Polaris - Breast Reconstruction

What is breast reconstruction?

Breast cancer is the number one cancer amongst women in Singapore. Thankfully, it has become very treatable through advancements in medicine and surgery. Surgery remains the mainstay of treatment for breast cancer and involves the removal of part or the whole breast. Plastic surgeons play a vital role in reconstructing these resultant defects, which is important in maintaining psychological health, cosmesis, the ability to wear clothes, and restores the wholeness that the patient deserves. In addition, reconstruction is important to aid in adjuvant therapies such as radiotherapy and chemotherapy, all with the aim of curing the patient of cancer.

When is breast reconstruction performed?

There are a few factors to consider when discussing breast reconstruction. In terms of timing, breast reconstruction can either be performed immediately at the time of breast resection surgery (primary reconstruction), or in a delayed fashion after all adjuvant therapies have been performed. There is no time limit to when it can be done. However, patients often choose primary reconstruction as this leads to immediate restoration of the breast with as much original tissue as possible, reduces the need for future operations, and with modern techniques, can be very aesthetically pleasing.

Even if a delayed reconstruction is chosen, your surgeon may recommend the insertion of a tissue expander at the breast resection surgery, as this will help to recruit skin for reconstruction at the time of your definitive reconstructive surgery.

How is breast reconstruction performed?

Breast reconstruction can either be performed with implants, or with your own tissue (autologous reconstruction). There are many pros and cons to both. Generally, implants (including expanders) provide a faster form of reconstruction with no additional donor sites but can be more prone to infection and later problems such as capsular contracture. In addition, despite advances in implant technology, they do not feel as natural as your own tissue.

Traditionally, breast implants have been placed behind the pectoralis major muscle for breast reconstruction. But in recent years and with development in materials such as acellular dermal matrix, placing the implant under the skin and in front of the muscle, (pre-pectoral breast implant reconstruction), which is the natural plane of breast tissue, has gained increasing popularity, and Dr Adrian is very familiar with these procedures.

Autologous reconstruction borrows tissue from another part of your body to reconstruct the breast and can be performed with the blood supply attached (pedicled reconstruction) or by reattaching the blood supply at the breast (free tissue transfer). Tissue can be taken from many areas where there is excess skin and fat, most commonly the abdomen, but also from the back, thighs, and buttocks. The most common forms of autologous reconstruction are the Deep Inferior Epigastric Perforator (DIEP) and Transverse Rectus Abdominis Myocutaneous (TRAM) flaps, which can either be performed as a pedicled or free flap. Autologous reconstruction provides the most natural and lasting method of reconstruction, but often takes longer and results in donor site scars. These scars, however, can be well hidden.

After the initial reconstruction, your surgeon may recommend additional procedures such as nipple reconstruction and other touch-ups to enhance symmetry and appearance. Secondary problems resulting from breast cancer treatment, such as lymphedema and radiation injury, can also be treated at the same time as the reconstructive surgery, or later.

At Polaris Plastic and Reconstructive Surgery, our board-certified plastic surgeon will be happy to perform a thorough assessment and discuss the appropriate options for your breast reconstructive surgery. Dr Adrian is sub-specialist trained in all forms of breast reconstruction and fellowship certified specifically in free DIEP and TRAM flap procedures, areas in which he is well published.

What happens before surgery?

The treatment modalities will be decided in close discussion with you, your breast surgeon, and the plastic surgeon. Factors such as tumour size and location as well as the type of mastectomy (simple, skin-sparing or nipple-sparing) will be taken into consideration, and the best therapeutic plan will be formulated.

The majority of breast reconstruction surgery is done under general anaesthesia. Various investigations may be done to help with the diagnosis and planning, as well as to optimize you for surgery. If you have any pre-existing medical conditions, you should be optimized for these prior to the operation. Necessary pre-operative blood and radiological tests will be done. If autologous free flap reconstruction is chosen as the modality, you may require a CT-angiogram prior to the operation, which provides a road map for surgery and makes the procedure more efficient.

During the procedure

You will either be admitted to the hospital the day before or the day of surgery. If a sentinel lymph node analysis is needed, you may be sent for a tracer injection prior to the operation. The vast majority of breast resection and reconstructive surgeries are done under general anaesthesia. While you are asleep, the surgeon and anaesthetist will ensure your comfort and safety throughout the procedure. If there is any significant blood loss expected, consent would be taken from you beforehand for a blood transfusion if necessary. Surgical times can last up to 10 to 12 hours all in, especially if bilateral mastectomies and autologous reconstructions are required.

Post-operative care

Following surgery, the patient can expect to be monitored closely for the first few days, with emphasis on rest and nutrition. You will have post-surgical drains and usually a urinary catheter for comfort. You should be allowed out of bed after 1 to 2 days, and rehabilitation will be gradually instituted. Close attention will be given to the success of your reconstruction, any post-operative infection as well as your surgical wounds. Most breast reconstruction patients are discharged from hospital after 5 to 7 days. Full recovery is generally expected after 1 to 2 months.

Potential risks and complications

As with any surgery, general risks include pain, bleeding, and infection. Post-operative pain is usually well controlled after surgery with medication, and the risk of bleeding and infection leading to the need for another procedure is low. There is also the general anaesthetic risk, which will be explained to you by the anaesthetist, and is typically low especially if you are healthy. Specific to autologous reconstruction, if there is any sign of problems with the blood supply to the transferred tissue, you may be brought back to operating theatre expediently. Also, if a significant amount of native breast skin and nipple is kept after mastectomy, due to the thinness of skin, there may be a risk of some skin necrosis post-operatively. Other known sequelae include scarring, numbness at the operative sites, and asymmetry, which are usually managed well in the post-operative period.

More recently, textured implants have been associated with a rare form of lymphoma (BIA-ALCL) which is usually treatable. Thus far, smooth implants have not been implicated. Your surgeon should discuss this phenomenon with you if implant reconstruction is considered. For more information on this, see our FAQ on BIA-ALCL.

FAQ

Will Medisave/Medishield/private insurance plans cover breast reconstruction?

Yes. Breast reconstruction as well as the follow-up balancing procedures are usually covered by Medisave/Medishield/private insurance plans. The aim of breast reconstruction is to restore the patient’s appearance back to normal.

Does breast reconstruction interfere with breast cancer surveillance?

With adequate clinical and radiological follow up, breast reconstruction does not interfere with breast cancer surveillance.

Can I reconstruct both breasts at the same time?

If bilateral mastectomies are being performed, both breasts can be reconstructed at the same time, either with implants or the patient’s own tissue. The surgical time, as expected, will be longer.

What is Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?

BIA-ALCL is a rare lymphoma that is associated with breast implants, mostly occurring in patients who have undergone textured-surface breast implants. Since 1997, there have been over 300 cases reported. As this is an uncommon disease, data is still being accumulated and medical knowledge on this topic continues to evolve.

The most common presentation is a late effusion, with breast enlargement more than one year following the breast implant surgery. Other less common symptoms include a breast mass, enlargement of the lymph nodes of the axilla, or fever and night sweats. The average time to onset of BIA-ALCL after implantation is 10 years. BIA-ALCL may affect patients with either silicone- or saline-filled implants.

BIA-ALCL is diagnosed radiologically together fluid aspiration which is sent for testing. If confirmed, further investigations may be required. BIA-ALCL usually presents early, and curative treatment can be performed by implant removal and complete excision of the peri-implant capsule. Unless spread is found, no other treatments are usually needed.

If you already have breast implants, there is no need to change your routine medical care and follow-up. Should you experience any of the symptoms described above, do arrange for a consultation with your plastic surgeon.

References

1. Ooi A SH, Song DH. Discussion: Does the use of incisional negative pressure wound therapy prevent mastectomy flap necrosis in immediate expander-based breast reconstruction? Plast Reconstr Surg 2016;138:567-9.

2. Ooi A SH, Chang DW. Discussion: Volumetric planning using computed tomographic angiography improves clinical outcomes in DIEP flap breast reconstruction. Plast Reconstr Surg 2016;137:781-782.

3. Park, J. E., Shenaq, D. S., Silva, A. K., Mhlaba, J. M. & Song, D. H. Breast Reconstruction with SIEA Flaps. Plastic and Reconstructive Surgery 137, 1682–1689 (2016).

4. Nealon, K. P. et al. Prepectoral Direct-to-Implant Breast Reconstruction. Plastic and Reconstructive Surgery 145, 898e–908e (2020).

5. hang, D. W. Breast Reconstruction with Microvascular MS-TRAM and DIEP Flaps. Archives of plastic surgery 39, 3–10 (2012).

At Polaris Plastic & Reconstructive Surgery, we provide the highest standards of plastic, reconstructive and aesthetic surgery services to suit the individual needs of each of our patients, placing their well-being and concerns at the center of a seamless, holistic interaction with our practice.

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3 Mount Elizabeth, #08-05 Mount Elizabeth Medical Centre, Singapore 228510

Reconstructive Procedures

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Reconstructive Procedures

Breast Reconstruction

What is breast reconstruction?

Who would benefit from breast reconstruction?

When is breast reconstruction performed?

How is breast reconstruction performed?

What happens before surgery?

During the procedure

Post-operative care

Potential risks and complications

Why choose Polaris Plastic Surgery?

Conditions and procedures

FAQ

Will Medisave/Medishield/private insurance plans cover breast reconstruction?

Does breast reconstruction interfere with breast cancer surveillance?

Can I reconstruct both breasts at the same time?

What is Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?

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