken if the abdominal skin is not sufficient. A vein needs to be taken from one leg to supply blood to the tissue in its new location.
• Inner thigh (TUG) flap – uses skin, fat and muscle from the upper inner thigh.
• Hip flap – a flap of skin from the hip may be used if the abdomen and buttock are unsuitable.

As with all operations, there is a risk of complications, such as problems with healing, the anesthetic, infection, bleeding, loss of sensation, and muscle problems. If these happen, recovery takes longer. Many complications are temporary, but some may be permanent, so discuss possible problems with your surgeon or breast care nurse before the operation.

Nipple reconstruction#

It is best to wait at least three months after breast reconstruction before having nipple reconstruction, to allow the new breast time to “drop” into position. The new nipple is fashioned using skin flaps from the abdominal scars or the reconstructed breast. It can then be medically tattooed to match the color of the existing nipple and areola, although this is optional.

The reconstructed nipple will not have any feeling. Some women prefer to use a nipple prosthesis, attached with special glue, while others choose nipple tattoos.

Making your decision#

After a mastectomy there are various choices available. Reactions to the loss of a breast vary from woman to woman, and only you can choose what feels best for you. It is important to understand the advantages and disadvantages of having or not having reconstruction, and to discuss them with your surgeon and treating team. A team of breast cancer specialists, which may include a breast surgeon, reconstructive (plastic) surgeon, medical oncologist and radiation oncologist, can provide support, information and referrals at all stages of the experience. Peer support communities and breast care nurses can also be valuable sources of help.

Key points#

• Treatment for early breast cancer aims to remove the cancer and reduce the risk of the cancer spreading or coming back
• One of the main treatments for breast cancer is surgery
• Breast-conserving treatment, followed by radiotherapy, is just as effective in surviving breast cancer as a mastectomy
• After breast-conserving surgery most of the breast remains, although it may be smaller than (and a different shape to) the other breast
• All types of surgery carry risks

Where to get help#