Skin sparing mastectomy is a relatively new technique of breast resection for breast cancer. The technique has been well established in the United States over the last 15 years, and in Singapore, surgeons have been practicing it for about 10 years.

The entire breast including the nipple, is removed through a circular incision made over the nipple and areola. The breast is reconstructed during the same operation by filling the breast skin with abdominal fatty tissue, back tissue, or a breast implant. Apart from patients who have large tumors, which may involve the chest wall, and those in whom there, is residual tumor after resection, virtually everyone else is a candidate for immediate reconstruction.

There are many advantages of breast reconstruction. A patient does not wake up after mastectomy with a flattened chest, resulting in immediate restoration of body image improvement in psychological well-being. Scarring over the chest is reduced. In many instances, the natural beauty of one’s body is restored with no visible scar after the nipple has been reconstructed.

Methods of breast reconstruction

The breast can be reconstructed using either a breast implant or a flap (living tissue). Two stages are involved: the first involves creating the breast form and the second, reconstructing the nipple and areola.

The most common method of reconstruction is the TRAM flap (transverse rectus abdominis myocutaneous flap) that uses fatty tissue from the tummy. Fig 1 depicts the procedure in which an ellipse of skin and fat is transferred from the lower abdomen to the chest. The flap is nourished by blood supply from one of the paired rectus abdominal muscles. Because this is living tissue (as opposed to an implant), it is warm and soft, and moves and feels like a normal breast. A secondary advantage is that the patient receives a “tummy-tuck” at the same time. Patients undergoing the TRAM flap will have a horizontal scar, which is similar to a Caesarian scar, but longer. The disadvantages include longer surgery (4-6 hours) and longer recovery period (1-3 months), depending on the patient. A rare but possible complication is the formation of an abdominal bulge, due to loosening of the abdominal wall muscles. The laxity can be tightened in a separate surgical procedure.

Fig 1a	Fig 1b

Another technique utilizes skin and fatty tissue taken from the back (latissimus dorsi flap). Typically it is used in women with smaller breasts (A or B cup size). Fig 2 depicts the procedure in which a flap of skin and muscle from the back on the same side as the operated breast is transferred forward to create a new breast. Like the TRAM flap, tissue taken from the back will feel natural as it is living tissue. Surgery time is about 4 hours and the recovery time is between 1 and 2 months. The disadvantage is that patients will have an oblique scar over the back, which is noticeable when one wears an open-back dress or swim suit.

Fig 2a	Fig 2b

Breast implants containing silicone or saline are widely used for breast reconstruction. The surgery is fast (2-3 hours) and recovery time is short as there are no scars on other parts of the body such as the abdomen or back. However, although they may look natural, they seldom feel as natural as those reconstructed out of one’s own tissue. Implants may need maintenance surgery at a later date due to hardening and leakage.

Nipple Reconstruction

Nipples can be created by using the existing tissue on the breast skin or by taking a small graft from the opposite nipple. The dark color of the nipple and areola is created by a skin graft taken from the groin or labia region. Another method of coloring the areola is tattooing. Nipple reconstruction is usually done 6 months after completion of breast cancer treatment (i.e., surgery, chemotherapy and radiotherapy if necessary). It can be done under local anesthesia and the length of procedure is about an hour.

 

Tan Bien Keem
Senior Consultant
Plastic Surgery
Singapore General Hospital