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Reconstructive & Oncoplastic Surgery

Breast reconstruction surgery is a complex and highly personalised surgical procedure aimed at restoring the shape, appearance, and size of the breast following a mastectomy or lumpectomy. This procedure is a vital component of the treatment journey for many breast cancer patients, providing not only physical restoration but also psychological and emotional support.

Oncoplastic breast surgery combines the principles of oncology and plastic surgery to remove breast cancer while preserving or improving the breast’s appearance. This approach is increasingly popular in Australia due to its dual focus on effective cancer treatment and cosmetic outcomes in the one surgical procedure. Oncoplastic surgery can be performed as part of breast-conserving surgery (BCS) or mastectomy, depending on the patient’s condition and preferences.

The exact cause of breast cancer is not fully understood, but it is believed to result from genetic mutations in breast cells. Several factors can increase the risk of developing breast cancer:

  • Genetic Factors: Inherited mutations in genes such as BRCA1 and BRCA2 significantly increase the risk.
  • Hormonal Factors: Long-term exposure to oestrogen and progesterone, such as from early menstruation, late menopause, or hormone replacement therapy, can increase the risk.
  • Environmental and Lifestyle Factors: Factors such as alcohol consumption, obesity, lack of physical activity, and exposure to radiation can contribute to the risk.

Symptoms of breast cancer can vary widely, and some individuals may not experience any symptoms. Common signs and symptoms include:

  • A Lump in the Breast or Underarm: Often the first noticeable symptom, a lump may be painless or tender.
  • Changes in Breast Shape or Size: Swelling, dimpling, or changes in the shape or size of the breast.
  • Nipple Changes: Inversion, discharge (especially bloody), or changes in the appearance of the nipple.
  • Skin Changes: Redness, scaling, or thickening of the breast skin or nipple.
  • Pain: Persistent pain in the breast or nipple area.

Several risk factors increase the likelihood of developing breast cancer. While some factors cannot be changed, such as age and genetics, others can be managed through lifestyle choices:

  • Age: The risk of breast cancer increases with age, with most cases diagnosed in women over 50.
  • Family History: A family history of breast cancer, especially in a mother, sister, or daughter, increases the risk.
  • Genetic Mutations: Inherited mutations in BRCA1, BRCA2, and other genes.
  • Hormonal Factors: Early menstruation (before age 12), late menopause (after age 55), and hormone replacement therapy.
  • Reproductive History: Having no children or having the first child after age 30.
  • Lifestyle Factors: Alcohol consumption, obesity, physical inactivity, and a diet high in saturated fats.

Breast reconstruction surgery and oncoplastic surgery can be performed using various techniques, broadly categorised into implant-based reconstruction and autologous (or flap) reconstruction. Each method has its advantages and considerations, and the choice of technique depends on multiple factors including the patient’s anatomy, cancer treatment plan, and personal preferences.

Reconstructive Surgical Techniques

Implant-based reconstruction involves the use of silicone or saline implants to recreate the breast mound. This technique can be performed immediately following mastectomy (immediate reconstruction) or at a later date (delayed reconstruction).

Immediate Implant Reconstruction

  • Overview: This procedure is performed at the same time as the mastectomy, allowing patients to wake up with a newly reconstructed breast.
  • Procedure:
    • Tissue Expander Placement: A temporary tissue expander is placed under the chest muscle and gradually filled with saline over several weeks to stretch the skin and create space for the final implant.
    • Implant Placement: Once the desired size is reached, a second surgery is performed to replace the expander with a permanent implant. Some advanced techniques allow for direct-to-implant placement, where the permanent implant is inserted immediately without the need for a tissue expander.

Delayed Implant Reconstruction

  • Overview: This procedure is performed months or even years after the mastectomy, often after completing other cancer treatments such as chemotherapy and radiation.
  • Procedure:
    • Preparation: Similar to immediate reconstruction, a tissue expander may be used initially.
    • Implant Placement: Once the tissue expander has created enough space, the permanent implant is inserted in a subsequent surgery.

Autologous reconstruction uses the patient’s own tissue to reconstruct the breast, providing a more natural look and feel compared to implants. Common types of flap reconstruction include the TRAM flap, DIEP flap, and latissimus dorsi flap.

TRAM Flap (Transverse Rectus Abdominis Myocutaneous Flap)

  • Overview: This technique uses muscle, fat, and skin from the lower abdomen to reconstruct the breast. It can be performed as a pedicled flap, where the tissue remains attached to its original blood supply, or as a free flap, where the tissue is completely detached and reattached using microsurgery.
  • Procedure:
    • Pedicled TRAM Flap: The abdominal tissue is tunneled under the skin to the chest area while remaining attached to the rectus abdominis muscle.
    • Free TRAM Flap: The tissue is detached from the abdomen and transplanted to the chest, where blood vessels are reconnected using microsurgery.

DIEP Flap (Deep Inferior Epigastric Perforator Flap)

  • Overview: Similar to the TRAM flap, the DIEP flap uses skin and fat from the lower abdomen but spares the abdominal muscles, reducing the risk of muscle weakness and hernia.
  • Procedure:
    • Harvesting: Skin and fat, along with the deep inferior epigastric perforator vessels, are harvested from the abdomen.
    • Transplantation: The tissue is transplanted to the chest, and the blood vessels are reconnected using microsurgery.

Latissimus Dorsi Flap

  • Overview: This technique uses muscle, skin, and fat from the upper back to reconstruct the breast. It is often combined with an implant to achieve the desired size and shape.
  • Procedure:
    • Tissue Transfer: The latissimus dorsi muscle, along with overlying skin and fat, is tunneled under the skin to the chest area.
    • Implant Placement: An implant may be placed under the flap to provide additional volume and shape.

Following the reconstruction of the breast mound, additional procedures can be performed to recreate the nipple and areola, enhancing the aesthetic outcome.

  • Nipple Reconstruction
    Procedure: A small flap of skin on the reconstructed breast is used to create a nipple-shaped projection. This can be done several months after the initial reconstruction surgery.
  • Areola Reconstruction
    Procedure: Tattooing techniques are used to create a natural-looking areola around the reconstructed nipple. Skin grafts from other parts of the body can also be used if necessary.

Proper postoperative care is essential for successful recovery and optimal results. This includes:

  • Pain Management: Pain medications and management strategies are provided to alleviate discomfort.
  • Wound Care: Instructions on keeping the incision sites clean and dry, and recognising signs of infection.
  • Activity Restrictions: Guidelines on limiting physical activity and avoiding strenuous exercises to allow proper healing.
  • Follow-Up Appointments: Regular follow-up visits to monitor recovery, address any complications, and discuss further treatment or adjustments.

Following breast reconstruction, additional treatments may be required depending on the stage and type of breast cancer:

  • Radiation Therapy: Administered to destroy any remaining cancer cells in the chest area.
  • Chemotherapy: Systemic treatment to target cancer cells throughout the body.
  • Hormone Therapy: For hormone receptor-positive cancers, to reduce the risk of recurrence.
  • Targeted Therapy: For HER2-positive cancers, to block growth-promoting signals.

Oncoplastic Surgical Technique

A comprehensive preoperative assessment is critical for successful oncoplastic breast surgery. This includes:

  • Multidisciplinary Consultation: Involving oncologists, plastic surgeons, radiologists, and pathologists to develop a tailored treatment plan.
  • Imaging Studies: Mammograms, ultrasound, and MRI scans to accurately assess the tumour size, location, and extent.
  • Biopsy: Confirmation of cancer diagnosis and determination of its characteristics, including hormone receptor and HER2 status.
  • Patient Evaluation: Consideration of the patient’s overall health, medical history, and personal preferences regarding cosmetic outcomes.

Volume Displacement Techniques

  • Overview: These techniques involve reshaping the remaining breast tissue to fill the defect left after tumour removal, suitable for small to moderate-sized breasts and tumours.
  • Techniques:
    • Local Tissue Rearrangement: The remaining breast tissue is mobilised and rearranged to fill the cavity, maintaining breast shape and symmetry.
    • Therapeutic Mammaplasty: Similar to breast reduction surgery, this technique is used for larger breasts where a significant portion of tissue is removed. The remaining tissue is reshaped, and the opposite breast may also be reduced to achieve symmetry.

Volume Replacement Techniques

  • Overview: These techniques involve using tissue from another part of the body to replace the removed breast tissue, suitable for larger defects or smaller breasts.
  • Techniques:
    • Latissimus Dorsi Flap: Tissue from the upper back is used to reconstruct the breast. This flap includes muscle, skin, and fat, which are rotated to the breast area.
    • Local Flaps: Nearby tissue, such as the lateral chest wall or abdomen, is used to fill the defect.

Skin-Sparing Mastectomy (SSM)

  • Overview: SSM involves removing the breast tissue while preserving most of the skin, excluding the nipple and areola. This approach allows for immediate reconstruction with better cosmetic outcomes.
  • Techniques:
    • Implant-Based Reconstruction: An implant is placed under the preserved skin to restore breast shape. This can be done immediately or in a staged approach.
    • Autologous Tissue Reconstruction: Tissue from another part of the body, such as the abdomen (TRAM or DIEP flap), is used to reconstruct the breast.

Nipple-Sparing Mastectomy (NSM)

  • Overview: NSM involves preserving the nipple-areola complex along with the skin. It is suitable for select patients with tumours that are not close to the nipple.
  • Techniques:
    • Implant-Based Reconstruction: Similar to SSM, an implant is used to reconstruct the breast.
      Autologous Tissue
    • Reconstruction: Tissue from another part of the body is used, providing a more natural feel and appearance.

Postoperative care is crucial for ensuring successful recovery and optimal cosmetic outcomes. It includes:

  • Pain Management: Prescribed pain medications to manage postoperative discomfort.
  • Wound Care: Instructions on keeping the incision sites clean and dry, and recognising signs of infection.
  • Activity Restrictions: Guidelines on limiting physical activity to allow proper healing.
  • Follow-Up Appointments: Regular follow-up visits to monitor recovery, discuss further treatment, and address any concerns.

Following oncoplastic breast surgery, additional treatments may be recommended to reduce the risk of cancer recurrence:

  • Radiation Therapy: Commonly administered after BCS to destroy any remaining cancer cells in the breast.
  • Chemotherapy: Depending on the cancer’s stage and characteristics, chemotherapy may be recommended to target cancer cells throughout the body.
  • Hormone Therapy: For hormone receptor-positive cancers, hormone therapy (such as tamoxifen or aromatase inhibitors) can help reduce the risk of recurrence by blocking the effects of oestrogen.
  • Targeted Therapy: For HER2-positive cancers, targeted therapies like trastuzumab (Herceptin) may be used to block the growth-promoting effects of the HER2 protein.

Oncoplastic surgery offers several advantages over traditional breast surgery techniques, including:

  • Enhanced Cosmetic Outcomes: By combining tumour removal with plastic surgery techniques, the breast’s natural shape and appearance are better preserved.
  • Improved Psychological and Emotional Well-Being: Maintaining breast appearance can significantly impact a patient’s self-esteem and quality of life.
  • Comprehensive Cancer Treatment: Oncoplastic surgery addresses both the oncological and reconstructive aspects of breast cancer treatment in a single procedure.

However, oncoplastic surgery is not suitable for all patients. Considerations include:

  • Tumour Characteristics: The size, location, and number of tumours may affect the suitability of oncoplastic techniques.
  • Patient Health: Overall health, including any coexisting medical conditions, may influence surgical options.
  • Patient Preferences: Personal preferences regarding cosmetic outcomes and willingness to undergo more extensive procedures play a significant role in decision-making.

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