Mammoplasty and breast health

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Mammoplasty refers to reconstruction of the mammary gland (breasts). Reconstruction is necessary following surgery for breast disease or for correction of breast disparities. The adage goes that no woman should leave the hospital without her breasts i.e. reconstituted after surgery. Reconstruction “restores” a woman’s feminity and a sense of confidence. It minimises the stress and psychological distress associated with loss of the breast(s) following breast cancer as well as emotional distress from perceived excess of breast size. Furthermore mammoplasty maintains relationship with partners as relationships are known to be affected following loss of breasts. In recent times mammoplasty has become synonymous with reduction or augmentation mammoplasty destined to boost a woman’s confidence.

Indications

There are however genuine medical indications for mammoplasty and they include the following-

1. Women with large breasts who experience back, neck and shoulder pains.
2. Large breasts causing skin changes such as intertrigo.
3. Reduction mammoplasty is sometimes indicated following excision of contra lateral breast as part of a programme for rehabilitation following treatment for breast cancer.

Approach to reconstruction is multidisciplinary, comprising a Plastic Surgeon, a Breast Surgeon, Breast Care Nurses, Oncologists, Physiotherapists, Implant Manufactures Psychiatrist, Patient Groups etc.
By working together, these groups bring in their skills to ensure the success of the procedure and providing counselling right from the pre operative preparation to post operative rehabilitation.

Pre-operative preparation

Preoperative preparation is designed to allay anxiety and to address unrealistic outcome and expectations. The pre op information must be clear that the breast will never be the same again: the ‘reconstructed’ breast would not be similar to what it was before surgery.
Outcome can be short of expectation whilst complications such as infection, loss, rupture or reaction to implants can occur.
Preoperative assessments also identify contraindications to surgery. These may include obesity, smoking, diabetes mellitus, breast feeding, clotting disorders, certain benign ‘lumps’ and /or cancers etc.
Assessment involves an evaluation of the volume of breast tissue to be excised and the best modalities or techniques for tissue reconstruction. Other alternatives to surgery such as liposuction and mastopexy are also discussed, as might individually apply. The woman is also informed of possible risks such as scars, loss of nipple sensation and the possible inability to breastfeed thereafter. In addition, she is shown photographs of similar procedures and outcome in other patients.
It is also good practice, which also modifies patient motivation, that patients are introduced to other patients’ groups.

Counselling

Patients undergoing breast reconstruction, particularly cosmetic mammoplasty must be carefully counselled. A reduction could turn out to be a major, life-changing, personal decision. The woman going into it must consider that she is probably doing it ‘solely’ for herself. There are inherent risks and possible complications including considerable scarring. Women must understand the subject matter as much as possible in order to make an informed choice.
Mammoplasty is considered a cosmetic procedure and is therefore not funded by the NHS. Reconstruction following cancer surgery is, however, well funded.

Procedures/technique:

In reduction mammoplasty the aim is to reduce breast volume, correct drooping and re-site the nipple areolar complex higher into a mound of breast atmosphere. The surgical technique of achieving this involves creating skin and glandular pedicle based inferiorly or superiorly to hide the scar along the infra-mammary fold.
The technique for reconstruction following mastectomy are more complex requiring musculo cutaneous free or pedicled flaps using back or abdominal wall muscles with or without artificial silicone implants.

Aftercare

Surgery of course carries some risks not least the loss of breast tissue through ischemia and infection. Re operation is carried out for correction assymmetry, scars, capsule formation, removal of ruptured implants, infection or for correction of unsatisfactory breast volume.

Breastfeeding:

There is a possibility of impairment of breast feeding function particularly with reduction mammoplasty. This should made clear to the woman as part of pre-operative counselling. Other issues of note include possibility of loss of nipple sensation.

Medicolegal issues

Patients feel let down when surgery goes wrong, many times because of unrealistic expectations. Reduction/augmentation mammoplasty undertaken mainly for cosmetic reasons remains a high risk area for patient dissatisfaction and such procedures must be considered carefully.
Patient expectations of good outcome is less for post mastectomy reconstruction than for cosmetic surgery of the breast. Litigation from poor cosmetic outcome after surgery for breast cancer for instance is relatively uncommon primarily because of patients greater concerns regarding breast cancer although even that is changing.

The future of mammoplasty

Because of recent concerns regarding certain implants many women are very apprehensive about the future of implant reconstruction. As such there may be more shift towards biological tissues such as myocutaneous flaps.
There will also be tighter regulation regarding the provision of cosmetic surgery in England in the future. Such regulations will increasingly be ensured by Governments and professional bodies such as the British Association of Plastic and Aesthetic Surgeons as well as the General Medical Council.

References

1. Boulton TN, Malacrida C. Women and cosmetic breast surgery: weighing the medical, social and lifestyle risks. Qualitative Health Research (2012) 4: 511-523.
2. Berry MG, Cucchiara V, Davies M. Breast augmentation: Part III-preoperative considerations and planning. J Plast Reconstr Surg (2011) 64(11) 1401-1409.
3. Cannon CL III, Lindsey JT. Conservative augmentation with periareolar mastopexy reduces complications and treats a variety of breast types: a 5-year retrospective review of 100 consecutive patients. Ann Plast Surge (2010) 64(5) 516-521.
4. Richards E, Vijh R. Analysis of malpractice claims in breast care for poor cosmetic outcome. Breast (2011) 20(3) 225-228.
5. Smith R, Lunt N, Hanefield J. The implications of PIP are more than cosmetic. Lancet (2012) 379 (9822) 1180-1181.
6. SIGN Guidelines Network(NHS Quality Improvement Scotland). Breast reconstruction after mastectomy. Guideline No. 84(2005) pg 8.

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