Breast reconstruction and mastectomy

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. The two types of surgery are:

• breast-conserving treatment – only part of the breast is removed; also known as partial mastectomy, wide local excision or lumpectomy
• mastectomy – the whole breast is removed.

In many cases, breast cancer surgery may also involve the removal of one or more lymph nodes from the armpit (axilla).

Breast-conserving treatment, followed by radiotherapy, is just as effective in surviving breast cancer as a mastectomy. You may be able to choose between the two. Sometimes, however, the size and location of the cancer may mean that mastectomy offers the best chance of getting rid of all the cancer (for example, if the cancer is large compared to the size of the breast or the cancer is in more than one area of the breast).

Women undergoing mastectomy should be offered a choice about whether they would like to undergo breast reconstruction surgery or not. Women who choose not to undergo breast reconstruction have a mastectomy with an aesthetic flat closure, which is sometimes referred to as “going flat” or “living flat”. There are several reasons why women may choose to “go flat”, including personal preferences, health issues which prevent further surgeries and concerns about costs. For women who choose to undergo breast reconstruction surgery, this can be done at the same time as the mastectomy or in a separate surgery sometime after the mastectomy.

There are several reasons why women may choose to have breast reconstruction surgery, including achieving a similar appearance to the look of their original breast when wearing normal clothes as well as managing emotional aspects of their experience.

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

Breast-conserving treatment (lumpectomy)

The tumour, some of the surrounding breast tissue (known as the margin) and nearby lymph nodes in the armpit are removed during breast-conserving treatment. Most of the breast remains, although it may be smaller than (and a different shape to) the remaining breast.

A follow-up operation is sometimes needed to make sure the margins of breast tissue surrounding the excised tumour (the place where the tumour was cut out) are free of cancer. After breast-conserving surgery, most people will be recommended to have radiotherapy, which is the use of high energy X-rays to kill any remaining cancer cells in the breast or armpit. Some studies have shown that women may have fewer body image and sexuality concerns following breast-conserving treatment than after mastectomy.

Mastectomy

Mastectomy is an operation that removes the entire breast. Usually, the underlying chest muscles are still intact. In most cases, breast cancer surgery will also involve the removal of one or more lymph nodes from the armpit (axilla).

Lymph nodes are found throughout the body, including the armpit. Their function is to protect the body against disease and infection. The lymph nodes in the arms are often the first place breast cancer cells spread to outside the breast. To check if cancer has spread to the lymph nodes, they are removed via two methods:

• sentinel lymph node biopsy (SLNB), or
• axillary lymph node dissection (ALND).

The recovery from a mastectomy surgery may include a hospital stay between two and seven days. In some cases, radiotherapy and chemotherapy might be used after the operation.

Complications of breast cancer surgery

All types of surgery carry risks. Some of the possible complications of breast cancer surgery include:

• infection
• death of tissue along the edges of the incision
• post-mastectomy pain syndrome (sharp pain on the chest wall).

Side effects of breast cancer surgery

Before undergoing breast cancer surgery, you should speak with your doctor and understand what you may be able to expect in terms of recovery from surgery. This includes time to recover, what care will be available to you during your recovery, and the side effects that may occur after surgery.

Some of the side effects that can happen in the first few months after surgery include:

• pins and needles across the chest
• numbness of the armpit and arm – surgery may damage nerves causing numbness. This can improve but may not go away completely. Shoulder exercises can help
• seroma – fluid may collect in or around the scar and can last up to six weeks after surgery. Your doctor or breast nurse can drain the fluid if needed
• shoulder stiffness – exercises can help prevent or manage this. Your physiotherapist or occupational therapist can help
• lymphoedema– swelling of the arm, if the lymph nodes in the armpit have been removed
• breast pain
• cording – caused by hardened lymph vessels, cording feels like a tight cord running from your armpit down the inside of the arm, sometimes to the palm of your hand.
• changes in balance because the weight of one breast is missing
• fatigue, depression and anxiety – talk to your medical team about how you can manage these symptoms if they happen. Talking to a professional (e.g. counsellor or psychologist) may be helpful.

Your feelings about breast cancer surgery

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

Breast forms (prostheses)

After breast surgery, you may be given a temporary ‘soft form’. This is a soft breast-shaped cushion that you pin inside your bra. After around two months, when you are no longer sore and your surgical wound has healed, you can be fitted for a permanent ‘breast form’, or ‘external prosthesis’. This breast form is weighted to restore your balance. It also moves and looks like your other breast when worn under normal clothes.

Breast Cancer Network Australia (BCNA) provides the My Care Kit for women who have recently had breast surgery. It contains a temporary prosthesis and a special Berlei post-surgery bra. Alternatively, BCNA can provide a gift voucher to be used on Berlei’s website. My Care Kit is available free of charge to women in Australia who undergo surgery for breast cancer and is ordered by your health professional. Any queries can be directed to your health professional or BCNA's Helpline on Tel. 1800 500 258.

A permanent prosthesis (breast form) is generally made of medical grade silicone gel and is worn inside your bra. Your local breast care nurse will be able to advise you where to purchase one in your area. A permanent prosthesis is best fitted by an accredited breast prosthesis fitter to ensure the size is right for you. You may also be eligible to receive partial or full reimbursement for a purchased prosthesis via Medicare. You can make a claim for a new prosthesis every two years. For more information visit the Services Australia website External Breast Prostheses Reimbursement program. Some private health insurance funds also provide a rebate for post-mastectomy items including prostheses, bras and swimming costumes. If you have private health insurance, check with them to see what you may be able to claim.

Breast reconstruction surgery

If you decide that breast reconstruction surgery is your preferred option after mastectomy, you can discuss with your surgeon your options in terms of timing. Surgeons can perform the breast reconstruction either at the same time as your mastectomy (called an immediate reconstruction) or later on (a 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 what you did before the mastectomy.

Depending on the type of reconstruction you choose, you may have scars on your breast and on other parts of your body. The actual method of reconstruction will depend on the nature of the problem. There is no single method that is suitable for all women.

The type of reconstruction recommended for you will depend on your body shape, general health and personal preference. Breast reconstruction is a significant operation and needs a substantial recovery time. Ask your treating team any questions you may have.

There are two major types of breast reconstruction:

• implant reconstruction – an implant is placed under the skin and muscle to recreate the shape of the breast
• flap reconstruction – skin, fat and muscle are taken from elsewhere on the body to make the new breast.

Implant reconstruction (prosthesis)

An implant is a sac that's filled with either silicone gel or saline to create a breast shape. You may have an implant reconstruction as a one-stage or two-stage operation.

In the one-stage operation, the surgeon puts in a permanent implant during the mastectomy. In the two-stage operation a tissue expander is used to inflate and stretch the skin so there is room for the implant.

After the reconstruction you will have a scar on your breast. The type of scar will depend on the type of cut (incision) that your breast and reconstructive (plastic) surgeons choose.

Silicone gel implants are used in almost all implant reconstructions. They are made of a soft, semi-solid filling called cohesive gel. This gel is quite firm and holds its shape like jelly. The surface of these implants can feel smooth (micro textured) or have a rough surface (macro textured). Textured implants grip to tissue better and are less likely to move position than smooth implants.

Saline implants are no longer commonly used as they are more susceptible to deflation than silicone, and a subsequent operation to replace the implant may be necessary. The main drawback of using implants is that they may not look or feel like natural breasts, particularly after aging or changes to your weight.

Flap reconstruction

If you have larger breasts, do not have enough skin to cover an implant, or for other reasons prefer not to have an implant, one of several flap methods may be used. They are named after the muscles used in the reconstruction.

TRAM flap

Transcutaneous rectus abdominus myocutaneous muscle (TRAM) flap reconstruction is particularly suitable for women who have lax abdominal (loose stomach) skin. A section of skin and fat from the tummy is removed (similar to the ‘tummy tuck’ cosmetic operation) and transferred, along with a tag of abdominal muscle and two blood vessels, to the chest.

The flap’s blood vessels are connected to blood vessels of the armpit or beneath the ribs. The flap is then formed into the shape of a breast and sewn together. TRAM flap reconstruction offers a more natural looking breast (with normal ‘hang’) than prosthetic implant reconstruction. It does, however, leave a large scar across the abdomen where the muscle was removed.

Some women feel there is benefit in this procedure as they feel they have had a ‘tummy tuck’ as well. The reconstructed breast will change in size if you gain or lose weight.

DIEP flap reconstruction

Some surgeons now perform what is known as a deep inferior epigastric artery perforator (DIEP) flap reconstruction. It is a complicated operation and uses only skin and fat to reconstruct the breast. Unlike the TRAM flap, the rectus abdominis (abdominal) muscle is not used, so supporting mesh is not required. This allows you to maintain your core strength long-term.

Other advantages of this method are a quicker return to normal activities and a smaller risk of hernia. This method of flap reconstruction is now the preferred type of flap reconstruction surgery as it has fewer post-operative complications and has a faster recovery time.

Skin flaps from other areas of the body

Other skin flaps used for breast reconstruction include:

• back – this operation may be preferred if the chest muscles were removed during the mastectomy. Muscle from the back (latissimus dorsi, or LD flap) and the overlying skin are taken and used to form a breast shape. In many cases, the reconstructed breast has to be filled out with an implant. The back is left with a visible scar and a slight hollowing near the shoulder blade where the muscle was removed.
• buttock – a small flap from the buttock (gluteus muscle) is sometimes taken if the abdominal skin isn’t sufficient. A vein needs to be taken from one leg to secure a blood supply to the tissue in its new location on the chest wall.
• Inner thigh – a transverse upper gracilis (or TUG) flap uses a flap of skin, fat and muscle from the upper inner thigh to reconstruct a breast.
• hip – a flap of skin from the hip may be used if the abdomen and buttock are unsuitable.

Complications of breast reconstruction

As with all operations, there is a risk of complications. If these happen, your recovery will take longer.

Complications might relate to:

• healing
• your general health
• the anaesthetic
• infection
• bleeding
• loss of sensation
• muscle problems
• scars and body image.

Many complications are temporary, but some may be permanent. You should be aware of possible problems and discuss them with your surgeon or breast care nurse before the operation.

Nipple reconstruction

It is best to wait at least three months after breast reconstruction surgery before having a nipple reconstruction. This is to allow the new breast sufficient time to ‘drop’ into its position.

In a nipple reconstruction procedure, the new nipple is fashioned using skin flaps from either the abdominal scars or the reconstructed breast. It is then medically tattooed to colour-match it to the existing nipple and areola (although this is optional and is often not included in the cost of general breast reconstruction). The reconstructed nipple will not have any feeling.

Some women may prefer to use a nipple prosthesis, which can be attached to the reconstructed breast using special glue. Others may choose to have nipple tattoos.

Making decisions about breast reconstruction

After having a mastectomy there are various choices available. Reactions to the loss of a breast or breasts vary from woman to woman, and only you can choose what feels best for you.

It is important that you know the advantages and disadvantages of having a reconstruction. Breast reconstruction is a specialised form of surgery, and you should discuss the advantages and disadvantages of having or not having the surgery with your surgeon and treating team.

Where to get help

• Your GP (doctor)
• Breast cancer specialists (e.g. breast surgeon, breast reconstructive/plastic surgeon [breast reconstruction] medical oncologist, radiation oncologist)
• Breast Cancer Network Australia (BCNA)
  • BCNA Helpline team is available to provide support, information, resources and a referral service for people affected by breast cancer, at all stages of the breast cancer experience. Open from 9:00am to 5:00pm Monday to Friday, Tel: 1800 500 258
  • BCNA My Care Kit – the My Care Kit is for free for women who have recently had breast surgery. It contains a specially designed Berlei bra and soft form(s). talk to your health professional or call BCNA’s Helpline team on Tel. 1800 500 258 or email mycarekit@bcna.org.au
  • Find services, government programs and support groups at the BCNA website
  • BCNA Online Network – online peer-to-peer support community for people affected by breast cancer, a safe space to connect with others.
  • Breast care nurse (BCN) or cancer nurse – to find a BCN near you visit the McGrath Foundation website.
  • BCNA has a series of free resources, booklets and fact sheets in a number of languages.
• Cancer Council Victoria, cancer information and support line Tel. 13 11 20
• Multilingual Cancer Information Line, Victoria Tel. 13 14 50
• WeCan website helps people affected by cancer find the information, resources and support services they may need following a diagnosis of cancer.
• Counterpart - Women supporting women with cancer.