Plastic surgery of the breast

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Breast Reconstruction after cancer

Breast reconstruction may be performed at the time of mastectomy (primary reconstruction) or at a later date (secondary reconstruction). Primary reconstruction is discouraged if radiation therapy is anticipated as the reconstructed tissue may be distorted and there is a higher incidence of fat necrosis. A breast reconstruction requires both breast skin envelope and breast volume. During a consultation the surgeon will assess the availability of suitable tissues to forma a new breast. The opposite breast may be reduced or lifted concurrently to match the reconstructed breast.

The most commonly employed techniques of breast reconstruction are:

Lat Dorsi flap
The latissimus dorsi flap form the back is a robust flap that may be combined with an implant if there is insufficient volume to match the opposite breast

TRAM flap
The TRAM flap uses the same tissue removed during a tummy tuck (abdominoplasty) and is a workhorse in breast reconstruction due to its ability to transfer large amounts of tissue. It may be transferred as a pedicled flap or a free flap using microvascular surgery techniques. A variation is the DIEP flap, a perfortaor flap that attempts to spare some of the abdominal wall muscle function

Prosthetic reconstruction

An implant alone may be used if there is sufficient soft tissue and skin. Often a period of expansion is required first to allow natural breast ptosis prior to inserting the final implant

The figure below shows a breast reconstruction using a TRAM flap prior to nipple/ areola complex reconstruction

Breast reduction

Breast reduction patients are among the most grateful patients I treat. Quiet apart from relief of physical symptoms, there are usually marked psychological benefits. The technique used very much depends on the individual size and degree of anticipated reduction. A short scar technique is appropriate in many instances (eg Le Jour or Marchac). There are many consequences of surgery which must be thoroughly discussed beforehand. Some insurances schemes will cover a significant portion of the costs of surgery in specific circumstances.

The figure below shows a breast reduction using the inferior pedicle (Robbins) technique.

Breast lift after breast feeding/ Mastopexy

A Mastopexy lifts a breast and the nipple-areola complex to give it a more youthful appearance. This is a particularly popular procedure after breast feeding. A breast implant may be placed concurrently if more volume is desired. This procedure is often combined with abdominoplasty.

Male breast reduction (Gynaecomastia)

Males with breast often suffer extreme psychological distress and go to some length to avoid publicly embarrassing situations. Complete treatment includes identifying those factors which may contribute to an individuals’ breast formation. Treatment is tailored to the extent of reduction required. Liposuction alone is usually not appropriate due to the fibrous nature of the tissue. When I excise tissue, the scar is placed around the areola to avoid giveaway scars on the chest. The breast skin envelope is baggy following removal however this contracts quickly over the next 4-6 weeks and is preferable to chest wall scars. It is important not to excise too much chest tissue as this will also look out of proportion.

Breast implants/ Breast augmentation

Breast implants are an option for women dissatisfied with the size of their breasts, when the breasts do not form properly and in some cases of asymmetry. I placed over 100 breast implants during my Swedish fellowship and have experience using the whole range of possible incisions and anatomical placements. I also used a technique that places the implant during abdominoplasty thereby leaving no additional scars around the breast itself. A paper describing this technique has been submitted to Plastic and Reconstructive Surgery journal.

The figures below show textured round, subglandular silicone cohesive gel filled implants inserted via an inframammary incision

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