Breast reconstruction is a common procedure in Singapore because breast cancer is a relatively common cancer in Singapore. In fact, it is the commonest female cancer in Singapore with an incidence of about 1 in 11 women. The annual number of new breast cancer cases in Singapore is more than 1000, and the number of yearly deaths from breast cancer is more than 400.
Patients who require breast reconstruction are those who have undergone a mastectomy for breast cancer. A mastectomy is an operation where the breast containing the cancerous growth is surgically removed. In the old days, the nipple, areola, a substantial amount amount of skin, and sometimes even the underlying pectoralis major muscle were removed as well. Fortunately, with advances in breast health screening, and early breast cancer detection and diagnosis, such radical and mutilating operations are now rarely required.
When breast cancer is picked up early and the tumor is small, it can be surgically removed without removing the entire breast. This is known as a lumpectomy. If it turns out that the entire breast needs to be removed, most cancerous tumors can still be removed using mastectomy techniques that preserve the skin of the breast, the nipple areolar complex, or both. This allows the breast surgeon performing the mastectomy to minimize disfigurement to the breast and chest, and simplifies the task of breast reconstruction by the plastic surgeon. The two modern and common techniques of mastectomy are the skin sparing mastectomy and the nipple sparing mastectomy.
The skin sparing mastectomy involves removing the breast and the nipple areolar complex, but preserves all of the skin. The nipple sparing mastectomy, also known as a subcutaneous mastectomy, involves removal of the breast tissue only, while sparing the nipple areolar complex and all of the skin. The choice between these types of mastectomy will depend on a number factors such as the size of the tumor, its location, and whether the milk ducts close to the nipple are involved.
Upon completion of the mastectomy by the breast surgeon, the plastic surgeon then becomes involved, and his job is to reconstruct the breast to make it look as natural as possible and as symmetric as possible with the opposite breast. The breast can be reconstructed using a breast implant, the patient’s own tissues harvested from another part of the body, or both. Each reconstructive option has its pros and cons, and this will be discussed in detail beforehand so that the patient can make a fully informed choice.
If the plan was to reconstruct the breast with an implant but a significant amount of skin had to be removed (which is uncommon nowadays), it may be necessary to first expand the skin gradually with a tissue expander over a period of 8 to 10 weeks before replacing the expander with an implant. This is to compensate for the loss of skin by slowly stretching the remaining skin so that it can subsequently accommodate the breast implant.
If no skin was removed, i.e. either a skin sparing or nipple sparing mastectomy had been performed, it should be possible to perform an immediate direct to implant reconstruction without the need for an initial period of tissue expansion.
If the choice was to reconstruct the breast with the patient’s own tissues, this is often harvested from the back (the latissimus dorsi muscle flap, with or without an overlying piece of skin), or from the patient’s abdomen (the TRAM flap). In certain cases, the reconstruction may be consist of a combination of implant and the patient’s own tissues. Again, these reconstructions are usually performed immediately after the mastectomy and during the same operation.
Whether the reconstruction is implant based or soft tissue based, fat grafting can be useful ancillary tool to fine tune and enhance the result of the reconstruction. Fat grafting involves removing fat cells from other parts of the body using gentle, non-traumatic liposuction technique, purifying the fat, then injecting the purified fat cells carefully and meticulously in small parcels into the areas that need it. Thus, fat grafting allows the plastic surgeon to add volume and tissue thickness to areas that need it in order to optimize breast size and breast shape and make the result look as natural as possible. It can be considered as an “icing on the cake” procedure that provides enhancement and refinement to the overall result.
Regardless of the method of reconstruction, with current advanced techniques and the availability of high quality breast implants such as the Motiva Ergonomix implant, it is often possible to fully reconstruct a breast following mastectomy and produce a new and natural looking breast.
Apart from restoring volume and shape in the reconstructed breast, we should also pay attention to the issue of symmetry with the opposite breast. If the opposite breast is significantly different from the reconstructed breast in terms of size or shape, it may be necessary to modify the opposite breast accordingly by performing a breast reduction (if the opposite breast is larger), a breast augmentation (if the opposite breast is smaller), or a breast lift (if the opposite breast is sagging).