Local Tissue Rearrangement

Breast Reconstruction

The surgical management of breast cancer and benign breast tumours has significantly evolved over the years. It has shifted away from radical procedures towards methods that achieve complete tumour resection while preserving normal breast tissue.

This change has allowed for improved quality-of-life and aesthetic outcomes for patients. It also maintains previous oncologic safety as well as reducing the risk of lesions returning.

For patients who are happy with their current breast shape and size, the tumour can be removed with the surrounding breast tissue being mobilised to fill in the defect, so there is no contour deformity.

Patients who choose to have breast conservation often require post-operative radiotherapy to reduce any risk of remaining abnormal cells in the breast. Radiotherapy is normally started 7 weeks after the surgery is performed.

What does the operation involve?

The surgery is performed under a general anaesthetic (you will be asleep during the procedure), and it takes approximately one hour to perform. Providing all is well, you can expect to go home the same day.

An inconspicuous incision is placed where it will be well hidden. This is often in the crease under the breast or at the junction of the areola and breast skin. The skin and soft tissue is elevated to identify the lesion, and it is removed with enough surrounding tissue to ensure that it is cleared. The excision is performed using an intraoperative ultrasound to verify that it has been completely removed. The breast tissue is then mobilised to fill in the defect without distorting the remainder of the breast. The incisions are closed with dissolvable sutures that lie under the skin and are not seen, and a waterproof glue and tape dressing is applied.

The lesion is sent to be looked at under the microscope to confirm the histology and that it has been removed with an adequate margin.

What are the risks and side effects of surgery?

Having surgery should be a very positive experience. Complications are infrequent and usually minor. However, no surgery is without risk and it is important that you are aware of these potential problems.

Scars

The scars are usually hidden in the crease under the breast or around the areola. They normally settle remarkably well, so that the scars are barely perceptible. However, some patients heal with thick, thin or stretched scars which can be noticeable.

Bruising and swelling

Bruising and swelling is very common and may take several weeks to settle.

Haematoma

This is clotted blood that collects in the breast. It occurs in between 1% to 4% of women who undergo breast surgery. It tends to occur within 4 to 6 hours post-surgery.

Any increase in swelling or pain should be reported immediately for assessment. Should the haematoma be significant, it will have to be washed out in theatre and any bleeding vessel(s) identified and cauterised. This does not normally delay your recovery or change the cosmetic result.

Infection

The risk of infection is inherent with any surgical procedure, albeit very uncommon in elective breast procedures. Antibiotics are administered during surgery. Less than 1% of patients develop an infection post-operatively and rarely require any intervention, apart from further antibiotic treatment.

Numbness, reduced sensation or oversensitivity

A reduction in nipple sensation occurs in most patients and often recovers to some degree, although it may never completely recover. Occasionally patients feel that nipples become more sensitive.

Wound healing problems

These are rare but can occur following surgery. Healing difficulties can range from minor problems, such as small scabs or areas of wound separation, to major issues, such as skin or nipple loss. Although very rare, skin grafting to close the wound may be required thus resulting in further surgery.

Patients who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

Asymmetry

Each breast is slightly different and will continue to be following surgery; remember that, “your breasts are sisters and not twins”. However, if you have noticeable asymmetry before your surgery then this will be corrected as part of the surgery and will be discussed with you.

Further excision

The tissue removed at is assessed under the microscope by a histologist to verify the type of lesion and that it has been completely removed. Although uncommon, it is possible that the lesion is wider than expected or that it has not been completely excised. In this instance, more tissue may need to be removed in a second operation.

DVT/PE

Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and travel to your lungs. If the blood clot is large enough, it could prove fatal.

The overall risk for surgery is less than 1%, but in order to reduce any risks of a DVT/PE, you will be provided with special stockings to wear in bed together with a blood thinning injection, if you are not mobile or have previously had a DVT or PE. It is not recommended to fly within 4 weeks of surgery, or this risk will increase.

Fat necrosis

Sometimes areas of fat within the breast scar and form hard lumps called fat necrosis. Usually, no specific treatment is required, and the problem settles down over a 12-month period.

Breastfeeding

Not all patients will be able to breastfeed after breast surgery, depending on how much tissue is removed and where it is in the breast.

What happens after the operation?

Your incisions will be closed with dissolvable sutures that do not need to be removed. I use a glue and tape dressing (Prineo), which is waterproof and can be peeled off 2 to 3 weeks after surgery, when it starts to lift at the corners. You can shower as soon as you like after surgery and do not require any dressing changes.

I recommend that you wear a support bra for 4 to 6 weeks and that you purchase 2 bras, so you have one to wear and one in the wash. These are worn continuously for approximately 6 weeks post-surgery, before returning to any bra of your choice. You will need to purchase these prior to your surgery, and I will provide the relevant details in clinic. Details can also be found in the compression garment guide below.

Before you leave the hospital, you will be given a follow up appointment to see the nurses at one week to check your incisions and an appointment to see me in 2 weeks. You will not be able to drive yourself home from hospital and, ideally, you should have someone to stay with you for a few days to assist you. If you have any concerns during this period, do contact the clinic for advice.

Once the dressings are removed, I recommend that you massage the incisions, using small circular motions at least twice a day for 5 minutes. You can use any moisturising cream of your choice and apply firm pressure until it blanches.

The scars will also benefit from silicone scar gel (ScarAway® or Kelo-Cote®) twice a day, which will soften and fade them, as well as applying sunblock for 12 months to provide sun protection. The ScarAway® can be purchased from Healthcare Pharmacy at Governors Square in Grand Cayman.

What is the estimated time for recovery, absence from work and return to usual activities?

When you get home, you should take things easy for the first week or so. Most people take 1 to 2 weeks off from work. You should be able to drive from 2 weeks, return to the gym for lower body work at 4 weeks and begin upper body exercises at 6 weeks.

To help shape and support your breasts as they settle, you will need to wear your support bra continuously for 6 weeks.