Mastectomy & Reconstruction
A mastectomy is surgical excision of the whole breast for the treatment or prevention of breast cancer. The tissue removed is sent to the pathology laboratory to be analysed under the microscope.
There are three main types of mastectomy depending on how much skin is removed and whether or not the nipple-areolar-complex (NAC) is preserved:
- Simple mastectomy (SM): removing the breast tissue including the skin and NAC with the end result being a flat chest wall and a transverse scar. This is done in the setting of no immediate reconstruction. Delayed reconstruction is possible with tissue-based techniques.
- Skin-sparing mastectomy (SSM): removing the breast tissue and NAC but preserving a skin envelope. Immediate reconstruction is performed which can be tissue-based or implant based.
- Nipple-sparing mastectomy (NSM): removing the breast tissue while preserving a skin envelope as well as the NAC. Immediate reconstruction is performed which can be tissue-based or implant-based.
What does reconstruction involve?
Reconstruction refers to replacing breast tissue following a mastectomy. It can be done at the time of the mastectomy (immediate) or may be done at a later date (delayed).
Reconstructive options include tissue-based and implant-based techniques:
This is the use of your own tissues to make a new breast.
Two main options exist – one is rotation of a flap to fill the cavity, the other is using tissue from a different part of the body to make a new breast (called a free flap).
The most commonly used tissue is your lower abdominal fat (the same fat removed for an abdominoplasty or “tummy-tuck”. This is removed together with its blood vessels which are joined to blood vessels from the chest wall. The tissue is shaped like a breast and survives from the new blood supply from the chest wall. This is called a free-flap and is performed by plastic surgeons.
Free-flaps can be used for immediate or delayed reconstructions. When used for a delayed reconstruction where the breast skin envelope has been removed, abdominal skin is retained and used. When used for an immediate reconstruction, only a small amount of abdominal skin is retained as the original skin envelope is usually preserved.
The abdominal wall free-flap is called a DIEP flap which is named after the blood vessels that are harvested with the flap (Deep Inferior Epigastric Perforator flap). There are other types of free-flaps which use tissue from the buttocks or inner thigh but the DIEP free-flap is the most commonly used.
The most common type of rotation flap used for breast reconstruction is the latissimus dorsi flap. This is the name of a large muscle in the upper back which functions to bring the arm down towards the body (adduction). It is the muscle you use at the gym when doing “lat pulldowns” – hence the name of the exercise.
This muscle is rotated through the axilla to replace the breast tissue. It is commonly combined with an implant-based reconstruction.
The details of the procedure including the length and direction of the scar over the back is discussed with you by the plastic surgeons who perform this procedure.
Most women are familiar with the idea of breast implants used for breast augmentation. The same implants can be used to replace breast tissue following a mastectomy. They are placed under the chest wall muscle (the pectoralis).
When the implant is used straight away for reconstruction, the procedure is called: “straight to implant”. Often, however, the definitive implant is not put in at the initial operation. A so-called tissue-expander is put in immediately following the mastectomy.
This is like a balloon which is shaped like the implant when fully expanded. When a tissue-expander is placed, it is not filled up fully during the surgery. It contains a metallic port which can be injected through the skin gradually over the next few weeks allowing it to get to the desired size gradually. The advantage of this is to expand the space under the muscle slowly and to allow the patient to have radiotherapy if required without the risk of complications related to the definitive implant.
When the patient is ready, a second procedure is performed where the expander is removed and replaced by the definitive implant.
Reconstruction procedures may require multiple future procedures to improve the cosmesis such as fat-filling and nipple reconstruction.
You may be referred for nipple tattooing as the final step of the reconstruction.
What are the risks of surgery?
The risks of surgery depend on the type of mastectomy and reconstruction as well as the type of axillary surgery (sentinel node biopsy vs axillary clearance) if required.
The risk of post-operative bleeding depends on the extent of surgery and is obviously greater with tissue-based techniques. However, significant bleeding requiring a transfusion is unlikely. When bleeding forms a clot, it is called a haematoma which may or may not require a return to the operating theatre to be drained.
The risk of infection is higher in the setting of reconstruction given longer surgery, more tissue dissection and the potential use of a foreign body such as the implants. The risk is reduced by giving prophylactic antibiotics at the start of the procedure which may continue for a few days after surgery.
When removing the breast tissue from under the skin, the skin may lose its blood supply if it is too thin. This may result in the death (necrosis) of an area of skin. It may be treated with dressings but may require return to the operating theatre.
Nipple sparing mastectomy (NSM) involves removing the tissue underneath the nipple to ensure all breast tissue has been removed. This may result in death (necrosis) of the nipple which may be partial or full thickness. It may be treated with dressings but may require return to the operating theatre and may result in nipple loss.
Complications such as bleeding, infection and wound breakdown may occur away from the breast where the flaps come form – such as the abdomen, buttocks, inner thigh or back. This will be discussed in more detail with you by the plastic surgeons.
- Deep venous thrombosis or DVT: formation of blood clots in the legs. This risk is reduced by wearing compression stockings (called TEDS), injection of blood thinning medications (Clexane) and mechanical calf-compression.
- Chest infection: This is prevented by adequate pain-relief, deep breathing, early mobilization and chest physiotherapy.
Fast from midnight for a morning procedure OR from 7am for an afternoon procedure.
If you are having a sentinel node biopsy with your mastectomy, you will be booked for the lymphoscintigram. This is done on the morning of surgery for an afternoon procedure, or on the afternoon before for a morning procedure.
You will be informed of your admission time which will depend on the above.
Following a simple mastectomy without reconstruction, you will be admitted to hospital for an overnight stay and may be discharged home the next day.
Following a reconstruction, you will be in hospital for 3 to 5 days. While in hospital, you will be looked after by both the breast and plastic surgeons.
You are encouraged to mobilise early and will be given Clexane injections under the skin to prevent leg clots.
A simple mastectomy is very well tolerated and does not require strong pain-killers. Reconstruction is usually associated with more pain.
You should take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).
Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.
Stronger pain killers such as opioid anaelgesics (Endone, Codeine) may be required but should be taken sparingly as they can cause constipation.
A simple mastectomy wound is dressed with Dermabond glue which is waterproof. The glue feels hard which is normal. It sheds off over the 2-3 weeks.
Dressings following reconstructive procedures are the plastic surgeon’s choice. You will be given specific instructions about your dressings by the plastic surgeon.
Following a simple mastectomy, you will have a drain which will stay in for 1-2 weeks depending on the drain output. Once the drainage is <20mls/day for two consecutive days, the drain is removed. Otherwise, the drain is removed at 2 weeks.
The drain output is usually monitored by the Hospital In The Home (HITH) nursing service but can also be done through our rooms with our breast care nurse if your private fund does not pay for this service. If the drain is removed too early, there is an increased risk of seroma formation.
If there is an axillary drain following an axillary clearance, this usually stays in for at least 1 week but otherwise follows the same rules as the mastectomy drain.
Following a reconstruction, drains are managed by the plastic surgeons who will give you their specific instructions prior to discharge.
You will be followed up within 1-2 weeks of your surgery to review the wound(s), the drain output and discuss your pathology results. This will usually involve two appointments – one with the breast surgeon and the other with the plastic surgeon.
Your follow up appointment is usually made for you prior to discharge.