Breast reconstruction surgery with Mrs Jacqueline Lewis

We sat down with Mrs Jacqueline Lewis, leading Oncoplastic Breast Surgeon at The Breast Unit who talked us through breast reconstruction surgery. Revealing all from what a patient can expect from a consultation, the various procedure types and finally the different stages of surgery and guidelines for recovery.

Tell us a bit about yourself and where you currently practice?

I am an Oncoplastic Breast Surgeon trained in both Plastic and Breast Surgery. This stemmed from the fact that during my final years of training in plastic surgery, my mother developed breast cancer. I qualified in 1986 as a doctor, then trained in general surgery, plastic surgery and then breast surgery. I have 32 years clinical experience with a special interest in cosmetic breast surgery, breast cancer surgery and facial aesthetics. Currently I practice at the world leading clinic, The Breast Unit at the Hospital of St John & St Elizabeth where I see and treat all sorts of breast disease, from screening normal women and diagnosing benign breast conditions and cancer. My focus is always to obtain the best outcome for women with breast cancer.

What does breast reconstruction surgery involve?

Breast reconstruction is a staged process often involving three or more operations. The first operation involves forming the breast mound with a prosthesis or flap, or a combination of these.

The patient will usually need further surgery to achieve symmetry between the breast mounds since often the opposite breast may be too droopy, too large or too small. This could include a reduction of the skin (mastopexy), reduction of the volume (breast reduction), or I may need to augment the volume (breast enhancement with an implant or lipomodelling). Finally, the nipple areola is reconstructed.

As implants do not act like natural tissue, over time the opposite breast will age at a faster rate than the reconstructed side. Radiotherapy also affects how the tissues age. Further symmetrization surgery in the future may be appropriate because of this.

One of the major drawbacks with an implant-based reconstruction is that a patient will need to have the implant exchanged every 10 to 15 years. Additionally, there is the risk of developing capsular contracture, which involves the hardening of the scar tissue around the implant. The patient will probably need several operations throughout their lifetime. To start with it involves approximately three operations for the reconstruction.

Who is breast reconstruction surgery for?

It is important that before anyone undergoes breast surgery, there has been careful thought put into what outcome will be best for the individual, not only in terms of removing the cancer completely but also the best cosmetic result. For example, if a patient needs a wide local excision (otherwise known as a lumpectomy) I may need to remove a big chunk of that breast tissue, which may leave a significant deformity. However, even removing a small amount of breast tissue may be significant if the breast is small, as the outcome is relative to the size of the breast. Using oncoplastic techniques of moving nearby tissue into the defect at the same time as the wide local excision, meaning I can fill in the defect and avoid a contour deformity. Therefore, even for a small cancer, I might need to perform reconstruction. People tend to think that breast reconstruction is only needed after a mastectomy, but I offer oncoplastic reconstruction techniques for wide local excision as well. If a patient needs a mastectomy, she can opt for reconstruction of the breast mound either at the time of the mastectomy or anytime later down the line.

Are their various types of surgery options available?

There are many different procedures that we offer women for whole breast reconstruction after a mastectomy.

1. The use of a prosthesis – Either a tissue expander that can be inflated gradually or a fixed volume silicone implant
2. Flaps – Using the patients own body tissue in the form of a flap of tissue as this is used either as a ‘pedicled’ flap (with it’s own blood supply kept intact) or as a ‘free’ flap (where a microsurgical anastomosis is made to an artery and vein close to the breast)
3. Free fat transfer or lipomodelling – Liposuctioned fat transferred to the breast

Examples of the different types of flaps:

• LD (Latissimus Dorsi) – Pedicled flap taken from the back
• Tummy flap – Tissue from the lower abdomen
• TRAM (Transverse Rectus Abdominis Muscle) – Pedicled or free flap
• DIEP (Deep Inferior Epigastric Artery Perforator) – Free flap
• Inner thigh flap – TUG (Transverse Upper Gracilis muscle) – Free flap
• Buttock flap– SGAP or IGAP (Superior or Inferior Gluteal Artery Perforator) – Free flap

One of the least complex breast mound reconstruction options is the use of a prosthesis. The results of a prosthesis compared with using a woman’s own tissue that is soft and warm does not tend to be as natural.

A popular flap is the lower abdominal DIEP flap which gives a beautifully natural end result. It is quite a complex operation and if done at the same time as the mastectomy, involves a two-team approach. I have a team of specialist plastic microsurgeons who work on the flap while I perform the mastectomy.

Lipomodelling or free fat transfer is also very versatile and can be used for the correction of various breast defects and problems. For example, free fat can be used to fill in a localized breast contour defect after a wide local excision, or it can be used in conjunction with the other methods of flap or implant reconstruction. It is particularly useful for extra cushioning over a visible implant where the surface of the edges are visible.

What is free fat transfer?

Free fat transfer involves liposuction of fat from an area where there is some to spare, commonly the lower tummy, thighs or flanks. The fat is then processed by washing or centrifugation to remove the blood and oil and then reinjected into the breast area. Some of the injected fat will resorb but most of it survives long term.

How are the nipples achieved?

When working to achieve the nipples I consider the nipple mound and the areola which is the pigmented skin around the nipple mound.

For the areola I use medical tattooing. For the nipple mound there are a variety of different options. Often I can use local flaps of tissue if there is enough supple tissue in the right place to reconstruct a nipple mound. Another option is a free graft shared from the opposite nipple, or even the labia minora.
Women who do not want to have either a local flap or free graft can either have a 3D tattoo of the nipple-areola, or they can have a prosthesis made.

There are two types of prostheses, either an ‘off the shelf’ prostheses or a custom-made prosthesis that is made to match the opposite nipple areola. The custom-made technique achieves a very realistic result. There are two glue types available to stick on the prosthesis; one for everyday use where the glue comes off very easily, and the other that is longer lasting, which acts like a super glue that can even be used for swimming.

What can a patient expect when they come in for a consultation with you?

During the consultation I will go through the patient’s history, conduct an examination and discuss the proposed treatment. I will give detailed options tailored to each individual, with consideration of their desires and best interests. The patient will then have time to go away and consider what has been discussed before returning for a follow up, which often involves questions and queries that we will discuss to ensure they are happy.

What is the recovery time and is there a follow up?

This depends on the type of reconstruction. It normally takes between one to six weeks for the recovery period depending on the type of surgery performed.

What are the benefits of a patient coming to the Breast Unit at the Hospital of St John & St Elizabeth?

At the Breast Unit, we work as a multidisciplinary team right from imaging and diagnosis, to surgical and adjuvant treatments suitable for every patient. From the initial diagnosis to the most complex oncoplastic breast reconstructive surgical intervention, we work in partnership with colleagues across imaging and pathology to ensure patients are seen and investigated, usually at the same appointment.

Additionally, we work alongside specialist plastic microsurgeons for men and women who need the more complex procedures.

Located at the Hospital of St John & St Elizabeth, The Breast Unit team has access to the very latest, imaging and diagnostic technology.

Make an appointment

We have eight expert Breast and Oncoplastic Surgeons including Mrs Jacqueline Lewis available for appointments at The Breast Unit. For appointments and enquires please email [email protected] or call 020 3370 1041.

Flexible appointment times are available.