Category: Procedures

Breast reconstruction after cancer surgery should be offered to all suitable patients before surgery and adequately discussed. Therefore, a team approach involving breast surgeon, reconstructive plastic surgeon, oncologist, breast care nurse and various counsellors is of the utmost importance.

Since the early eighties it became clear that breast reconstruction performed at the time of mastectomy in cases of early breast cancer is indeed safe and not compromising the oncological treatment or outcome for the patient. Should immediate breast reconstruction be contra-indicated due to advanced disease or other problems then a delayed reconstruction is always an option once a disease free period has lapsed. Significant improvement in body image and quality of life scores have been shown in-patients after reconstruction especially the younger patient groups.

Several accepted surgical alternatives are available. Breast reconstruction after mastectomy neither prevents early detection of disease recurrence nor precludes the use of chemo or radiotherapy.

Once the necessity for surgery has been established a detailed discussion should follow regarding surgical options:

• lumpectomy with radiotherapy
• mastectomy
• mastectomy with breast reconstruction

Studies have shown this discussion is very important and only 40% of patients recalled mentioning breast reconstruction preoperatively and only 55% recall that lumpectomy had been discussed. This emphasizes the continuing inadequacy of patient information.
Whereas not all women may wish to assume an active role in treatment decision-making, it is important to be well informed about all options available.

Options available:

A. Implants

In small-breasted woman an implant only may be suitable which can be inserted through the incision that was used for the mastectomy. Silicone gel implants is currently available for use.

B. Tissue Expansion

A balloon type device is placed under the chest wall skin at the same operation that mastectomy is performed. It can be inflated after insertion to stretch the skin and produce more skin and improve symmetry with the other breast. Inflation or stretching is normally done over a period of time (with weekly visits at the office or out-patient department), until the right volume and amount of skin is reached, sometimes overcorrecting (to achieve a similar amount of droop to the healthy side). This option is not indicated if radiotherapy to the chest wall has been given or is to be done postoperatively.

C. Fat transfer

It’s indicated only in patients that have undergone skin sparring mastectomy so that their skin envelope is intact and have a small sized breast, up to cup B. It can be done at the same time with the mastectomy or later on but within time limits of 3-6 months in order to avoid skin and wound shrinkage. Liposuction is performed from the areas decided prior to surgery and the fat is injected in the skin pocket of the breast until the wanted size is reached. Fat is absorbed at some extent (up to 40%), therefore another session under sedation might be necessary.

D. Latissimus Dorsi Flap

The muscle from the back with an amount of back skin can be used to replace the skin taken during a mastectomy. An implant or fat from another site of the patient is normally used with it to provide the bulk for the newly created breast. This obviously leaves a linear scar on the back of the patient that is partly hidden by the bra.

E. TRAM Flap

Skin and fat from the lower abdomen can be used. The patient then has a “tummy tuck” type of scar on the lower abdomen. Enough tissue has to be available for transfer. No implant is used. There are 3 ways to transfer the flap:

1) It can be “pedicled”, that is stay attached to the donor area

2) Free flap, to totally separate it from the donor area, transfer it and re-attache it to the recipient area for it’s blood supply, under microscope

3) By the DIEP technique. By this method, no muscle is taken and the blood supply is re-attached under the microscope (DIEP).

The operation

The surgery can be performed at the time of the mastectomy or later during a second operation. Hospital stay varies with each technique and between patients and range from 3-7 days. Early postoperatively you will have surgical drains coming out of the wound to drain away excess fluid. These are normally removed on day 2 or 3 after the operation. Sutures are normally removed between 8-12 days post-surgery. A recovery period from between 6 weeks and 3 months should be expected.

Complications

Complications are increased in overweight patients, smokers and women who had undergone radiotherapy.

Conclusion

Breast reconstruction should be offered as an option to all patients undergoing mastectomy, partial mastectomy or lumpectomy. Recent studies have confirmed the belief that a woman undergoing breast reconstruction has significant psychological benefits. Patients undergoing immediate reconstruction did not show the same poorer preoperative body image compared to patients undergoing delayed reconstruction, however, both groups benefit significantly from reconstruction. The type of reconstruction does not appear to influence patient satisfaction.

Implants have been used to enlarge the breast or reconstruct the breast for more than 40 years. Not only is size important but also shape. An appropriate sized breast for the size and type of body is very important for a good body image and confidence.

Pregnancy and breast-feeding can also alter the shape and size of the breast as well as normal ageing. Some patients may require a lift (see the section on mastopexy) in addition to more volume.

4a.Breast implants

A breast implant consists of an outer silicone elastomer shell, which can be filled with a variety of materials. The outer shell can be smooth walled or textured. Currently there are two fillers on the market – silicone or saline (salt water). Silicone is available as a gel or a cohesive gel. Implants can be round or shaped.

The surgeon prefers textured silicone implants. When an implant is inserted into the body a membrane forms around the implant in the same way as it forms around a knee prosthesis or any foreign body. The membrane or capsule normally stays soft and the patient is unaware of it. Sometimes, however, it may becomes thicker in some patients and cause asymmetry or pain. This may require further surgery. Textured implants are normally associated with a reduced risk of capsule formation.

The implant may be inserted through a little scar in the crease under the breast or through an incision around the areola. The implant may be inserted in a submuscular (under the chest muscle) or subglandular (under the breast tissue) position. The type of implant, the size of the implant as well as the position of placement and the type of incision will be discussed during the consultation. It varies greatly from patient to patient.

Mammography is possible after breast implants but with Magnetic resonance mammography. This imaging modality has the possibility to detect possible implant rupture and to clearly visualize dense breasts with silicone implants. The disadvantage is the cost of the examination, the use of contrast medium, the inability to detect calcifications <3mm and the duration of the examination.

Complications

The operation is usually free of complications but any of the following may occur:

• Capsular contracture
• Collection of blood around the implant (haematoma) from a blood vessel that has opened up which may require drainage
• Displacement of the implant
• Infection
• Changes in nipple sensation
• Wrinkling of the implant

The surgery

A general anaesthetic is normally required and can be performed as a day case. Pain is minimal to moderate and can be controlled by painkillers taken orally most of the time. The breasts are taped up during the surgery in a supportive bandage. The breasts will be swollen and tender and may feel very tight.

Complications

Capsular contracture (in some studies the rate is up to 20%)
Hematoma (blood collection under the implant) that needs to be drained
Implant migration
Infection
Altered nipple sensitivity (15%)
Implant rippling
24-33% of patients undergoing breast augmentation with silicone implants developed one of the above mentioned complications and need to be re-operated early or much later in their lives.

After the surgery

You can normally sit in a shallow bath but should not get the breasts, dressings or incision lines wet. The sutures will be removed after 10-12 days. You should refrain from doing heavy lifting or exercise for 4 weeks after the surgery. Massaging of the scars four weeks after the surgery will help the scar to fade quickly.

4b. Breast augmentation with lipotransfer

The surgery

It’s done under general anaesthesia and the patient spends one night in the hospital. Postoperative pain is moderate and can be controlled by tablets. The breasts are swollen and tender.

The fat is suctioned from pre-agreed areas of the abdomen and thighs through small 4-5mm incisions. After centrifugation fat is injected in different levels under the breast gland through small incisions.

During the operation an overcorrection is done since about 70% of the transferred fat cells will survive. The incisions are covered with small stere-strips and the breasts wrapped in a soft athletic type top.

The best candidates are patients from whom one can remove fat and are interested in a small augmentation (up to one cup)

Complications

According to the % of fat survival, a second session might be required. The small incision scars usually fade with time to normal skin color. Because of many levels of fat injection, though rare, the formation of lumps can occur. This usually resolves with massaging of the area. Swelling and bruises, subside within 10 days. You will receive prophylactic antibiotic treatment.

After the surgery

The fat remaining 3 months postoperatively is considered permanent. Sutures are removed after a week and you’ll be ready to return to your everyday schedule.

Excess skin and fat as well as slack muscles can be addressed during the surgery. Sometimes if only a small amount of fat is problematic it may be removed by liposuction. Stretch marks are not really addressed during this type of surgery except the marks that are on the skin that will be removed.

The procedure

You will be left with a noticeable scar from one hip to another. It can be positioned so that it is hidden when wearing swimsuit. A small circular scar not unlike a laparoscopy scar is left around the umbilicus as it reappears through a new skin “window”. Some liposuction around the “love-handle” area normally enhances the overall result. The operation is performed under a general anaesthesia and the hospital stay includes at least one night. It’s possible that you will have surgical drains coming out of the wound afterwards that will normally be removed the day after the surgery. Pain in the early phase after the surgery can be controlled by iv painkillers and when you return home by tablets.

Limitations and complications

It is generally not indicated in very overweight patients and your weight should be fairly stable. Smoking can lead to impaired wound healing and wound breakdown. There is also a small risk of:

• Infections
• Haematoma (collection of blood under the skin from a ruptured blood vessel)
• Seroma (collection of clear fluid) that can form after the surgery and that may need to be aspirated
• Scars as mentioned before. Remember some patients have a genetic predisposition to form bad scars (keloid). Discuss this during the consultation if you think you are such a patient
• There is a small risk of a blood clot in the leg (DVT or Deep Vein Thrombosis) but standard precautions are always followed

After the surgery

It may feel more comfortable in the early phase to sleep with a few pillows under the head and the knees as this will remove the pulling effect on the suture line. If liposuction was also done a support garment should be worn for a period of 4-6 weeks. Sutures are normally removed around two weeks at which time you can return to work as long as it is not a very physically demanding job. Full recovery to a normal exercise level can vary from 4 to 6 weeks. The wound should be kept clean and dry at all times and bathing is not advisable.

Breasts that are out of proportion with the rest of the body can cause many problems. Shoulder pain, back pain and chronic infections under the breast have all been attributed to large breasts.

Overgrowth of breasts can happen in adolescence or after pregnancy or middle age. The excess breast tissue can be removed and the skin tightened to create a normal size and shape. The nipples are normally lifted to suit the new shape of breast and can be done using different techniques each suitable for a specific patient.

The patient normally has a scar around the nipple and a vertical scar from the nipple downwards. The appearance of the scars normally resembles a lollipop shape. There is also another technique where the scar is around the nipple and then vertical from the nipple downwards to continue horizontally under the breast. The surgeon prefers the first method due to a smaller surgical wound and better shape of the breast.

It is not always possible to reduce the breast to a very small size as this may compromise the blood supply to the nipple. Asymmetry in breast size is common and the discrepancy can be addressed during surgery although perfection is not always possible.

Surgery

It is performed under a general anaesthetic and you have to stay in the hospital for at least one night. On the day of the surgery I will come to your room and do some markings on the breast and we will have a final discussion on the size you would like to be. It’s possible that you will have surgical drains coming out of the breasts after the surgery to remove excess fluid. They are normally removed after 24 hours. Pain is moderate and can be controlled by pain-killing injections or tablets. The sutures are removed on the 15th day.

Consequences and complications

After breast reduction surgery breast feeding may not be possible. The nipples will be numb afterwards but do normally recover. Infection may happen but is rare. The blood supply to the nipple may be compromised during the surgery and this might lead to partial loss of the skin of the nipple, but this is extremely rare. Smokers are at greater risk for healing problems. A blood transfusion is not normally required. You can still have breast screening for cancer afterwards if required. The scars normally settles down to white lines but may be problematic in people with a tendency towards bad scarring.

After the surgery

You should keep the breasts strapped up with in a firm athletic top until the sutures are removed. You can sit in a shallow bath for the first 5 days and after that you can wash normally but covering the wounds with waterproof adhesive. Should any water or moisture fall on the wounds you will dry the area using a hair-drier with cold air from a distance.

Heavy exercise should be avoided for at least 4 weeks. Driving needs to be avoided for at least 2 weeks. A soft sports bra should be worn after removal of the sutures for a period of six weeks.

Growth of the breasts during pregnancy is common due to increase in glandular content and milk production. The subsequent loss of volume and excess skin leads to droopiness of the breasts. This can also be seen as part of the natural ageing process or after massive weight loss.

The surgery

Excess skin is removed under a general anaesthetic to lift the nipple and remodel the breast shape. Sometimes it may be necessary to add additional volume as well as remodelling the skin envelope – this is called a mastopexy-augmentation can be done at the same time. The design of the scar depends on the degree of droop and breast shape. Hospital stay is normally limited to one day. The sutures are removed after 10-12 days. You may have surgical drains (plastic pipes) taking away excess fluid after the surgery that is normally removed after the first day.

Complications

Numbness of the nipples is normally a temporary feature which may last up to 6 months. Permanent numbness is observed in 7% of cases. The scars are normally fine lines but may be visible on close inspection. Some patients do tend to make wide and more visible scars. Smoking can contribute to healing problems. Infection is a possibility but rare. You may get a collection of fluid from a ruptured blood vessels that need to be drained but that is uncommon. There is a very low probability not to be able to breastfeed after this kind of surgery.

After the surgery

The breasts are normally bandaged and that stay in place until removal of the sutures. Pain is mild to moderate and can easily be controlled by oral medication after the first 24 hours. You should not do any strenuous exercise for the first 4 weeks. It is best to avoid driving for the first two weeks. A sports bra is recommended after removal of the sutures for a period of 4 weeks. Lifting of heavy objects should be avoided for the first 4 weeks.

Liposuction and liposculpture are not procedures aiming at weight loss. They involve the removal of body fat with a hollow cannula and suction. The fat is softened first by injection of fluid or through an ultrasonic machine. It is ideally suited to patients that have a stable body weight and are not obese. Localized fat is ideally suited for treatment with this method. Liposculpture describes the method of using liposuction to contour the body.

The surgery

Large areas are done under a general anaesthetic while a small area can be done under local anaesthetic and sedation. It can in some cases be done without staying overnight in the hospital. A series of tiny incisions is made in the skin to insert the cannulas in order to address the appropriate areas. It is necessary post-surgery to wear a compression garment (bought by you according your size), to assist skin shrinkage. The garment has to be worn for 15 days continuously (except when you take a shower) and for 30 days more at least 12-18hs daily. Pain is mild and can be controlled by oral medication.

Complications

It may be necessary if huge amounts are removed to have a blood transfusion. Skin irregularity may result after removal of excess superficial fat. Asymmetry of the areas treated may occur. Infection of the wounds is a theoretical possibility. If ultrasonic liposuction is used the viability of the skin may be compromised especially around the insertion area of the cannula.

After the surgery

The area treated will be swollen and bruised. It can take 2-3 weeks for the bruising to disappear. The incision lines are covered and should be kept clean and dry. It is better to avoid strenuous physical exercise for 3-4 weeks. The sutures are removed 10 to 12 days later. The same fat cells cannot re-grow after the removal but if a lot of weight is gained fat cells may form again in the same area.

Transplanting fat from one part of the body to augment the soft tissues in another part has been done for a long time in plastic surgery. However recently a technique has been described to transfer the fat in a more careful way (liposculpture) so that a larger percentage of the fat will survive.

About 60% of the injected fat survives and therefore there might be a need for a second session of lipotransfer in case that the first result isn’t satisfactory. It can be used for breast augmentation with specific indications, lip enhancement, nose to mouth lines (nasolabial folds), or any other area suffering from lack of soft tissue.

Lipotransfer also helps in cases of facial lipodystrophy as in the case of scleroderma, AIDS, Parry-Romberg syndrome etc.

The surgery

Depending on the area involved it can be done under sedation and local anaesthesia or under general anaesthesia. You do not have to stay in the hospital. Fat is taken from an area like your tummy or thighs through two or three small incisions. It is then injected in a multi-layer technique to improve contour. Small incisions have to be made once again to inject the fat in the appropriate area. A certain amount of overcorrecting will be necessary as only around 60% of the fat survive. A small dressing will cover the incision lines.

Complications

Depending on fat survival you may need to repeat the procedure (especially in the case of breast augmentation). The small scars from the incisions normally fade after a time and blend in with the rest of the skin. Due to the multi-layer technique lumpiness is not common but may occur. Swelling and bruising can last from a few days to 10 days depending on the area. To reduce the risk of infection you will be given a suitable antibiotic.

After the surgery

Fat surviving at three months can be considered permanent. The sutures will be removed after 7 days. Depending on the area involved and the amount of swelling and bruising you may wish to avoid social contact for the first 5-7 days.

Gynecomastia (woman-like breast) is an extremely common condition occurring in approximately 50% of all men. The degree of the condition may vary from a small nodule of breast tissue behind the nipple-areola complex to real female like breasts of mixed fat and/or glandular tissue.

Certain medical conditions can cause the problem as well as certain medication for example anabolic steroids. The etiology of gynecomastia should be investigated and treated before surgery is considered. Suitable candidates for surgery should ideally have a stable weight and be emotionally balanced.

The operation

Depending on the degree and whether the problem is mainly caused by excess fat and/or gland the problem can either be corrected by liposuction only (mainly fatty tissue) or surgical removal of the glandular tissue or in some cases a combination of the two. The aim is to create a male shaped breast without removing excessive tissue that can cause a contour deformity.

An incision on the edge of the areola is normally used for surgical removal while an incision in the side of the breast or the edge of the areola can be utilized for liposuction. In extreme cases more skin around the areola as well as perpendicularly from the nipple-areola complex, may have to be removed and then scarring in that case will be more extensive.

The procedure is normally performed as a day case procedure under general anaesthetic in the hospital. If large amounts of glandular tissue are removed an overnight stay may be required. Surgical drains are usually inserted overnight in cases of glandular resection.
The wounds are normally covered by a dressing and you may be required to wear a compression garment for up to 6 weeks post surgery. Pain is normally mild and can easily be controlled by adequate medication.

Complications

• Infection occurs rarely but you will be given some antibiotics during the operation in the operating theatre to prevent infection
• Haematoma (collection of blood inside the breast) may occur if the drainage tubes cannot manage the amount of fluid. This is unusual and will normally occur while you are still hospitalized and may require a return visit to the operating theatre to evacuate the excess fluid. This if it happens does not influence the ultimate result

• Sensation in the nipple is preserved but may be temporarily reduced for up to 3 months postoperatively
• The scars run around the nipple margin as previously described or at the edge of the breast. My incisions are closed with buried stitches, which avoid unsightly stitch marks and produce the finest possible scar line. A few people do develop red unsightly scars – (hypertrophic scars) but fortunately this is rare, and can often be anticipated from a previous history of operation scars or accidents and there is a treatment, which helps control, this problem. Your scars will usually fade out progressively over a two year period
• Pre-existing asymmetry cannot always be fully corrected
• A seroma (collection of clear fluid) may require aspiration after the surgery but is usually self-limiting and doesn’t influence the ultimate result

After the operation

Your sutures will be removed on the 12th postoperative day. Sometimes the fine sutures around the areola will be removed earlier. The wound should be kept clean and dry until the removal of the sutures. It is possible to sit in a shallow bath and keep the dressings intact and dry.

You can drive 2 weeks after the operation if you did not have any wound healing problems. A full exercise program should be avoided for 6 weeks. You may be required to wear a compression garment for 6 weeks after the surgery.

Excess skin on the upper arms is common and can be due to excessive weight loss, as part of the natural ageing process or loss of tone of the muscles. Some patients may have a predisposition genetically for this defect. Liposuction is normally not indicated as the skin shrinkage after fat removal in this area is often inadequate and may make the appearance worse.

The procedure

It is normally performed under a general anaesthetic and can be done as a day case procedure. An incision is made on the inside of the arm from the armpit to the elbow. You may require surgical drains to remove excess fluid after the operation. Sutures are normally removed after 10-12 days. Sometimes it is possible to perform the procedure through a more limited incision but that will restrict the amount of improvement that can be expected.

Complications

Normal scars are usually fine lines but can be raised and widened in some patients genetically predisposed to keloid formation. Infection of the wound is possible but some antibiotics will be prescribed. A collection of blood under the skin may form from a ruptured blood vessel and may need to be drained. A rare complication is the dissection of a cutaneous nerve branch running in the surgical field that causes numbness of the inner forearm skin (5%). Physiotherapy might help to easily regain your full range of movement after the 15 postoperative days that upper extremity motions are restricted.

After the surgery

You will need some assistance when returning home at least until the sutures are removed. Pain is normally moderate and can be controlled with oral medication. The scar will improve with time and is really best after 6 months to a year. Over a year time, no visible changes can be observed in scars

Excess skin and fat can cause sagging on the inside of the upper leg. Sometimes it is enough to remove some fat by liposculpture but often this will create excessive skin that needs to be removed. The scar is in the inside fold of the thigh and continues to the back in the fold of the buttock. It’s usually long and visible. It is anchored to the deeper layer of the leg and to the bone in the groin and that prevents unrolling.

The surgery

It is performed under a general anaesthetic and often combined with other procedures for example breast lift or brachioplasty. The surgeon doesn’t combine this operation with abdominoplasty or belt lipectomy because the incisions are parallel thus increasing wound tension. You will have some surgical drains coming out of the wound removing excess fluid. These are removed within 2-3 days. Pain is moderate and can easily be controlled by injections while in hospital and by oral medication once you are discharged home. It may be uncomfortable to walk for the first few days.

Complications

Bruising and swelling is moderate. Infection is a possibility but you will be provided with some antibiotics to prevent it for 10 days. Meticulous hygiene of the area is very important. You can dry up your wounds with the help of a hair-dryer. Wound dehiscence can occur especially at the points of maximal tension (where the horizontal line meets the vertical). Some collection of fluid from a ruptured blood vessel may need drainage.

After the surgery

Walking should be restricted for the 1st week postoperatively. Sutures are removed 10-12 days after the surgery. You will be able to freely move around 2 weeks after the operation and if you’re exercising, you can return to your everyday schedule after a further 2-4 week period. It is unlikely that this problem will recur unless you gain or loose excessive amounts of weight.

Body contouring (after massive weight loss)
a. abdominoplasty (see section)
b. Arm lift (see section)
c. Belt lipectomy

Skin excess around the trunk is one of the most common findings after massive weight loss. Abdominoplasty addresses only the frontal part of the problem. Therefore belt lipectomy is advised. The incision is placed from one flank to the other, to the front as in abdominoplasty and to the back as in buttocks lift. It’s mainly planned in such a way that it can be hidden by the underwear. It’s one of the most extended incisions in plastic surgery.

The operation

The incision leaves a scar around the base of the trunk. There is also an additional scar around the umbilicus (resembling a laparoscopic scar), through which, umbilicus is placed in its new position. Liposuction is routinely carried out at the sides of the trunk, to augment the postoperative result. The procedure is done under general anaesthesia and you have to be hospitalized for minimum one day. Postoperative pain is controlled by iv painkillers and after your discharge from the hospital with tablets. There is a possibility of having 2 drains (tubes that collect excess fluid from the surgical wound) when you come out of surgery. These are usually removed the next day. The surgeon doesn’t usually use drains.

Complications

Belt lipectomy is not indicated in obese patients, therefore your weight must be relatively stable and within healthy limits. Smoking might lead to bad wound healing and wound dehiscence. There is also limited possibility for:

• Infection
• Hematoma (blood collection under the skin from a ruptured blood vessel)
• Seroma (clear fluid collection) can be a result of the operation and it sometimes needs drainage by a syringe
• Visible hypertrophic scars. The formation of “ugly” scars is genetically controlled. Certain people have a predisposition in the formation of keloid scars.
• There is low possibility (1.2%) for clot formation in the lower extremity and for pulmonary embolism (0.8%), even though you will be receiving anticoagulant injections postoperatively.

After the operation

It will be more convenient to sleep with a pillow under your knees and your head for a couple of days, as this will relieve tension on the incision line. If liposuction was carried out, you have to wear a special compression garment for 4-6 weeks. Sutures are removed after 15 days and then you can return to your job if it’s not physically demanding.

Full recovery is expected after 4-6 weeks from the operation. The surgical wound has to be kept dry and clean, therefore it’s advised to cover it with a waterproof adhesive when you shower.