Therapeutic mammoplasty is a work of art. It is essentially surgery to remove breast cancer (therapeutic) and then reshape the breast by removing skin and breast tissue (mammoplasty). The aim is to try to preserve a normal breast shape that will usually be smaller and more uplifted. There is a limit to how much breast tissue can be removed with a standard lumpectomy without adversely affecting the appearance of the breast, but this technique allows us to remove more breast tissue and attempt to leave an acceptable cosmetic outcome.
The operation is suitable for women with moderate to larger breasts, and who have a degree of droop (ptosis). If there is significant asymmetry (difference between your breasts), the breast on the other side may also need to be reduced, to provide a better match in size and shape if so desired. This is known as symmetrisation surgery and ideally is done at the same time, however can be performed at a later date if preferred. Picture below shows the anatomy of the breast, 'mammary gland.'
The technique aims to produce a normal breast shape with no indentation, distortion or loss of cleavage that might otherwise be likely. It is particularly useful for lower breast tumours that are more likely to develop a deformity if a simple lumpectomy, Breast Conserving Surgeryis performed.
For women with larger breasts, with back pain, neck pain and heaviness who desire smaller breasts this is an added benefit.
For women with very large breasts, reducing the size makes radiotherapy more conducive.
The surgery is more extensive than a simple lumpectomy with longer albeit well hidden wounds.
There are more risks associated with the surgery, including altered nipple sensation or numbness, potential for nipple necrosis (1%), and fat necrosis, and problems with wound healing.
A specific cosmetic outcome cannot be guaranteed and there is still a risk you may have a degree of distortion or indentation.
There might be a need for re operation should we not get clear surgical margins around the area of disease; oncological safety is always the primary goal.
The other surgical options are to have a simple lumpectomy (wide local excision) without reshaping the breast, or to have a mastectomy and remove all of the breast tissue; this can be done with immediate or delayed reconstruction.
On the morning of surgery your surgeon will do some marking on you to plan out the operation and may take some photographs. You will also meet the anaesthetist. If the tumour is difficult to feel, you may need to go to the X-ray Department before the surgery for the Radiologist to localise the tumour/or a previously inserted clip and put a hookwire(guide) into it under local anaesthetic, as a guide to which breast tissue to remove.
The operation may also involve surgery to your lymph glands in your armpit, Sentinel Node Biopsy. This is done to assess whether the cancer has spread to any of the lymph nodes (also called glands) as this information helps plan any further treatment you may need. This procedure requires a preoperative test called a ‘Lymphoscintigram’.
To perform the operation, the tumour and a margin of tissue around it are removed first, and then the breast is reshaped with the nipple repositioned. The full extent of surgery depends on the technique being used:
Round block mammoplasty
A small donut of skin is removed from around the areola (darker skin around the nipple), and then the skin in the area of the cancer and more widely beyond it is freed up from the breast tissue. The breast cancer is removed and the surrounding breast tissue on either side, which has been freed up from the skin, is stitched together to fill the space. The wound around the areola is then closed with dissolvable stitches buried underneath the skin surface to leave a donut scar. A dressing
Round block mammoplasty (donut) is placed on top. This tends only to elevate the breast slightly and slightly flattens the breast projection.
Vertical scar mammoplasty
A small donut of skin is removed from around the areola and the lower central part of the breast. The skin in the lower part of the breast is freed up from the breast tissue and the breast cancer is then removed with or without some of the overlying skin. The breast tissue on either side is then stitched together to fill the space and the nipple lifted up into a higher position. The wound around
Vertical scar mammoplasty (lollipop) the areola and lower central breast is then closed with dissolvable stitches as before to leave a lollipop scar and a dressing placed on top. This elevates the breast a little more and has a greater effect on changing the shape.
Wise pattern mammoplasty
Scars are usually around the nipple and down the middle of the lower breast and then along the lower fold of the breast to produce a so-called anchor scar. This will normally be hidden by the bra cup. The breast cancer is removed, along with any excess breast tissue and skin from the lower part of the breast, with the breast reshaped with the nipple in a higher position to suit the new smaller uplifted breast. The wounds are closed and dressed as per the other techniques.
Occasionally it may be necessary to remove the nipple if the breast cancer lies close to the centre of the breast. If removal of the nipple is required, a new nipple can be reconstructed at a later date, usually under local anaesthetic.
At the same time, some or all of the lymph nodes may be removed from the armpit. This is done to assess whether the cancer has spread to any of the lymph nodes (also called glands) as this information helps plan any further treatment you may need.
This procedure usually results in a significant breast lift, reduced volume and major shape change. Most patients usually decide to have surgery to the other breast at the same operation to create better symmetry.
All surgery carries some element of risk. The breast may be painful, swollen and bruised following your operation. Most complications can be detected and treated without difficulty, some need further surgery, like Lipofillingfor further reshaping, Scar revision, Reexcision.
You will go back to the ward and we will encourage you to get up and move around. If you have a drain it is usually removed the following day and then you can go home.
You will need to take regular painkillers following surgery. You may experience some shooting pains in the breasts - these will ease over the next few months. The breasts will be swollen and your nipple sensation may be altered. The swelling and bruising subside in 4-6 weeks but can take 6-12 months for the scars and shape of the breasts to settle.
Your wound will be covered with a waterproof dressing to keep it clean. You are able to shower the day following surgery. There will be swelling and some discharge from the wound when you are at home, this may produce some blood staining on your bed clothes or bed sheets. This is nothing to worry about. Please contact your breast care nurse for advice or attend our clinic if you have concerns. Stitches are dissolvable.
If you feel unwell with a temperature, vomiting or notice significant redness of the skin on or around the breasts you should either contact your GP or Emergency department, if out of normal working hours, as you may have an infection and will need antibiotics. Sometimes fat necrosis is mistaken for infection, with redness and swelling but you are not unwell and there is no significant wound discharge.
You should wear a soft supportive bra (no underwiring) immediately after the operation. This helps prevent the weight of the breasts pulling on the wounds and affecting the healing process. You should wear the supportive bra for four to six weeks day and night, only taking it off to shower.
If there is a significant difference in size it may be necessary to wear a partial prosthesis in your bra, this can be discussed with your breast care nurse who will advise you about fitting.
The length of time you need to take off work depends on the nature of your job but plan for two to four weeks. Please ask staff if you require a medical certificate and this will be given to you before you leave hospital.
You are advised to avoid strenuous exercise for a minimum of six weeks. You are advised not to have sex for at least a week following the surgery as sexual arousal can cause further swelling of the breasts. Allow only gentle contact with your breasts for about six weeks.
You are advised not to drive for up to two weeks following surgery and only when you can safely perform an emergency stop.
Avoid heavy lifting, including vacuuming, washing and carrying heavy shopping.
Do not undertake exercises for 10 days following surgery. If you have ongoing problems with shoulder or arm stiffness, we will refer you to the physiotherapist.
You will be seen our clinic 7-14 days after your surgery to review the results of the surgery and remove your dressings. It may be helpful to bring a relative or friend with you to discuss the results and additional treatment you may require.
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