I reckon most of my patients are pretty marvellous. I only say that so it doesn’t sound like I am playing favourites when I say that I saw a really lovely lady the other day. Anyway, this lady came to see me about a breast reconstruction.
Now, it should be clear by now (if you’ve read any of these articles), that every breast reconstruction is different. I could see two ladies who are identical twins, who had mastectomies on the same day by the same surgeon and had the same course of post-op radiotherapy, and I would still have two different conversations when discussing their options. There are just too many idiosyncrasies in terms of how people heal, how they respond to radiotherapy, and how their tissues would then respond to different types of reconstruction.
This lady wasn’t a great candidate for a DIEP flap, and her secondary flap options weren’t that great either. So, despite my reservations, I was leaning towards an implant-based reconstruction for her, in spite of the fact that she had previously had “conservative” mastectomies (so the surgeon had removed the skin of the breast, leaving her flat) AND radiotherapy to one side. And she wasn’t just flat – she had a really obvious “edge” where the breast surgeon had removed the breast tissue, and the skin left behind was quite a bit thinner than the skin on rest of the chest.
So, we have two big issues here if we’re thinking about using an implant. The first issue is the fact that skin has been removed, and we have a tight scar exactly where we want the skin to stretch the most to allow us to make a breast. Secondly, the skin that has been left behind is really thin, which means every bump and irregularity relating to the implant is going to be both seen and felt. Obviously, in an ideal world I would use a DIEP flap to introduce new skin into the chest wall to allow for a natural breast feeling & shape. But without that option, I need to find a way of making an implant work. So what can I do?
We haven’t spoken much about fat grafting before now, but it is certainly something we need to consider. Perhaps you’ve heard about fat grafting, perhaps you’ve even seen some videos of the procedure being performed. Perhaps you’ve heard about Kim Kardashian’s butt?
Fat grafting sounds pretty simple. You suck fat out of some place (by liposuction), you maybe do some “stuff” to it, and then having done some “stuff” to it, you inject it back into the body wherever you want to. Of course the reality (as always) isn’t quite so simple.
Obviously there are subtleties and technical issues which we can consider another time, but the benefits of fat grafting are quite unique and fat grafting is playing a more and more significant role in breast reconstruction. So how can it help?
Well, fat grafting is certainly not a solution in and of itself. It’s a helper; a way of making other things (both flaps and implants) look better. I don’t use fat grafting to make a breast. I don’t use fat grafting to add volume. For me, fat grafting has two very distinct uses:
- 1. I use fat grafting to smooth out contours, and to soften edges. I use fat grafting after DIEP flap surgery often in the upper pole of the breast where sometimes the flap doesn’t quite reach;
- 2. and I use fat to change the quality of the skin on the chest. This is possible because the fat may allow me to create a more robust, more supple envelope before placing an implant. But one of the most amazing things about fat grafting is the way in which the fat can allow skin which has been irradiated to soften and stretch more easily.
Which brings me back to the original story.
My lovely patient, who is flat after her mastectomies, who has had radiation therapy to one breast, and who isn’t a great candidate for a flap reconstruction, would really love a breast reconstruction. For her, an implant may be the only option. But an implant on its own would be an unmitigated disaster.
So, instead we can think about the combination of an implant with fat grafting: a so-called “hybrid breast reconstruction”.
Taking this approach requires time, patience and a bit more time. This is not a one-operation magic fix. We have to stage things, working sequentially towards an end result. In this case, a rough idea of how we will do things might be:
- 1. First, we fat graft to deal with the sharp “edge” where the breast tissue has been removed, and to soften her scars and irradiated skin.
- 2. A few months later, we place a tissue expander and then gradually stretch the chest skin.
- 3. Once the expander has been inflated, we may need another round of fat grafting before we replace the expander with a definitive implant.
- 4. A few months after that, there may be more fat grafting to tidy up any contour problems or perhaps areas where the implant is palpable, or not quite sitting right.
- 5. And a few months after that, we might even have to think about a bit more fat grafting, depending on how everything has settled down after the preceding operations.
So, we’re talking about anywhere between 3 and 5 (or even 6) procedures to get a final result. This requires understanding on the part of the patient, because as you can see, we could be talking about 12 months before we get to what we consider the final result. Phew!
Breast reconstruction is becoming more refined, and I think we are rapidly coming to a point where a breast reconstruction is being held to the same standard as an aesthetic breast operation. As breast reconstruction becomes an equally aesthetic procedure, and as our patients have higher and higher expectations of what they can achieve, the acceptance of staged reconstructions over a relatively long period of time to obtain the best results is increasing.
Of course, we cannot escape the fact that more operations means more time and more money: so we had better be able to justify it.