The simplest way to reconstruct a breast is by inserting an implant under the skin and muscle. If there is no excess skin, the reconstructed breast could end up smaller than the opposite side and may have an unnaturally round shape.

In ladies who have not had, and do not require radiotherapy, I usually insert a tissue expander through the mastectomy incision. This looks like an implant but can be inserted almost flat to avoid tension on the skin.

Every three weeks saline fluid is injected through a port under the skin to slowly increase the size of the expander. Once the desired size has been achieved the expander is exchanged for a permanent implant. Expanders and implants can be round or have a more natural teardrop appearance (anatomical implant).  

If a patient requires, or has had, radiotherapy I prefer using the Latissimus Dorsi muscle from the back to reconstruct the breast. This is the largest muscle in the body (which pulls the arm towards the body) but it is fairly disposable. Although patients initially experience a decrease in strength (such as when they try to push themselves up from a chair) there is very little functional loss in the long term.

As can be seen in the images below, an incision at the bra line is made. The muscle is lifted, tunnelled to the front and then stitched into the breast cavity. This reconstruction works perfectly well when the patient does not want synthetic implants, as long as the opposite breast is not very large and when there is enough fat over the muscle on the back. When done at the same time as the mastectomy, the back skin can be used as a disc for nipple reconstruction.

If there is not enough volume a prosthesis may still be required. In a delayed reconstruction, skin from the back is often used when necessary.

The skin and fatty tissue usually discarded during a “tummy tuck” can also be rotated into the breast cavity to create a new breast. This is called a pedicled Transverse Rectus Abdominus Myocutaneous (TRAM) flap and usually produces a breast that is soft and behaves like a breast with the scar well hidden on the lower abdomen.

TRAM flaps take longer to perform, giving a higher complication rate (e.g. a risk of clots in the legs) as well as weakness of the abdominal wall.

Free TRAM flaps (the blood supply is reconnected to the blood supply at the mastectomy site) and Deep Inferior Epigastric Perforator (DIEP) flaps (like the free TRAM flap but with less muscle damage) require a reconstructive surgeon with a special interest in micro-surgery.

If you are considering either of these procedures be aware of the risks and ask your reconstructive surgeon how often they have successfully performed the operation.

Written by Dr Carla Norval