Types of breast reconstruction

My name is Dr Melanie Walker I'm a breast surgeon based in Melbourne I'm also the president of BreastsurgANZ which is the society representing breast surgeons in Australia and New Zealand and I treat people with breast disease.

In the surgical management of breast cancer, the ultimate aim is to remove the cancer. That can either be done as a lumpectomy – or what's called breast conserving surgery or a wide local excision – or a mastectomy.

In terms of who's suitable for what surgery, if you have a lump that can be removed with a clear margin of tissue and preserve the breast size and shape to an extent, then you would be suitable for breast conservation.

In most cases it's a simple removal of the tumour with some moving around of the breast tissue to fill in the defect.

In cases where we have to remove a larger volume of tissue, we may look at moving your breast tissue around to fill in that defect so you're not left with a with a divot in the breast. Or we may also look at moving tissue in from elsewhere to fill in the hole.

They are the so-called ‘volume replacement’ where we're moving some volume in to fill in the defect or volume displacement using techniques – breast reduction and breast lift techniques – to move the tissue around. That may also involve having to have surgery to your normal breast, the other breast, to match up for symmetry.

The mastectomy involves removing all the breast tissue. There are three main types of mastectomy.

The simple mastectomy, where you are left flat, so we're removing the skin, the nipple, and the breast tissue and leaving you with a flat chest wall and usually a transverse scar that goes across the chest wall. When you’re having an immediate reconstruction, we can usually keep the skin envelope so you maintain the outer part of your breast. Then that volume is replaced either by an implant or your own tissue. And sometimes we can make that a total skin sparing mastectomy, where you keep the nipple.

If you have a genetic predisposition, there may be an advantage to you… if you have a cancer diagnosis, it may be recommended that you do remove both breasts as part of your treatment to reduce your risk of getting a new cancer in the future.

A patient is always involved in the decision making. Obviously the surgeon will guide you in what they recommend is going to give you the best cancer outcome. 
With regards to flat closure, that's what happens when we do what we now would call a simple mastectomy. That's a mastectomy without preserving any of the skin. We want to leave a chest wall as flat as possible.

For some people, their body shape and size may mean that it's not possible to achieve a perfect flat closure in a single operation, although that would always be our aim. It is possible that you might require a second operation to make you completely flat.

The difference between immediate and delayed reconstruction is that an immediate reconstruction, as it sounds, you have it immediately. You have it at the time of your mastectomy. When you wake up from the operation you will have had your reconstruction.

Some of the reconstructions are quite big operations and so if you have a lot of other medical problems or if you're a smoker or you have some factors that make that more dangerous for you, it may be something that is discussed with you, to say we'll treat the cancer; you can get your other health issues better as much as you can, modify them, and then we could look at doing a reconstruction later.

Sometimes radiotherapy – if we know that someone will need radiotherapy following a mastectomy – that may have some influence on the timing of reconstruction.

Sometimes for other reasons – social reasons, work reasons and so forth – or even just from a psychological point of view or just not able to cope with all the information and decision making, it might be better to think about it at a later date.

The important message is that you should always feel empowered to ask questions, particularly if you feel there's an option that is not being discussed with you, and that you shouldn't be afraid to ask for a second opinion.