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Indication: Breast reconstruction is a cosmetic surgery done after mastectomy (removal of breast as a treatment for breast cancer) where breast will be rebuilt using either natural tissue from the one,s own body (called autologous) or using artificial implants. This procedure can be immediate, delayed or immediate-delayed.
Whatever may be the type of surgery, general anesthesia is given to make you asleep so that you will not feel the pain during surgery.
Immediate- Reconstruction is done during your mastectomy surgery itself. A method called skin-sparing mastectomy may be used to save enough breast skin to cover the reconstruction.
Delayed- Here the surgeon will rebuild the breast, after your chest has healed from the mastectomy and you have completed adjutant therapy.
Immediate-delayed- With this, your doctor will place a tissue expander under the skin during the mastectomy to preserve space for an implant while the breast tissue is removed and sent for histopathological examination. If your doctor decides that you do not need a radiation therapy, then an implant can be placed where the tissue expander was, without further delay. However, if you need radiation therapy after mastectomy, then your breast reconstruction will be delayed until your radiation therapy is completed.
Breast reconstruction using the natural tissue includes taking tissue containing skin, fat, blood vessels, and sometimes muscle (called the flap) from different body sites like:
Deep inferior epigastric artery perforator flap (DIEP or DIEAP)
Transverse upper gracilis flap (TUG)
In these methods, the doctor will make a cut on the skin depending on from where the flap is being taken. This flap tissue is taken and placed in your breast area to create your new breast. During this method, the arteries and veins are cut and reattached to blood vessels under your arm or behind your breastbone. This tissue is then shaped into a new breast. Your doctor will match the size and shape of your remaining natural breast as closely as possible. After completion of the procedure the skin is closed with sutures. When breast reconstruction is done at the same time as a mastectomy, the entire surgery may last 8 to 10 hours. When it is done as a second surgery, it may take up to 12 hours.
If you are undergoing Breast reconstruction using implants then it will be done in two stages: In the first stage your doctor creates a pouch under your chest muscle, where a small tissue expander (balloon-like made of silicone material) is placed. A valve is connected to the expander by a tube. For 2-3 weeks, the chest looks flat itself after which you will have to visit your doctor every 1 or 2 weeks. During these visits, your doctor will inject a small amount of saline (salt water) through the valve into the expander. Over time, the expander slowly enlarges the pouch in your chest. When it reaches the right size, you will have to wait for 1 to 3 months. In the second stage your doctor will remove the tissue expander from your chest and replaces it with a breast implant which can either be of saline or silicone gel. This surgery takes 1 to 2 hours.
Which type of implant you want can be discussed with your doctor before surgery.You may have another minor procedure later to remake the nipple and areola area. You may need to stay in the hospital for 2-5 days depending on the procedure you have undergone. Reconstruction using natural tissue is slightly complicated compared to implants. So you may need to stay 2-3 days more in the hospital after the surgery. You may also need blood transfusion for the procedure.
Self-care instructions: Do's and Don'ts after breast reconstruction:
Keep the wound clean and dry. If you have undergone a flap surgery then the wound at the donor site also has to be taken care of.
Drains may be still present when you go home. Your doctor will teach you how to take care of it at home. It will be removed after few days (usually after 1-2 weeks) when you visit your doctor for check up.
You can take sponge bath above your waist and shower below your waist after the surgery. After your drains are removed you can take a shower but confirm with your doctor.
Do not apply a heating pad or warm compress directly on the breast mound
Due to changes in the sensation over your breast, you may burn your skin. So be careful.
You will have to limit upper body exercises after the surgery.
Never get up directly from the lying posture. Instead turn to one side and then get but not on the side of surgery.
Even though you have undergone a breast reconstruction you will still have to undergo investigations regularly to rule out recurrence of cancer. Reconstruction does not make it harder to locate the tumour if any. However if you have got an implant, then the chances of recurrence may be less.
Common things to expect at home: Recovery usually takes 3-6 weeks4 but you can be back to normal only after 6-8weeks.
You may have pain around the cut in your skin, for which you need to take pain relievers as your doctor's prescription.
You may also feel tired and sore for a week or two or even more after the surgery.
Sometimes fluid may get collected under the incision which resolves on its own. But rarely drainage may be required which will be done by your doctor on an out patient basis.
There may be no normal sensation of the new breast, nipple and the areola but some may be restored after a few years.
If you have undergone autologous breast reconstruction you may have weakness at the donor site, like the abdominal weakness. Physical therapy may help you make up for weakness.
Risks with implants
Pooling of blood (haematoma) within the reconstructed breast
Extrusion of the implant (the implant breaks through the skin)
The implant may break or leak in the first 10 years. If this happens, you will need more surgery.
A scar may form around the implant in your breast. If the scar becomes tight, your breast may feel hard and cause pain or discomfort. This is called capsular contracture. You will need more surgery if this happens.
Infection soon after surgery. You would need to have the expander or the implant removed.
Breast implants can shift. This will cause a change in the shape of your breast.
One breast may be larger than the other (asymmetry of the breasts).
You may have a loss of sensation around the nipple and areola.
Risks with autologous tissue
Necrosis (death) of the transferred tissue
Loss of sensation around the nipple and areola
One breast is larger than the other (asymmetry of the breasts)
Loss of the flap because of problems with blood supply, requiring more surgery to save the flap or to remove it
Bleeding into the area where the breast used to be, sometimes requiring a second surgery to control the bleeding
Pain and weakness at the site from which the donor tissue was taken
Risks of any surgery
Blood clots in the legs that may travel to the lungs
Heart attack or stroke during surgery
Infection at the surgical wound, lungs (pneumonia), bladder, or kidney
Schedule for Consultations/Diagnostic tests: The follow up schedule depends on the type of reconstruction you have undergone. Few types of surgeries will require visit to your doctor every week.
Once the reconstruction is completed, you will have to get investigations done regularly to check for recurrence of cancer. You may be advised to get Magnetic Resonance imaging (MRI) done at regular intervals. The first scan may be done 1-3 years after the reconstruction. Thereafter every 2 years you will have to get the scan done.
Recommended Physical Activities, Do's and Don'ts: Exercises play a very crucial rule after the reconstruction surgery to prevent stiffening of shoulder and also regaining of the muscle strength. Different exercises are advised at different points of time depending on the range of movements that can be done.
First 1-2 weeks: Shoulder shrugs, Shoulder rolls, Shoulder raise, Arm swings, Body turns (rotations)
At 3-4 weeks: Lifting your arm above your head, Walking your fingers up the wall, Walk your fingers up the wall sideways, Beach pose, Chest stretch
Start with 5 and gradually increase to 10 by 3 weeks. Repeat these every 2-3 hours.
After 6 weeks: You will be able to do most of your normal activities. If you are still having difficulty then you may need some extra exercises from a physiotherapist. Continue walking and start to increase the distance and pace gradually.
The exercises have to be continued even when you have full movement in your shoulder. On some days you may have shoulder stiffness, which usually settles over time.