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Plastic and reconstructive surgery

Kent profile magazine 2011

Very often, when people hear that I am a plastic surgeon, they presume that my job is composed of breast enlargements, facelifts, tummy-tucks and other cosmetic operations. However, the aesthetic side of plastic surgery forms only a small part of the full repertoire of a plastic surgeon. Plastic surgery also includes, burns surgery, cleft lip and palate surgery, cancer reconstruction, surgery for birth defects and much more. With this in mind, I have written the following article about my main reconstructive plastic surgery interest: breast cancer reconstruction.

The psychological impact of losing a breast, on top of the diagnosis of cancer and the grueling treatment regime, can be devastating. Fortunately, using modern plastic surgery techniques, breast reconstruction can restore some femininity to women who find themselves in this situation.

Breast reconstruction can be carried out at the same time as the mastectomy (immediate breast reconstruction) or may be done at a later date some time after the mastectomy (delayed breast reconstruction). Broadly speaking, the reconstruction can either be based on using only the patient’s own tissue (skin, fat and occasionally muscle) or performed by techniques that involve the use of a breast implant.

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No matter what technique of breast reconstruction is chosen, it is common for two or thee operations to be needed to complete the breast reconstruction. The first is to make the breast ‘mound’, the second to make any adjustments (often to the other breast for symmetry) and the third is to reconstruct a nipple.

As a plastic surgeon, whenever possible, I prefer to use techniques that involve only the use of the patient’s own tissue. These techniques are complex and time-demanding (for patient and surgeon) and are not always suitable for everyone. However, they give the best long-term aesthetic outcomes and, in addition, unlike implantbased techniques, once the breast reconstruction journey is complete, no further surgery is necessary in the patient’s lifetime.

The gold standard method of breast reconstruction is the DIEP flap, which involves taking skin and fat from the abdomen (the same tissue that is removed during a tummy-tuck) and sculpting this into a new breast.

However, taking the tissue off of the abdomen means that it is no longer alive, as there is no blood running through it. Therefore, blood circulation needs to be restored to bring it back to life. This is done through microsurgery, in which an artery and vein that have been carefully removed with the tummy tissue are stitched to an artery and vein in the chest under the operating theatre microscope. Once the blood flow is restored, the tissue is ‘brought back to life’ and can then be sculpted into a new breast. The whole operation takes six-eight hours and needs about five days in hospital.

months to get all their energy levels back to normal, so is quite an initial commitment, but the benefit is that the reconstruction does not need to be re-operated on later in life. Other parts of the body can also be ‘borrowed’ from to reconstruct a breast without an implant if there is not enough tummy fat. Areas include the upper inner thigh, the buttocks or the back.

If the complexity of the above procedure deters someone from this route, or the patient is not suitable for these operations for other reasons, implant-based reconstructions are alternatives.

The most straight forward is to use a ‘fixed-volume’ implant straight away – i.e. using an implant of the appropriate size to recreate the breast mound. However, many women will have an inflatable implant (an expander) placed as the first of a two-stage procedure: the empty, deflated expander is inserted under the muscle of the chest wall as the first operation. Subsequently, in the outpatient clinic, saline is injected into it to inflate it gradually until the desired size is reached. Once this has been achieved (usually after several months), a second operation may be performed to replace the expander with a softer, more realistic fixed-volume prosthesis.

Many women receive radiotherapy as part of their breast cancer treatment and this causes long-term scarring in the tissues of the chest wall. If so, it is not advisable to put in an implant as described above, as problems with tight scarring around the implant will occur within a year or two in most cases.

In this situation, a protective layer of soft tissue needs to be brought in from a part of the body that has not been affected by radiotherapy. The area used is the back, in which case a muscle and piece of skin attached to the muscle (the latissimusdorsi) is used. The skin and muscle are brought through to the front via a tunnel created under the armpit, and are used in combination with an implant for the reconstruction.

short overview of the common options available. What is important is that any woman considering breast reconstruction is given the choice of all the techniques that are suitable for her. This may often need the input of a plastic surgeon, as well as the breast cancer surgeon.

Not all methods will be suitable and one size does not fit all; the best choice is the one decided on between patient and surgeon after a thorough discussion of all the options.