Breast cancer is a devastating disease. In addition to having to contend with a potentially life-threatening condition, sufferers have to cope with potentially mutilating surgery to their breasts, which are an integral part of the female identity and form. The introduction of immediate reconstruction has brought many advantages to patients undergoing breast cancer surgery. Immediate reconstruction allows preservation of self-image, which is known to have a profound effect on patient psyche. Dr Farhadieh finds this one of the most rewarding aspects of plastic and reconstructive surgery.
Fortunately nowadays, breast cancer surgery has become less and less extensive, and adjuvant treatments such as radiation and more modern chemotherapeutic regimes are yielding better outcomes. Lumpectomy and skin-sparing mastectomy are increasingly becoming the standard treatment.
In general, breast reconstruction can be thought of as autologous (using body’s own tissues) or alloplastic (implant-based reconstruction). There are methods that utilize both autologous tissues as well as implants. Each patient, depending on their overall clinical picture, postoperative treatment regimen and personal preference, is considered as a unique case and a reconstruction plan is worked out to suit their needs. Dr Farhadieh strongly believes in a multidisciplinary approach to breast cancer, which includes specific specialty-based expertise: general surgery, plastic surgery, oncologists, radiation oncologists, as well as nurses specializing in care for breast cancer patients. To this end, Dr Farhadieh collaborates and cross-refers patients to general surgical colleagues. Women requiring breast cancer surgery as well as reconstruction will see Dr Farhadieh and one of his general surgery colleagues so that a complete surgical plan can be devised.
Replacing the removed breast tissue with the body’s own skin and fat has been the basis of breast reconstruction for decades. The donor tissues best suited for breast reconstruction include the abdominal wall, buttocks, inner thigh and the back. Pedicled or free flap techniques are used. Pedicled flaps are where the donor tissues are isolated on their blood supply and then moved into the defect left by breast resection without disconnecting this vascular supply. Free flap surgery is where the tissues are disconnected from their blood supply and are reconnected to vessels near the breast in the chest using microsurgical techniques.
Deep Inferior Epigastric Perforator (DIEP) flap
Refinements of reconstructive surgery have meant that surgeons increasingly attempt to undertake major reconstructions with minimal complications at the donor site. Developed over 30 years ago, transverse rectus abdominis myocutaneous (TRAM) flaps, using muscle, fat and skin from the abdomen, were for many years the ‘gold standard’ method for breast reconstruction. TRAM flaps provided abundant tissues with good match for texture and consistency. Harvesting of the TRAM flap included taking sections of the abdominal wall fascia (fibrous tissue layers), as well as underlying muscle along with abdominal wall fat and skin. In a significant number of patients, however, it was found that the loss of the abdominal wall fascia and muscle led to weakness of the abdominal wall and subsequent bulging. More recently, the deep inferior epigastric perforator (DIEP) flap was developed to reduce the rates of these complications by allowing preservation of the abdominal wall fascia and muscle. It is a technically more demanding procedure but one that is increasing becoming standard treatment in major units around the world.
Transverse Upper Gracilis (TUG) myocutaneous flap
For small breast reconstructions, especially for bilateral reconstructions, one alternative is to use the segment of the upper inner thigh for reconstruction. The blood supply of the gracilis muscle, an expendable inner thigh muscle, also supplies the overlying skin and subcutaneous fat. Harvesting this muscle allows small breast reconstructions. Fortuitously, the donor scar is hidden in the inner thigh crease.
Superior/Inferior Gluteal Artery Perforator (SGAP/IGAP) flaps
In a few cases, second-line autologous tissues need to be considered for breast construction. This can be due to a myriad of reasons, from patient preference to lack of other donor sites. The consistency of the gluteal (buttock) fat is not as soft as abdominal wall donor sites and not as good a match for breast tissues. It is a technically more challenging surgery, but in some cases it is the only suitable option.
Mr Farhadieh has amassed extensive experience in all of the aforementioned surgical procedures during his surgical training in Melbourne. He has had the opportunity to further consolidate his practice during his time spent in London working at St Thomas’ Hospital with Mr Jian Farhadi, a world authority in breast reconstruction. He also gained further experience in breast reconstruction while working as Microsurgical Fellow with Mr Ash Mosahebi at the Royal Free Hospital, London.
For many years a two-stage reconstruction was standard alloplastic treatment for breast cancer. Tissue expansion with inflatable expanders would be performed in the first step and, after a period of waiting, the expanders were exchanged for silicone implants. Increasingly, with the advent of skin-sparing mastectomy, immediate implant-based reconstructions have become common. Where the nipple–areola complex is retained, the surgeons attempt to preserve as normal a breast shape with the best-camouflaged scar possible. Where the nipple–areola complex has been removed it can be reconstructed as a day case, 3–6 months after reconstruction.
In recent years, fat injection has become a surgical option in the treatment of small contour deformities as well as radiation-induced chronic ulcers. Refinement of fat-harvesting techniques and isolation of fat cells has increased the survival rate for transferred fat cells. Interestingly, there is a growing body of evidence that some adult fat stem cells are capable of tissue rejuvenation by replenishing the local stem cell population and increasing capillary bed concentration. Although this holds the promise of tissue-engineered breast tissues from the patient’s own stem cells in the near future, the current indications for fat injections are predominantly for contour deficits. Mr Farhadieh has ongoing interest and involvement with stem cell-based tissue engineering research.
‘Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.’
Frequently Asked Questions
What else do I need to know about the reconstruction journey?
Breast cancer and reconstruction are a significant event in a woman’s life. It is vital that the patient and surgical team have a good relationship, coupled with realistic expectations. Perhaps the most important requirement is that the patient is provided with relevant information about the options available, so that she can make an informed decision about her treatment. Such information may be overwhelming, especially when you are coping with the sudden news of a disease such as breast cancer. Dr Farhadieh spends a significant amount of time during his consulting sessions listening to his patients, and explaining the surgical options, ensuring they have a clear understanding of the surgical pathway. Dr Farhadieh and his team endeavour to ensure that all patients feel supported during the entirety of their surgical journey.
Will the surgery be painful?
There is some discomfort associated with surgery. Although most patients report a ‘tightness’, rather than pain, due to the excellent pain control regime we use, which includes local anaesthetic for the immediate postoperative period as well as powerful analgesics.
What is the recovery period?
This is somewhat variable and depends on individual factors. In general, patients who have had alloplastic (implant)-based reconstructions are discharged earlier and recover faster than those who have had autologous reconstruction. Patients are often discharged 3–5 days postoperatively; they generally feel comfortable with increasing daily activities after 2–3 weeks. Microsurgical techniques involve a longer operative time as well as healing at the donor site. Patients are often discharged 5–7 days postoperatively and it will take 4–6 weeks before increasing normal activities becomes comfortable.
When will I be able to resume normal activity?
Within 3 weeks of alloplastic (implant) reconstructions and 6–8 weeks from autologous free flap reconstructions. Your ability to carry out normal activities will start slowly and rapidly increase in tolerance and scope.
What will my follow up include?
Dr Farhadieh believes that the relationship between doctor and patient is sacred and privileged. Our practice is based on compassion, honesty, transparency and, above all, patient welfare. We pride ourselves on making sure that our patients feel supported at all times. We will be available during all stages of your journey and will schedule short-, medium- and long-term follow-up appointments as part of our overall practice.