Breast reconstruction following treatment for breast cancer is routinely performed on the NHS. Such cases are NOT considered aesthetic and are not therefore subject to the Exceptional Aesthetic Referral Pathway. Breast reconstruction can occur immediately following mastectomy in a single operation or be delayed until the cancer treatment is complete.
The various surgical procedures that can be offered include:
Free Flap Breast Reconstruction (DIEP, TRAM and other flaps). This is often considered to be the gold standard for full breast reconstruction. It utilises autologous tissue that is commonly raised from the lower abdomen, but can be taken from the buttock or thighs. The procedure takes all day under general anaesthetic and necessitates a 5-7 day in patient stay. Overall success rates approach 98%.
Pedicled LD and extended LD flaps. The Latissimus dorsi muscle can be swung from the back to the breast for reconstruction, whilst remaining attached to its blood supply from the axilla. It can be transferred alone or combined with an underlying breast implant if required for additional volume. In some patients, the fat around the muscle can be harvested with it (extended LD) to obviate the need for an implant. This type of breast reconstruction takes between 3 and 5 hours to perform under general anaesthetic and typically necessitates a 3-4 day inpatient stay. Recovery is generally quicker than with a free flap reconstruction.
Implant only reconstruction may be indicated in suitable patients who have not undergone radiotherapy and are not expected to do so. It is the fastest and easiest form of breast reconstruction and can achieve excellent results, but the implants respond badly to radiotherapy and lifelong maintenance is usually required regardless. As with other forms of breast reconstruction, this procedure is carried out under general anaesthetic but with only a 1-2 day inpatient stay. Post-operative recovery depends upon the nature of the procedure but is often more rapid than with other types of breast surgery.
Fat Transfer alone can be used for filling lumpectomy defects or reconstructing small breast mounds. It is quick and simple to perform but may need to be repeated several times to achieve the desired results. It can normally be performed as a general anaesthetic day case procedure.
Nipple reconstruction and areolar tattooing are normally carried out some months after the initial breast reconstruction and only once the breast size and symmetry have been optimised. These are relatively minor local anaesthetic outpatient procedures associated with rapid recovery.
M.A. & E.M-P 12-12-24
Who to refer:
Any patient requesting breast reconstruction following breast cancer treatment.
Who not to refer:
Patients with suspected active breast disease should be referred to the breast department at the Western General Hospital.
How to refer:
Via SCI gateway to the Plastic Surgery service at St John’s hospital with appropriate details and background information.
