Reconstruction of a breast that has been removed because of cancer or other disease is among plastic surgery’s greatest achievements. New medical techniques and devices have made it possible for surgeons to create a breast that can come close in form and appearance to matching a natural breast, though it will never feel or look exactly like the breast that was lost.
The psychological difficulty of losing a breast to cancer may be so severe that breast reconstruction is now considered a medical necessity. Insurance policies are therefore mandated to pay not only for mastectomy but also for reconstruction of the lost breast and for surgical adjustments made to the opposite breast to achieve symmetry.
Breast reconstruction after a mastectomy is not a simple procedure and is usually done in stages. Patients have to consider many options and make several important decisions that will depend on individual circumstances, including other cancer treatments needed. Our BodyAesthetic team will guide you through all the options as you explore what type of reconstruction is best for you.
Most mastectomy patients are medically appropriate for reconstruction, many at the same time that the breast is removed. The best candidates, however, are women whose cancer, as far as can be determined, seems to have been eliminated by mastectomy.
Patients frequently choose to begin reconstruction immediately following breast removal (mastectomy) so they awaken from surgery with a breast mound already in place and are spared the experience of waking up with no breast at all. In fact, women who postpone reconstruction may go through a period of emotional readjustment not unlike grief for a lost body part.
Still, there are legitimate reasons to wait. Many women aren’t comfortable weighing all the reconstruction options while struggling to cope with a diagnosis of cancer. Others simply don’t want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeons to wait, particularly if radiation treatment will be needed after mastectomy or the breast is being rebuilt in a more complicated procedure using flaps of skin and tissue transferred from another part of the body. Women with other surgical risks, such as obesity, high blood pressure, or smoking, may also be advised to wait. Smokers are required to quit for 4 weeks prior to surgery, and 4 weeks afterward; this includes nicotine patches, nicotine gum, chewing tobacco or any product that contains nicotine. Regardless of the timing of reconstruction, being informed of the options before a mastectomy can help you prepare for cancer surgery with a more positive outlook for the future.
Reconstruction has no known effect on the recurrence of breast cancer, nor does it generally interfere with chemotherapy or radiation treatment, should cancer recur.
Women can begin talking about reconstruction as soon as they are diagnosed with cancer. Dr. Boswell prefers to work together with your breast surgeon before mastectomy to develop a strategy that will put you in the best possible condition (physical and emotional) for breast reconstruction.
After evaluating your health, your surgeon will explain which reconstructive options are most appropriate for your age, health, anatomy, tissues, and goals. Be sure to discuss your expectations frankly with your surgeon, and he will be equally frank when describing your options and the risks and limitations of each.
Breast Reconstruction Options
Breast reconstruction usually involves more than one operation. The first stage begins creation of a breast mound to replace the breast tissue removed in a mastectomy. This stage is performed either at the same time as the mastectomy or delayed until later.
Reconstruction with a breast implant:
The most common way to construct a breast mound is to use an implant. However, because some skin is removed during mastectomy in addition to tissue, there is usually not enough skin and tissue to cover and support an implant large enough to recreate a breast. This problem is solved by first inserting a tissue expander beneath the chest muscle.
This balloon-like expander has a tiny valve mechanism buried beneath the skin through which saline (salt-water) is injected on a regular basis by your plastic surgeon. Expansion, which is done in the office, takes only a few minutes as 50 to 100 cc (2 or 3 ounces) of saline are added weekly to gradually stretch the tissues over several weeks or months. When the tissues have been sufficiently stretched, a second surgery is done to remove the tissue expander and replace it with a more permanent breast implant.
Women who undergo breast reconstruction may receive breast implants filled with either silicone gel or saline. When the FDA restricted the availability of silicone gel implants in 1992, it made an exception for breast reconstruction patients, for whom getting an implant is not considered elective. In addition, silicone gel implants look and feel more natural than saline implants, especially when no breast tissue exists to pad the implant.
Reconstruction with a tissue flap:
An alternative approach to breast reconstruction involves transferring a flap of tissue taken from another part of the body, such as the back, abdomen, or buttocks. This complicated surgical procedure takes several hours in the operating room followed by a lengthy recovery period. Not everyone is a candidate for flap reconstruction, but those who choose this option are very pleased with the results because it produces the most realistic-looking breast mound, which is reconstructed entirely with your own tissue rather than an implant. Flap reconstruction leaves a scar at the tissue donor site in addition to the scar on the breast.
In one type of flap surgery, the tissue remains attached to its original blood supply, or its vascular pedicle. The flap–which consists of skin, fat, muscle and blood vessel–is tunneled beneath the skin to the chest and "molded" to create the breast mound or, in some cases, a pocket for an implant. The flaps most often used involve transfer of a muscle from the abdomen (called a transverse rectus abdominis muscle flap, or TRAM) or from the back (called a latissimus dorsi flap).
Transfer of a TRAM flap takes 4 to 6 hours and requires hospitalization for 3 to 5 days. Activity is restricted for 4 to 6 weeks. A TRAM flap leaves a permanent scar on the abdomen and may cause weakness of the abdominal wall.
Transfer of a latissimus flap takes 3 to 4 hours, followed by 2 to 3 days in the hospital. Activities may be resumed in 3 to 4 weeks. The latissimus muscle does not have as much tissue for transfer as a TRAM flap. Because of this, insertion of a breast implant is needed by some patients to add volume to the reconstruction. The scar produced by a latissimus flap starts below the armpit and curves downward toward the middle of the back.
Another flap technique uses tissue that is surgically removed from the abdomen, thighs, or buttocks and transplanted to the chest, where the flap’s blood vessels are connected to a blood supply source in the chest. This procedure takes even longer than a regular flap because it involves intricate microvascular surgery to reconnect the flap’s blood supply.
Reconstruction of the nipple and areola:
The nipple and areola (the darker skin surrounding the nipple) can be reconstructed in the final stage of breast reconstruction. Some women are content just with reconstruction of the breast mound and do not undergo this final stage, but many others choose this option because it makes the reconstructed breast look more normal.
Reconstruction of a structure that looks like a nipple requires a short surgery, usually under local anesthesia, that rotates a small amount of tissue from the center of the breast mound to form a nipple-like structure. The best way to recreate the areola is with tattooing to match the color of the areola of the areola on the opposite breast. This procedure takes about an hour and is performed in the office.
Surgery on the opposite breast:
A reconstructed breast will almost never match the size and contour of the remaining opposite breast. Many women therefore choose to have surgery on the opposite breast to achieve better symmetry. This may involve enlarging, reducing, or lifting the natural breast to match the reconstructed breast, with the procedure usually done at the same time that a tissue expander is replaced with a permanent implant. For patients undergoing reconstruction with a tissue flap, the opposite breast is typically revised in a later surgery.
Before You Choose Reconstruction With An Implant
Breast implants do not last forever and will eventually break (rupture or deflate). Please see the Breast Implant Complications page for additional information on the types of problems most often seen with breast implants. Many of these complications will require another surgery, and women must be prepared for this possibility before getting an implant. During your consultation you will receive written materials that explain these complications in detail. Please ask your surgeon about anything you do not fully understand.
Because breast reconstruction has so many options, no brief description can encompass all possibilities. Your surgical procedure will depend on whether you begin the reconstructive process at the time of mastectomy or delay it until later. Surgery differs if reconstruction is done with a tissue expander followed by an implant or with your own tissue transferred to the breast. Your surgeon will explain all these options, help you decide what works best for you, and explain the surgery in detail. Please ask about anything you don’t understand.
What To Expect After Breast Reconstruction
You are likely to feel tired and sore for a week or two after reconstruction, but most of your discomfort can be controlled with medication prescribed by your doctor. We prefer to do the first stage of breast reconstruction as an inpatient procedure, which means you will stay in the hospital for at least one night after surgery. If a mastectomy is done at the same time, a second day/night in the hospital may be needed. If your reconstruction is done with a tissue flap, the hospital stay may last as long as 5 days to guarantee that blood supply to the transferred flap is robust.
Many first-stage reconstruction options require a surgical drain to remove excess fluids from the surgical area immediately following the operation, but these are removed within 1 or 2 weeks after surgery. Most stitches are removed in 7 to 10 days.
Removal of a tissue expander and replacement with a permanent implant can be done on an outpatient basis, though some women prefer to spend 1 night in the hospital after surgery.
Recovery from a combined mastectomy and reconstruction may take up to 6 weeks, and much of the recovery time will depend on the type of mastectomy and whether lymph nodes are removed from the armpit area. If the first stage of breast reconstruction is delayed until after you have healed from a mastectomy or completed cancer treatments, your recovery time should be relatively short if you receive a tissue expander. Recovery from a tissue flap reconstruction takes up to 6 weeks.
Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return to your skin. The scars resulting from mastectomy and reconstruction will never disappear entirely but most scars will fade substantially over time, though it may take as long as 1 to 2 years.
Your surgeon will advise you about when to begin stretching exercises and normal activities. As a general rule, you should refrain from any overhead lifting, strenuous sports, and sexual activity for 3 to 6 weeks following reconstruction.
A reconstructed breast is likely to feel firmer and look rounder or flatter than a natural breast. It may not have the same contour as the breast before mastectomy, nor will it exactly match the opposite breast. But these differences will be apparent only to you. For most mastectomy patients, breast reconstruction dramatically improves the quality of life and appearance following cancer surgery.
SUMMARY COMPARISON OF RECONSTRUCTION OPTIONS
Expander/Implant: 1 to 2 hours
Latissimus Flap: 3 to 4 hours
TRAM Flap: 4 to 6 hours
Expander/Implant: 1 day
Latissimus Flap: 2 to 3 days
TRAM Flap: 3 to 5 days
Blood Transfusion Needed
Latissimus Flap: Unlikely
TRAM Flap: Possible
Expander/Implant: 2 to 3 weeks
Latissimus Flap: 3 to 4 weeks
TRAM Flap: 4 to 6 weeks
Latissimus Flap: Maybe
TRAM Flap: No
Expander/Implant: No additional incision
Latissimus Flap: Incision on back
TRAM Flap: Incision on abdomen
Expander/Implant: No loss of muscle strength
Latissimus Flap: May have shoulder weakness from tissue transfer
TRAM Flap: May have abdominal weakness from tissue transfer