Breast reconstruction is an important part of breast cancer management. It aims to restore your breast to its natural form after a mastectomy. In the past, not many Singaporean patients were keen on breast reconstruction due to a variety of reasons.
However, over the last decade, there’s been an increased number of patients choosing to go for breast reconstruction surgery.
This is because there are more Singaporean women being diagnosed with breast cancer, and most of them lead a long, healthy life after a mastectomy.
In this post, I will address some important things you need to know before making a decision on breast reconstruction.
First up, what is breast reconstruction surgery?
Breast reconstruction procedures are done to restore the size and shape of the breast. Typically, I do it when breasts have to be removed to treat cancer. However, it can also be done for other reasons.
Whenever I perform a breast reconstruction surgery, my goal is always to match the size and shape of your other breast in just one surgery. In the case where there're still differences in the breasts after surgery, I am able to perform a small procedure to correct the discrepancies.
Whenever necessary, a new nipple can be reconstructed and a new areola can be tattooed.
Who can perform breast reconstruction in Singapore?
In Singapore, breast reconstruction is traditionally performed by plastic surgeons. As plastic surgeons, we are trained specifically in plastic and reconstructive surgery techniques.
This gives us the expertise to perform different types of breast reconstruction procedures according to each patient’s individual needs and desires. We also have the most experience in using breast implants, the patient’s own tissues, as well as a combination of both.
How much does it cost to have breast reconstruction done in Singapore?
In Singapore, the cost of breast reconstruction procedures range from $20,000 to more than $70,000 per procedure. This wide cost range largely depends on the technique used and how long the procedure takes.
Note: Restructured hospitals will generally be less expensive than private hospitals.
What affects the price of breast reconstruction in Singapore?
The complexity of the operation is the main factor that affects the price.
1. The simplest forms of reconstruction use breast implants or tissue expanders.
Breast reconstruction using implants can be done in one operation or it can be staged. In a staged procedure, a tissue expander (basically an inflatable balloon) is inserted and gradually inflated. It is then replaced by the final implant after a few months of expansion.
If done in one operation, an implant is held in place with a mesh or collagen graft; these can be quite expensive.
2. More complex procedures take tissue from other parts of the body, such as the back, tummy, or thighs.
These surgeries may require really fine surgery to join blood vessels using an operating microscope. They require extra special expertise and generally take longer to perform.
Is breast reconstruction in Singapore covered by insurance or Medisave claimable?
Yes, breast reconstruction procedures are usually covered by insurance and are Medisave claimable. They are medical procedures done most commonly to treat patients with breast cancer.
What are the advantages and disadvantages of breast reconstruction?
More often than not, advantages of breast reconstruction are mainly psychological. However, there are also practical advantages.
- improved self-confidence and self-esteem
- improved quality of life
- able to fit normally into clothing without worrying about prosthetics (shown below)
- having a flatter tummy (if the tummy is used for reconstruction)
Breast prostheses to be worn after breast cancer surgery
A breast reconstruction surgery is an additional surgery on top of what is required for you to treat your cancer.
As with all other surgeries, you're exposed to the attendant risks and complications of surgery. You might also develop scars at the areas where the tissue was taken from.
Is breast reconstruction considered cosmetic surgery?
No, breast reconstruction surgery is not considered as cosmetic surgery. Although on a personal level, I aim to achieve aesthetically pleasing and symmetrical breasts for all my patients, the intrinsic purpose of the surgery is to restore what cancer has taken away.
When is the best time to go for breast reconstruction after a mastectomy?
For my experience, I get the best aesthetic results when I perform the reconstruction at the same time as the mastectomy (known as immediate reconstruction).
Reason being, the breast skin, and possibly the nipple, can be saved during the mastectomy (skin sparing and nipple sparing mastectomy).
I can still perform breast reconstruction in patients who have had a previous mastectomy (known as delayed reconstruction) with good outcomes, but there will be more scars on the breast compared to an immediate reconstruction.
What are the different breast reconstruction options available in Singapore?
Cancer survivors in Singapore can be divided into implant-based or tissue-based breast reconstruction.
1. Implant-based reconstruction
This type of reconstruction was done most commonly in two stages using a tissue expander for the first stage and replacing it with an implant in the second stage. Nowadays, more surgeons are placing an implant immediately after the mastectomy, saving the patient another operation.
2. Tissue-based reconstruction
This procedure is my preferred technique because the reconstructed breast is able to mimic the look, feel, and movement of a natural breast.
How do plastic surgeons do tissue-based breast reconstruction?
To a plastic surgeon, a good option for breast reconstruction is taking tissue from the tummy and moving it to the breast, which gives the patient a flatter tummy as well. There are two ways to go about it:
1. TRAM flap
The tummy fat and skin can be left attached to the abdominial muscle, and tunneled under the skin to the breast (called a pedicled TRAM flap). However, there's a problem with this technique. It can weaken your abdomen because your abdominal muscle is removed.
2. DIEP flap
Personally, I would prefer to leave your muscle intact and just transfer the skin and fat with the blood vessels. This is known as a DIEP (Deep Inferior Epigastric Perforator) flap.
In the case where you do not have enough tissue around your tummy, I would recommend my patients to do a TUG (Transverse Upper Gracilis) flap. For this technique, tissue is taken from the thigh and transferred to the breast.
Fat grafting is another option for breast reconstruction for smaller breasts. Fat is harvested using liposuction from anywhere in the body and injected to form a breast. This technique will require at least 2 to 3 sessions to achieve a reasonably sized breast.
How can you decide whether implant or flap breast reconstruction is best for yourself?
As a breast cancer patient, you will have a lot of decisions to make, and I understand that this process can be very overwhelming. Deciding on the type of reconstrucion surgery is not easy.
I'd strongly advise you to think about how comfortable you are with an implant. You also have to ask your medical team whether there is a chance that you will require radiation therapy after your mastectomy.
If you qualify for breast reconstruction surgery and prefer to use your own tissues, I'd always recomend taking the tissues from the tummy, the thigh, or do a fat graft. If you've thought about having a tummy tuck, the tummy is probably your best option. You'll be able to get a breast reconstruction and a tummy tuck at the same time.
Lastly, fat grafting is also a good option if your breasts are not too big and if you do not mind having a few smaller operations.
What happens during flap breast reconstruction in Singapore?
The most common surgery I perform is DIEP flap breast reconstruction, so I will focus on this.
I'll start the operation at the same time as the breast surgeon (who is removing the cancer). I will have to ensure that the patient is in the correct and safe position.
My surgery starts at the tummy while the breast surgeon is performing the mastectomy. I’ll start by making the incisions in the skin, looking for the fine blood vessels that perforate the adominal muscle to supply the overlying skin and fat.
After identifying the best vessels, they will be carefully separated from the muscle until a long enough length has been prepared. Once the tummy tissue and blood vessels have been prepared, I will move up to the chest and prepare the blood vessels to connect to.
The DIEP flap is then transplanted to the chest and the vessels are joined using an operating microscope. The flap is cut and shaped to resemble the opposite breast and all the incisions are closed.
The whole process takes about 7 to 8 hours. I'll always perform the operation with another plastic surgeon to ensure everything is done properly and time isn’t wasted.
What are the risks of breast reconstruction with the flap method?
For DIEP flap breast reconstruction, the main risk relates to the tummy and the joining of the vessels. The tummy can be weakened by the dissection, but the risk of having a bulge or hernia are low.
There is also a risk that the vessels supplying blood to the flap can become blocked and the tissue may not survive. In my experience, the failure rate is less than 2%. That means that there's a success rate of more than 98%.
TUG flaps have a higher risk of problems in the thigh area. A common complication is collection of fluid in the thigh, known as a ‘seroma’. This may need a small surgery if it doesn’t resolve on its own.
What are the risks of breast reconstruction using implants?
In the case of breast implants, the most common complications are:
- Infection - Being a foreign body, implants have a risk of getting infected, even in the future.
- Capsular contracture - This is hardening of the scar tissue around the implant, this does not occur immediately after surgery but can occur years later, especially if radiation is needed.
- Implant rupture - The implant might rupture, causing the liquid to leak from the shell.
Another rare complication is development of Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL). It is a rare form of lymphoma associated with the scar tissue surrounding the implant. It is curable by removing the implant and scar tissue.
What can I expect after breast reconstruction?
Immediately after the surgery, you will feel a bit groggy and perhaps nauseous. This is due to the anaesthesia. If you have had a flap reconstruction, you may be warded in a high-dependency area so we can keep a close eye on your flap and your condition. When everything is fine, you'll be transferred to the normal ward the next day.
You'll expect to see a lot of tubes coming out of a lot of places. However, please do not be alarmed. These are for delivering medications, draining urine, and other excess fluids. They'll be removed over the next few days.
As with any surgery, there will be some pain in the operated areas. Medications will be given to help you ease the pain. Trust me, the pain is usually not as bad as what you would expect.
You can expect to have some swelling in the breast. This is normal and will slowly resolve over the next few months. Massage and warm therapies can speed up the recovery process.
How long does it take to recover from reconstructive breast surgery?
I know a lot of patients are very concerned about the recovery after the reconstruction. As a plastic surgeon who has perfomed the procedure for many years, I'd like to assure you that it’s usually not as bad as you think it will be.
With implant reconstruction, there really isn’t any additional wounds. The only thing that requires your attention is a drainage tube to drain excess fluid. That can stay in for up to 2 weeks after the surgery.
For flap reconstructions, there will be additional operative sites to care for. They can be the tummy, thigh or back. You'll need to stay in bed for the first few days, but should be walking by the 3rd or 4th day.
Your drains can normally be removed by 7 days, but some may need to stay in a bit longer. Your movements will be a bit restricted at first, but you will be able to walk around and go out by 1 week.
In my experience, almost all my patients are usually back to normal activities by a month. These activities include running, dancing, swimming etc.
Does a reconstructed breast have no sensation?
Some surgeons advocate joining the nerves in the flap to nerves around the breast. This will supposedly help increase the sensation in the reconstructed breast.
In my patients, some sensory loss is inevitable. However, some recover fairly good sensation without having any nerve repair. Truth to be told, there's no good evidence that points to a better recovery of breast sensation when nerves are repaired, so I don’t feel that this is a necessary procedure.
Patients will be able to feel pressure, but may not feel a light touch on the reconstructed breast.
Will others be able to tell if you have had breast reconstruction?
If the surgery is done well, others will not be able to tell that you have had the surgery. The only time they will be able to tell is if they see your scars.
Will you still have to do mammograms and perform breast self-examinations?
The chances of getting breast cancer in the opposite breast is higher than normal if you have had breast cancer. Thus, it’s important to continue to monitor that breast. Mammograms are not needed for the reconstructed breast, but it’s good to monitor for any lumps in that breast as the cancer may recur.
Can breast reconstruction hide cancer or make it come back?
No, it cannot hide cancer or make it come back. There’s no evidence that breast reconstruction delays detection of a recurrence or is responsible for it. If breast cancer does recur, it most commonly recurs in the skin and subcutaneous tissue, so the reconstruction wouldn’t conceal it.
How long does breast reconstruction last?
Breast reconstruction is permanent. If you choose to use your own tissues, there is no maintenance needed, and the new breast will change similarly to your other breast.
Breast implants are more resistant to change over time, but complications such as rupture, hardening, deformation, and/or capsular contracture may develop over time. Implants typically last about 20 years.
How can you find the best plastic surgeon in Singapore for breast reconstruction?
I understand that it can be difficult to know if you’ve found the right surgeon for you. You'll have just been diagnosed with cancer, experiencing a flood of different emotions. You'll probably also be overwhelmed with a ton of information.
The first surgeon you will see will most likely be recommended from your breast surgeon. This is not a bad place to start because it means that that surgeon has experience in breast reconstruction.
However, very few plastic surgeons in Singapore perform muscle-sparing DIEP flap or TUG flap reconstructions and even fewer do it well.
Here's the the important thing: find out the exact type of reconstruction you’d like and find a surgeon that does it well.
Ask the surgeon about their experience and their philosophy on breast reconstruction. If you are not comfortable with what they tell you, they may not be the right surgeon for you.
How would you know if your breast reconstruction surgeon is good?
Yes, I'll admit that is not easy. My advice is for you to look at photos of previous reconstructions that they’ve done. If you're unable to tell which breast has been reconstructed, it's a good indication that he/she is a good surgeon.
Speaking to other breast cancer patients is great, if possible. Your surgeon can probably link you up with some of their patients. They can tell you about their experience and even show you their results. Most patients are very happy to share their experience with other patients.
Look for a surgeon who has a team that does their reconstructions together regularly. There is a lot of work to be done, so two plastic surgeons is better than one!
What else should I look for in a breast reconstruction surgeon?
Whether you should go for breast reconstruction surgery is a big decision. I know that finding the right surgeon for you can be an even harder decision.
My advice for you is to find a doctor who is patient enough to listen to your concerns and work within your comfort zone.
Some doctors may try to persuade you to choose a technique that they are more comfortable with, listen to them, but know that in the end the decision is yours.
Do not be afraid to share your fears, your needs and what you want to achieve from the procedure. A good plastic surgeon will never guarantee a perfect result but give you a realistic treatment plan for the best possible outcome.
I hope you’ve found this article helpful. If you need more information, feel free to get in touch and I will be more than happy to help out in any way I can.
Good luck on your journey. I wish you a speedy return to health!
Dr Christopher Chui is a fully trained, certified and accredited plastic surgeon and is a registered medical practitioner in Singapore and Australia. His special interest and passion is in autologous breast reconstruction, rhinoplasty, facial cosmetic surgery and cosmetic breast and body contouring. His personal philosophy towards breast reconstruction is to use patient’s own tissues as much as possible to give his patients the most natural feeling and looking breast possible. He is is committed to giving his best to his patients.
- Ter Louw RP et al. Prepectoral Breast Reconstruction. Plast Reconstr Surg. (2017)
- Ho AY et al. Radiotherapy in the setting of breast reconstruction: types, techniques, and timing. Lancet Oncol. (2017)