Breast Reconstruction – Therapeutic Mammoplasty

What is a therapeutic mammoplasty?

The surgical management of breast cancer and benign breast tumours has significantly evolved over the years. It has shifted away from radical procedures towards methods that achieve complete tumour resection while preserving normal breast tissue.

This change has allowed for improved aesthetic outcomes and quality-of-life for patients, while maintaining equivalent oncologic safety and reducing the risk of lesions returning.

A therapeutic mammoplasty is designed to remove the breast tumour as part of a breast reduction or breast uplift (mastopexy). The normal breast is also adjusted to make them symmetrical.

Both a mastopexy and reduction combine the removal of the breast lesion and skin with an uplift to elevate the nipple to the ideal position in the centre of the breast. For patients wishing a reduction then excess breast tissue is removed as well as skin. For patients who are happy with their current size and wish to be to perter and uplifted then a mastopexy is performed without removal of extra breast tissue.

The operation can also be performed to make breasts more symmetrical if one side is much larger than the other.

Ultrasound is used during surgery to visualise the breast lesion that needs to be removed whilst ensuring that it is taken with an adequate margin to give complete clearance. All the tissue excised is sent to be looked at under the microscope to confirm the histology and that the lesion has been removed with an adequate margin.

The surgery is performed under a general anaesthetic (you will be fully unconscious), and it takes approximately 2 ½ hours to perform. Providing there are no complications, you can expect to go home on the day of surgery.

Incisions are necessary to sculpt the breasts into a smaller and perter shape, whilst accessing the breast lesion that needs to be removed. The incisions are made around the areola, vertically down from the areola to the breast crease and horizontally in the breast crease under the breast.

Excess breast tissue and skin are removed, together with the lesion. The entire breast is reshaped with the nipples lifted to a higher and more youthful position. The incisions are closed with sutures that are hidden under the skin and dissolve themselves. Sutures will not be visible; therefore, scarring is reduced to a minimum.

Having surgery should be a positive experience and decisions about this surgery should never be rushed.

Complications are infrequent and usually minor. However, all surgery has risk, and it is important that you are aware of possible complications. All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to discuss them.

These risks can be divided into the risks specific to the surgery and the risks of anaesthesia.

General Anaesthetic risks: An anaesthetic is very safe, however, should a complication arise, the relevant medical expertise is immediately available to deal with this.

The risks increase if you have certain medical problems, which will be discussed at length during the consultation. The risks include:

  • Unintended intraoperative awareness, which is very rare
  • Dizziness and nausea
  • Sore throat
  • Damage to teeth or mouth
  • Nerve injury due to body positioning
  • Allergic reaction or anaphylaxis
  • Malignant hyperthermia, which is a rare life-threatening condition

The anaesthetist will go through these risks in more detail prior to your surgery.

Scars:  The scars are usually hidden in the crease under the breast, around the areola and vertically down the middle of the breast, from the lower areola border to the crease under the breast. They normally settle remarkably well, so that the scars are barely perceptible. However, some patients heal with thick, thin or stretched scars, which can be noticeable.

Bruising and swelling: A degree of swelling and bruising is normal, and this may take approximately 3 weeks to settle.

Haematoma: This is clotted blood that collects in the breast. It occurs in between 1% to 4% of women who undergo breast surgery. It tends to occur within 4 to 6 hours post-surgery.

Any increase in swelling or pain should be reported immediately for assessment. Should the haematoma be significant, it will have to be washed out in theatre and any bleeding vessel(s) identified and cauterised. This does not normally delay your recovery or change the cosmetic result.

Infection: The risk of infection is inherent with any surgical procedure, albeit very uncommon in elective breast procedures. Antibiotics are administered during surgery and for 10 days after surgery to minimise the risks. Less than 1% of patients develop an infection post-operatively and rarely require any intervention, apart from further antibiotic treatment.

Numbness, reduced sensation or oversensitivity: A reduction in nipple sensation occurs in most patients and often recovers to some degree, although it may never completely recover. Occasionally patients feel that nipples become more sensitive.

Wound healing problems: These are rare but can occur around the nipple, at the T junction (where the horizontal and vertical scars meet) or the abdomen. These healing difficulties can range from minor problems, such as small scabs or areas of wound separation, to major issues, such as skin or nipple loss. Although very rare, skin grafting to close the wound may be required thus resulting in further surgery.

Patients who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

Asymmetry: Each breast is slightly different and will continue to be following surgery; remember that they are, “sisters and not twins”. However, if you have noticeable asymmetry before your surgery then this will be corrected as part of the surgery and will be discussed with you.

Further excision: The tissue removed at is looked at under the microscope by a histologist to verify the type of lesion and that it has been completely removed. Although uncommon, it is possible that the lesion is wider than expected or that it has not been completely excised. In this instance, more tissue may need to be removed in a second operation.

Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE): Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and travel to your lungs. If the blood clot is large enough, it could prove fatal.

The overall risk for cosmetic surgery is less than 1%, but to reduce any risks of a DVT/PE, you will be provided with special stockings to wear in bed together with a blood thinning injection, if you are not mobile or have previously had a DVT or PE.

Fat necrosis: Sometimes areas of fat within the breast scar form hard lumps called fat necrosis. Usually, no specific treatment is required, and the problem settles down over a 12-month period.

Breastfeeding: Not all patients will be able to breastfeed after breast surgery, reduction or mastopexy. If you have further family plans and wish to breastfeed then this procedure should be delayed.

All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to discuss these with me.

Decisions about surgery must never be rushed and requires personal research.

Your incisions will be closed with dissolvable sutures that do not need to be removed. I use a glue and tape dressing (Prineo), which is waterproof and can be peeled off 2 to 3 weeks after surgery, when it starts to lift at the corners. You can shower as soon as you like after surgery and do not require any dressing changes.

I recommend that you wear a medical support bra for 6 weeks and that you purchase 2 bras, so you have one to wear and one in the wash. These are worn continuously for approximately 6 weeks post-surgery, before returning to any bra of your choice. You will need to purchase these prior to your surgery, and I will provide the relevant details in clinic. Details can also be found in the compression garment guide below.

Before you leave the hospital, you will be given a follow up appointment to see the nurses at one week to check your incisions and an appointment to see me in 2 weeks. You will not be able to drive yourself home from hospital and, ideally, you should have someone to stay with you for a few days to assist you. If you have any concerns during this period, do contact the clinic for advice.

Scar advice
Once the dressings are removed, I recommend that you massage the incisions, using small circular motions at least twice a day for 5 minutes. You can use any moisturising cream of your choice and apply firm pressure until it blanches.

The scars will also benefit from silicone scar gel (ScarAway® or Kelo-Cote®) twice a day, which will soften and fade them, as well as applying sunblock for 12 months to provide sun protection.

The ScarAway® can be purchased from Healthcare Pharmacy at Governors Square in Grand Cayman.

When you get home, you should take things easy for the first week or so. Most people take 1 to 2 weeks off from work. You should be able to drive from 2 weeks, return to the gym for lower body work at 4 weeks and begin upper body exercises at 6 weeks.

To help shape and support your breasts as they settle, you will need to wear your medical support bra day and night for 6 weeks.

Surgical fees are a combination of the hospital costs, the surgeon and anaesthetic fees and any consumables such as implants.

In breast reconstruction patients the fees are normally cover by your health insurance, however most patients have a co-pay of 20% and certain policies only cover one breast and half of the other breast. This means you are likely to have to pay towards the cost of your surgery. Any fees will be calculated, and you will be informed of the potential fees at your consultation.