Breast Reconstruction

Reconstruction of a breast that has been removed due to cancer or other disease is one of the most rewarding surgical procedures available today. New medical techniques and devices have made it possible to create a breast that can come close in form and appearance to matching a natural breast. Frequently, reconstruction is possible immediately following breast removal (mastectomy), so the patient wakes up with a breast mound already in place, having been spared the experience of seeing herself with no breast at all.

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.

Still, there are legitimate reasons to wait. Many women aren’t comfortable weighing all the options while they’re 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 the breast is being rebuilt in a more complicated procedure using flaps of skin and underlying tissue. Women with other health conditions, such as obesity, high blood pressure, or smoking, may also be advised to wait. Even if you or your surgeon decide to wait on your reconstruction for several years, it will always be covered by insurance.

You can begin talking about reconstruction as soon as you’re diagnosed with cancer. Ideally, you’ll want your breast surgeon and your plastic surgeon to work together to develop a strategy that will put you in the best possible condition for reconstruction.

After evaluating your health, I will explain which reconstructive options are most appropriate for your age, health, anatomy, tissues, and goals. Post-mastectomy reconstruction can improve your appearance and renew your self-confidence — but keep in mind that the desired result is improvement, not perfection.

While there are many options available in post-mastectomy reconstruction, you and your surgeon should discuss the one that’s best for you.

Skin expansion

The most common technique, because it is the easiest to perform and recover from, combines skin expansion and subsequent insertion of an implant.

The difference between a breast augmentation and breast reconstruction after a mastectomy is that there is no longer breast tissue to cover the implant. The breast tissue is what hides the implant and makes the breast look more natural. Additionally, there is a shortage of skin after a mastectomy because the majority of the time, the nipple and the areola are removed with some surrounding skin, because the nipple is breast tissue as well. Following the mastectomy, a balloon expander must be placed in the mastectomy site. In order to cover the expander so it is not as noticeable through the skin, it is placed beneath the pectoralis muscle, which covers the upper half of the expander. The bottom half of the expander is covered either with muscles on the lower half of the chest or with an allograft called Alloderm. Alloderm is a graft of human dermis that is acellular. Because of this, it is not rejected like a kidney transplant can be, and it is not capable of carrying any viruses. It is prepared and packaged and later used in breast reconstruction.

Now, the whole expander is covered with something other than skin. The reason we must use an expander before the implant is because of the shortage of skin caused by the removal of the nipple and the areola as well as the tight coverage of the muscle and the Alloderm. There are a few instances, ie smaller breasted women or nipple-sparing mastectomies used in mastectomies for women without cancer, where the expander step can be skipped. If an expander is used, the patient returns about two weeks after surgery and through a tiny valve mechanism buried beneath the skin, we will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has stretched enough, the expander may be removed in a second operation and a more permanent implant will be inserted. Some expanders are designed to be left in place as the final implant. The nipple and the areola are reconstructed in a subsequent procedure about 4 months later.

Some patients do not require preliminary tissue expansion before receiving an implant. For these women, the surgeon will proceed with inserting an implant as the first step.

If your surgeon recommends the use of an implant, you’ll want to discuss what type of implant should be used. A breast implant is a silicone shell filled with either silicone gel or a salt-water solution known as saline. Both silicone and saline filled implants are available on an unrestricted basis according to the Food & Drug Administration. Reconstructive candidates are encouraged to visit www.breastimplantsafety.org to learn more about these devices.

Flap reconstruction

An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the back or abdomen.

In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat, and muscle with its blood supply, are tunneled beneath the skin to the chest. In the case of tissue taken from the back, both skin and muscle are brought around to the breast. The skin is used to replace the skin taken in removing the nipple and the areola. The muscle is used to cover the bottom part of the implant, again using the pectoralis muscle to cover the top of the implant. Because extra tissue is brought in, this eliminates the need for an expansion technique prior to the placement of an implant. In the case of tissue tunneled from the abdomen, the surgeon is able to create the breast mound itself, without need for an implant.

Another flap technique uses tissue that is surgically removed from the abdomen and is then transplanted to the chest by reconnecting the blood vessels to new ones in that region. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well.

Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed breast, and recovery will take longer than with an implant. Additionally, when a microvascular flap is used, there is the risk of losing the flap if the reconnection of the blood vessels doesn’t work. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about an implant. In some cases, you may have the added benefit of an improved abdominal contour.

Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery may be required to replace a tissue expander with an implant, to reconstruct the nipple and the areola, or to further shape the reconstructed breast. Many surgeons recommend an additional operation to enlarge, reduce, or lift the natural breast to match the reconstructed breast. But keep in mind, this procedure may leave scars on an otherwise normal breast. These procedures are usually performed 4-6 months after the original procedure.

Depending on the extent of your surgery, you’ll probably be released from the hospital in two to five days. Many reconstruction options require a surgical drain to remove excess fluids from surgical sites immediately following the operation, but these are removed within the first week or two after surgery. There are usually no sutures to be removed.

You are likely to feel tired and sore for a week or two after reconstruction. Most of your discomfort can be controlled by medication prescribed by your doctor. It may take you up to six weeks to recover from a combined mastectomy and reconstruction or from a flap reconstruction alone. If implants are used without flaps and reconstruction is done apart from the mastectomy, your recovery time may be less. Also the subsequent procedure for reconstruction of the nipple, areolae, and symmetry procedures on the opposite breast involve much less recovery time.

Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. Most scars will fade substantially over time, though it may take as long as one to two years, but they’ll never disappear entirely. The better the quality of your overall reconstruction, the less distracting you’ll find those scars.

Follow your surgeon’s advice on when to begin stretching exercises and normal activities. As a general rule, you’ll want to refrain from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following reconstruction.

Chances are your reconstructed breast may feel firmer and look rounder or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. But these differences will be apparent only to you. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.

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