Breast reconstruction is an option and never an essential part of your treatment.

The number of patients needing surgery for breast cancer is rising every year. In Mr Ramakrishnan’s area of Essex a very high percentage of women are offered and undergo reconstruction at the same time as mastectomy (called primary or immediate reconstruction). Most of these women who choose immediate reconstruction opt to have what one surgeon removes, reconstructed by another. This is more often than not the circumstances under which Mr Ramakrishnan performs immediate reconstruction. A much smaller group of women will opt or will be advised to have reconstruction after mastectomy (called secondary or delayed reconstruction).

Experts say performing the mastectomy and reconstruction together minimises the psychological impact of losing a breast. Whilst immediate breast reconstruction has a longer anaesthetic and recovery time, it tends to achieve better cosmetic results, smaller breast scars and only one hospital stay.

For some women with aggressive disease or who need radiotherapy, reconstruction cannot be done immediately, but it may still be an option later on.

It must be said however that many women remain satisfied with an external prosthesis in the bra to achieve normal shape while dressed. Reconstruction always adds surgery and therefore potential complications to your treatment. This needs to be taken into consideration. You should never feel you must have breast reconstruction.

The motivation for women to have breast reconstruction is completely individual and is therefore unique to each. The attitude towards loss of a breast varies from patient to patient. Although a difficult time for all women, the importance attached to replacing a breast is totally down to the individual, neither response is right or wrong.

Immediate reconstruction (Primary reconstruction) is when the breast reconstruction is carried out at the same time as the surgery for your breast cancer. As with every procedure there are ‘pros and cons’ to reconstruction at the same time as mastectomy.

‘Pros’

• Mastectomy and reconstruction at the same time means that there is no delay between the two. Some experts feel that this minimises the physiological impact of mastectomy. It should be stressed that this is not true for all patients.
• Reconstruction and cancer surgery at the same time means that for the more major reconstructive methods such as those that use your own tissue only one operation is necessary, which means only one hospital stay.
• The patient is never without a ‘breast’.
• Depending on methods used the immediate breast reconstruction tends to achieve better cosmetic results, with smaller scars.

‘Cons’

• It is sometimes very difficult for the patient and their family to grasp all the information and understand the implications of reconstruction at an already difficult time.
• There may, in exceptional cases be complications associated with the additional reconstructive surgery, which could then lead to further surgery to treat the complications so as not to delay other recommended treatments for your cancer i.e. chemotherapy or radiotherapy.
• The two procedures at the same time make the surgery time longer and often the hospital stay as well.
• Radiotherapy may affect the aesthetic outcome of the reconstruction

Delayed reconstruction (Secondary reconstruction) is when the breast reconstruction is carried out after all the cancer treatment is over. This can be months or even years later. This is generally speaking an option for all patients. Some choose this and for some this is recommended, but there is no time or specific age limit.

‘Pros’

• Complications of reconstruction around the time of cancer treatment are avoided. If treatment such as radiotherapy or chemotherapy are required it is key not to delay this more than is necessary.
• Sometimes radiotherapy if required can affect the reconstructed breast (shrinking, firmness and deformity) this can be avoided with delayed reconstruction.
• Any decisions about reconstruction do not have to be made at the time of dealing with cancer diagnosis and treatment.

‘Cons’

• The patient will be without a breast until reconstruction is performed
• The cosmetic result may not be as good. This is generally because with immediate reconstruction the skin of the breast is often used to cover the reconstruction giving a more natural result. In a delayed reconstruction which uses your body tissue, skin needs to be added to the breast from another area. This will have a slightly different appearance.

Radiotherapy is still a key part of treatment for women with breast cancer. It is more commonly given to ladies who have only part of the breast removed (breast conserving surgery) as it can reduce the chances of a recurrence of cancer in the remaining breast tissue.

However it is true that some mastectomy patients also benefit from radiotherapy. The need for this can be ascertained in some patients before their mastectomy, but it will often only be known after the cancer has been removed and analysed.

Radiotherapy is not without its issues and these need to be taken into account with regard to the timing and method of any breast reconstruction.

• Radiotherapy can damage normal tissue as well as cancer cells. This can result in alteration in the skin colour, shrinkage and firmness of healthy breast tissue.
• Radiotherapy can have the same effect on tissue that has been used to reconstruct the breast.

It must be said that even with all the issues taken into consideration not all patients react adversely to radiotherapy and therefore it is difficult to give categorical advice.

Patients very often have concerns that go beyond the information given by the surgeon. This is a step by step guide of what to expect. Whilst every case is different, if there are no complications the steps involved from beginning to end tend to follow a pattern.

This is a summary of what you might expect, step by step.

1. After diagnosis your breast surgeon will discuss with you your options. If immediate reconstruction is an option then an appointment will be made to see a plastic surgeon.
2. At the initial consultation with the plastic surgeon your options as to the type of reconstruction will be discussed at some length. This is the case with both immediate and delayed reconstructions
3. A second consultation, a week or so later is usually very helpful. It allows you to have had a period of time in which to assimilate all the information you have received. You are bound to feel overwhelmed at this stage and a further meeting with the surgeon is generally beneficial.
4. Once the type of reconstruction is decided upon the wheels are put into motion to prepare you for the operation. This will include:i) A date – the two surgeons involved will generally decide this in discussion with you.
   ii) Anaesthetic assessment – generally the week before the operation
   iii) Pre admission tests i.e. bloods tests, ECG etc – a week to ten days before admission.
   iv) Doppler Scan – a simple ultra sound test, or CT scan is used to visualize the flow patterns of arteries and veins. This is sometimes required with a DIEP reconstruction and is usually carried out a week or so before admission.
   v) If you are an insured patient then you will need to inform and liaise with your insurance company to keep them fully informed.
5. When the day of the operation arrives admission is usually an hour or so before the scheduled start time in a private hospital. Possibly the night before in an NHS hospital. The surgeon will draw markings on you to guide him during the surgery.
6. During the surgery you will have a Bladder Catheter (a tube passed up into the bladder) inserted. This will allow you to pass water without having to get out of bed for the first few days after your operation. As soon as you are up and about the catheter can be removed. Many women worry about the catheter but it causes very little discomfort and is simply and easily removed by the nurse on the ward at the doctors request.
7. You can expect to be in hospital for around seven days depending on the type of reconstruction. In the case of reconstructions using a flap it is usual to spend some time on the High Dependency Unit. This allows the flap area to be constantly observed in those vital first few days. Very occasionally after surgery there may be some bleeding or a lack of blood supply to the flap. In this instance it could be necessary to return you to theatre to investigate the cause.
8. You will have surgical drains either side of your donor site wound and one at the side of your new breast mound. This is simply a tube used to remove blood or other fluids from a wound. These are usually removed the day before or the day you go home.
9. Physiotherapy is often required to help with breathing exercises and initially gentle arm movements. This may commence whilst you are in hospital or be arranged for after you come home.
10. Visits to the hospital to have dressings changed will be made.
11. A follow-up appointment to see your plastic surgeon will be made for about two weeks after you are discharged from hospital.
12. Depending on the advice of your oncologist regarding any chemotherapy and/or radiotherapy that you may need to have and your type of reconstruction a timetable for nipple reconstruction and nipple tattooing can be worked towards.
13. You will continue to see your breast surgeon and your plastic surgeon at extending intervals over several months until the reconstruction is complete.