Female Breast Surgery
The breast is an important secondary sexual character in females. Biologically, the presence of breasts to feed the baby classifies humans as mammals. An ideal breast shape and mound is one of the most fundamental and essential components, desired by most females.
The principal subdivisions of aesthetic breast surgery are
- Breast augmentation
- Mastopexy (breast lift)
- Reduction mammoplasty (breast reduction)
- Axillary / Accessory Breast Surgery
- Breast Reconstruction
- Oncoplasty& Partial Breast Reconstruction
- Implant Based Reconstruction
- Whole Breast Reconstruction
- Nipple & Areola Reconstruction
- Lipofilling
General Precautions / Information before breast surgery
- Make sure you understand what surgery involves, including possible risks, complications, and follow-up care.
- You will be asked to stop blood thinners like Aspirin before the surgery.
- Smoking interferes with healing and tissue perfusion and hence should be stopped 3-4 weeks before the planned breast surgery.
- General anesthesia will be given in the majority of cases.
- You may not be able to breastfeed after breast surgery – mastopexy/breast reduction / Breast Augmentation. If you plan to get pregnant in the future, check with your doctor before having the procedure.
- Firm supporting brassiere is generally advised for a few weeks post breast surgery.
Breast Reduction Surgery
Breast reduction surgery is an operation to remove extra fat, tissue, and skin from your breasts. It’s not the actual size of the breast that matters, it is the relative size of the breast for your physique that is more important.
The indications for breast reduction surgery are
- Breasts that are out of proportion to the rest of your body.
- Heavy breasts cause neck pain, back pain, or other symptoms.
- Large Ptotic breasts interfere with hygiene and cause recurrent skin infections.
The surgery is done under general anesthesia. Before surgery, the pattern for excision is marked with the patient in the standing position. There are different techniques for breast reduction. The specific technique will be based on the breast size, patient preference, and the surgeon’s expertise. Most women who get breast reduction are very satisfied with the results.
Mastopexy
Mastopexy is the medical name for a breast lift. In this procedure, your breast will be raised and reshaped to give them a firmer and more projecting look. The surgery also removes extra skin around your breast which corrects the ptosis and reduces the size of your areola – the coloured circle around your nipple.
As you get older, your breasts lose their elasticity and firmness. Pregnancy, breastfeeding, and weight gain or loss can accentuate this process. You might want to have this surgery if your breasts have started to sag or droop. If the sagging breast is large, then excision of the skin and rearrangement of the tissue will give the firm look. But if there is not enough breast tissue, then we have to increase the size of your breasts with implants as in breast augmentation at the same time as mastopexy.
Procedure
Surgeons perform a breast lift using a few different procedures. The technique used depends on the size and shape of your breasts, and how much lift you need. Before the surgery, the marking for the surgery is done with the patient standing and the procedure is usually done under general anesthesia.
Mastopexy should give your breasts a more lifted, firmer appearance. You may have some scars on your breasts. Newer breast lift techniques cut down on scarring. To maintain your new look, try to avoid significant changes in your weight.
Breast Augmentation
Breast augmentation – also known as augmentation mammoplasty – is surgery to increase breast size. It involves placing breast implants under the breast tissue or chest muscles. Breast augmentation can change the size and shape of your breasts. The surgery might improve your body image and self-esteem. The elasticity and the skin quality will be different for each individual, and so does the shape of the breast appear after augmentation. Hence discuss your goals with your surgeon so that you can be realistic about the result and outcome. Also, your breasts will continue to age after augmentation. Weight gain or weight loss might change the way your breasts look, too. If you become dissatisfied with the appearance of your breasts, you might need more surgery to correct these issues.
Breast augmentation might help you
- Enhance your appearance if you think your breasts are too small or that one is smaller than the other.
- Adjust for a reduction in the size of your breasts after pregnancy.
- Correct uneven breasts after breast surgery for other conditions.
- Improve your self-confidence.
How you prepare
The surgeon will examine and discuss your preferences for the size, feel, and appearance of your breasts. The surgeon will describe specific types of implants and their features. A baseline mammogram is done before the surgery. After the procedure, you will be advised to avoid strenuous activities for a minimum of 3 weeks and also to wear a supporting garment/sport brassier for a few weeks till the wound settles. You should understand certain features when using the implant for Breast Augmentation.
- The implant is not permanent. the average life span is 10 years but can extend up to 20 years.
- MRI scan to be done at specific intervals for breast screening.
Procedure
The procedure is generally done under General Anaesthesia and as a daycare procedure. Through a small incision below the breast, the implant is inserted in a sterile manner into the breast. Rarely the implant is placed through an axillary/periareolar incision. The implant is positioned under the skin/muscle / dual plane depending on the type/size of the implant and the projection needed.
Axillary Breast Removal
Breast tissue makes up the shape and size of your breasts. However, it can sometimes develop beyond the normal location of your breasts. It is particularly common in the area of your armpits (known as the axilla). According to medical studies, axillary breast tissue can occur in 2% to 6% of women.
If you have axillary breast tissue, there will be an abnormal bulge especially when your arms are down. It may become particularly troubling before menstruating or with pregnancy since the axillary breast can swell and feel more sensitive (just like your breasts). It interferes with axillary hygiene and wearing certain dresses. Weight gain can make it look worse
Procedure
Your axillary breast tissue can be safely removed with surgery. This can be done with
-
Liposuction, if there is little correction required or
- Excision (removing tissue with incisions) for extensive correction
- Combined -if contour correction is required for surrounding tissues also
The surgery will be done usually under general anesthesia or sometimes under local anesthesia. For liposuction, there will be only a small incision of about 0.5 to 1 cm, through which the fat / breast tissue is sucked out. For excision surgery, the incision will be longer but usually hidden in the armpit. The scar in the axilla is barely / less visible.
Breast Reconstruction Surgery
Women who have surgery as part of their breast cancer treatment or have congenital chest deformity, like Poland’s Syndrome, may choose breast reconstruction surgery to rebuild the shape and look of the breast. This is called breast reconstruction surgery. There are different types of breast reconstruction depending on the size of the breast, the amount of breast tissue missing/removed, and the patient preference. The breast is a secondary sexual feature and symbolizes feminity. Loss of whole or part of the breast, will not produce physical deformity but also mental agony for the patient. Though the patient might be free from cancer, the deformity will be a constant reminder of the disease. Studies have shown that females undergoing breast reconstruction have an improved “Quality of life” compared to those without reconstruction.
The reconstruction can be done immediately after the excision surgery or later. After a mastectomy, breast reconstruction can make you feel better about how you look and renew your self-confidence. Doing it immediately has the advantage of single anesthesia and hospitalization. But the disadvantage is that if the patient receives post-op radiotherapy, there are chances of distortion of the breast shape. For patients undergoing surgery later(after the adjuvant treatment), the disadvantages are repeat hospitalization, and operation on a scarred bed(if RT is given) with increased chances of wound breakdown. But the advantage is that the breast shape will not have much change.
Breast Reconstruction Surgery – is it needed for me?
If you are thinking about having this done, it is best to talk about it with your cancer surgeon and a plastic surgeon experienced in breast reconstruction before you have surgery to remove the breast. This lets the surgical teams plan the best treatment for you, even if you decide to wait and have reconstructive surgery later. Several types of reconstructive surgery are available, and sometimes the process means more than one operation. Give yourself plenty of time to make the best decision for yourself. You should make your decision about breast reconstruction only after you are fully informed.
A woman might choose to have breast reconstruction for many reasons:
- To have a normal chest appearance of a female
- To help make clothes fit better
- To permanently regain her breast shape
- No need to use a breast form that fits inside the bra (an external prosthesis)
- To feel better about her body and improve her quality of life
Important points to consider in Breast Reconstruction
- Breast Reconstruction will not hide recurrent cancer, provided an appropriate follow-up and radiological investigations are done.
- The reconstruction of the breast is done after the cancer surgeon does the excision surgery. Studies show that reconstruction does not make breast cancer come back.
- An uneventful Reconstruction of the breast will not affect the initiation of the adjuvant treatment.
- Breast reconstruction is not cosmetic surgery and it is a reconstructive surgery that also improves the quality of life of cancer patients.
- This surgery is covered under insurance policies – Both government and private.
- The reconstructed breast will not be a perfect match or substitute for your natural breast. They will not have sensations similar to a normal breast. If tissue from your tummy, back, or buttocks was used as part of the reconstruction, those areas will also look different after surgery.
Factors to consider in choosing the Breast Reconstruction
When choosing a breast reconstruction many factors – patient-related and disease-related are considered to choose the appropriate reconstruction and the best outcome.
- Your overall health (including issues that might affect your healing, such as smoking or certain health conditions)
- The size and location of your breast cancer.
- Your breast size.
- The extent of your breast cancer surgery (lumpectomy or mastectomy)
- Whether you will need treatments other than surgery for your cancer- chemotherapy & Radiotherapy
- The amount of tissue available in the donor site for reconstruction (for example, very thin women may not have enough extra tummy tissue to use this area for breast reconstruction).
- Previous surgery in the abdomen / Gluteal region will exclude such donor sites.
- Whether you want reconstructive surgery on one or both breasts.
- Your desire to match the other breast to achieve symmetry.
- How quickly do you want to be able to recover from surgery.
- Your willingness to have more than one surgery as part of the reconstruction.
- How different types of reconstructive surgery might affect other parts of your body.
Types of Breast Reconstruction procedures
Women who have had surgery to treat breast cancer can choose from several types of breast reconstruction. We will review your medical history and overall health, and will explain which reconstructive options might be best for you based on your age, health, body type, lifestyle, goals, and personal preferences. You will be explained the limits, risks, and benefits of each option.
The various options are
- Breast Implants.
- Breast reconstruction using tissues from other parts of the body.
- Fat Grafting.
- Reconstruction of Nipple Areolar Complex
Oncoplasty
These are reconstructive procedures done using the breast tissue. This is generally done in cases of lumpectomy/partial breast excision where the breast tissues itself is mobilized to fill the defect. This is based on principles of breast reduction so that the overall shape of the breast and Nipple Areolar complex is not distorted much. Sometimes a procedure has to be done on the opposite breast to make it appear symmetrical.
These are procedures in which the breast is reconstructed using implants usually made of silicone. The options for implant-based reconstruction can be
Immediate Reconstruction
The implant is placed after breast cancer excision in a single surgery.
Delayed Reconstruction
This type of reconstruction is considered if the patient is planned for radiotherapy or if the patient is not willing for immediate reconstruction. In this procedure, an expander is placed in the breast area immediately after the cancer excision. This expander is like a balloon which has a port to inject saline for the expansion process. Once the adjuvant or Radiotherapy treatment is over, the expander is gradually inflated (over a few weeks) to the desired size. Then the expander is removed and replaced with a permanent silicone implant of appropriate size.
A tissue flap procedure (also known as autologous tissue reconstruction) is one way to rebuild the shape of your breast after surgery to remove cancer. As with any surgery, you should learn as much as possible about the benefits and risks, and discuss them with your doctor, before having the surgery.
These procedures use tissue from other parts of your body, such as your tummy, back, thighs, or buttocks to rebuild the breast shape. Tissue flaps generally look more natural and behave more like natural breast tissue than breast implants. Also being our native tissue, there is no risk of allergy or rejection. For instance, they may get bigger or smaller as you gain or lose weight. Tissue flaps are often used by themselves to reconstruct the breast, but some tissue flap procedures can be used with a breast implant.
Tissue flap procedures can also have some potential downsides that need to be considered:
- In general, flaps require more surgery and a longer recovery than breast implant procedures.
- Sometimes the implant and flap procedures are used in combination to reconstruct a breast.
- Flap operations leave 2 surgical sites and scars – one where the tissue was taken from (the donor site) and one on the reconstructed breast. The scars fade over time but never go away completely.
- Some women can have donor site problems such as abdominal hernias and muscle damage or weakness.
- Because healthy blood vessels are needed for the tissue’s blood supply, flap procedures may not be the best option for smokers, and for women who have uncontrolled diabetes, vascular disease (poor circulation), or connective tissue diseasesTypes of tissue flap procedures – this has to be a sub-division to the prev sectionThe most common types of tissue flap procedures are:
- TRAM (transverse rectus abdominis muscle) flap & DIEP (deep inferior epigastric perforator) flap, which uses excess tissue from the lower abdomen (tummy). The tissue which is generally discarded in a tummy tuck surgery is harvested with its blood vessel and used for breast reconstruction. Hence An added advantage of this method of reconstruction is that Tummy tuck is done along with breast reconstruction. This is the most commonly done procedure as this tissue very well matches inconsistency with the breast tissue.
- Latissimus dorsi flap / TDAP Flap, which uses tissue from the upper back. This is used for partial breast reconstruction or for whole breast reconstruction in smaller breasts.
- GAP (gluteal artery perforator) flaps (also known as gluteal free flaps), use tissue from the buttocks.
TUG (transverse upper Gracilis) flaps, which – uses tissue from the upper inner thigh
When treating breast cancer with a mastectomy, the nipple is typically removed along with the rest of the breast. (Some women might be able to have a nipple-sparing mastectomy).
The nipple and areola creation are usually the final phase of breast reconstruction and it is an additional procedure done to make the reconstructed breast look more like the original breast. It can be done as an outpatient procedure. This is generally after a minimum of 3 months following breast reconstruction. If the patient has undergone Radiotherapy, then the procedure is carried out a minimum of 6 months after RT.
Ideally, nipple and areola reconstruction try to match the position, size, shape, texture, colour, and projection of the new nipple to the natural one (or to each other, if both nipples are being reconstructed). The tissue used to rebuild the nipple is recruited from the skin of the newly reconstructed breast. Additional tissues like cartilage are placed under the skin to maintain the nipple projection. Tattooing can be done later to match the colour if needed. The areola is created comes from the skin from another part of your body (such as the inner thigh) or by tattooing. Recently 3-dimensional professional tattoo has come into vogue to create the entire nipple-areolar complex as an alternative to surgery.
This is a technique where fat is aspirated from one part of the body (usually the abdomen/thigh) and injected into the breast. This is done to correct minor irregularities after the previous breast surgery. The fat is obtained by liposuction, cleaned, and then dissolved so it can be injected easily into the areas it is needed. This procedure has been found to be safe as far as cancer recurrence in patients who have had mastectomies.
Complications after breast surgery – This need not be a part of the drop-down
Though most breast surgery is elective and clean procedures, the chances of complications can vary from 2- 10% depending on the type of surgery, duration, patient factors like skin quality, scar-forming potential, and immunological status (patient receiving chemotherapy), smoking habits, etc.
- Scar tissue that distorts the shape of the breast
- Breast pain
- Infection
- Changes in nipple and breast sensation
- Asymmetry of breast
- Seroma / Haematoma
Complications related to Implants: – this is separate
- Implant leakage or rupture
- Capsular contracture and change in breast shape
- Implants generally have a life of 10 years and have to be removed/replaced
- More views of routine mammograms with might be uncomfortable has to be done when a patient has an implant-based reconstruction
- Implant-based reconstruction Could affect the ability to breastfeed the baby
- The FDA believes that women with breast implants might have a very low but increased risk of developing anaplastic large cell lymphoma (ALCL), a rare cancer of the immune system.
