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Breast Reconstruction Surgery
What is Breast Reconstruction Surgery?
Breast reconstruction is a surgical procedure to restore a woman's breast after it has been removed by mastectomy (surgery that removes the breast tissue because of cancer).
Breast reconstruction is generally performed to improve a mastectomy patient's physical appearance, and thereby to help the patient retain a sense of self-esteem and positive feelings about her femininity. A major consideration is ensuring symmetry between the patient's two breasts.
Breast reconstruction can be done in several different ways, including flap techniques that use the woman's own tissue to reconstruct the breast mound, or the use of breast implants under the skin and muscle to replicate the shape of the breast. In many cases, it can be performed immediately following mastectomy surgery, but it also can be performed months or even years later. Since the nipple and areola are usually removed in the course of a mastectomy, they can be reconstructed as well with tissue.
Breast reconstruction is generally considered a reconstructive procedure and is covered by most health insurance plans. You should check with your insurance carrier for its guidelines, and your surgeon can usually help you with documentation to demonstrate its reconstructive nature.
More than 80,000 women underwent breast reconstruction surgery following mastectomy in the United States in 2001, according to the American Society of Plastic Surgery.
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What Issues Should I Think About in Considering Breast Reconstruction?
The circumstances of each woman facing mastectomy is different, not just in terms of the size and extent of the tissue being removed, but of reconstruction options, including technique, timing or the decision to have reconstruction at all. Equally as important as the medical issues are the self-image and other psychological issues.
Many mastectomy patients choose breast reconstruction because it helps restore their physical appearance and their sense of "completeness" as women. In this sense, it's an important tool for self-esteem and psychological well-being. Some women who have undergone mastectomy may feel quite comfortable living without any reconstructive surgery, or making use of external breast prostheses worn under their clothing. It's a decision each woman undergoing mastectomy has to make for herself.
There are two basic approaches to breast reconstruction — with breast implants that form the shape of the breast under the skin and muscle, and with flaps of skin and muscle tissue moved from elsewhere on the patient's body. Which technique can be used may depend on the amount of tissue necessary to match the normal breast. Some patients have only one option while others may benefit from either technique.
A major consideration is ensuring that your reconstructed breast matches the opposite breast in size and shape. It's conceivable you might want or need to alter the opposite breast to achieve symmetry.
You should keep in mind that any surgery carries with it small but possible risks of complications such as a reaction to anesthesia, bleeding and infection. Some breast reconstruction approaches require multiple surgical procedures. And, any surgical procedure leaves scars. Your surgeon will seek to make incisions whose resulting scars are as inconspicuous as possible. Although it's not guaranteed, most scars involved will fade over time.
Finally, you should be aware that treatments for breast cancer such as radiation therapy and chemotherapy can affect the technique of your breast reconstruction, and the final result. The reconstruction may have to be delayed until these therapies are completed.
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What Are Important Issues for Breast Reconstruction with Implants?
Saline-solution implants are safe. Although there have been some concerns about silicone-gel implants, there has never been any suggestion that saline-solution implants represent a threat for the recurrence of cancer or other systemic health problems. (Currently, silicone-gel implants are used only as part of clinical studies.)
Although less than five percent of saline-solution implants leak or rupture over a period of about 10 years, most implants last for many years. If a saline-solution implant leaks, the major result is a loss of shape of the breast over a period of hours or days (and the implant can be replaced). The saline solution itself will be absorbed harmlessly by the body.
A consideration is that breast reconstruction with an implant — using a temporary tissue expander to begin with — is a multi-step process that requires two surgical procedures over a period of months. While it can be begun immediately following the mastectomy procedure, you will have to return to your surgeon regularly to have your tissue expander increased in size and finally to have it replaced by the permanent implant. Use of any implant immediately following mastectomy requires that enough skin and muscle tissue be preserved following the mastectomy procedure.
With some implants a process called "capsular contraction" takes place — the scar tissue that forms around the implant tightens, making it feel too firm. An additional operation may be needed to correct the problem.
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How is Breast Implant Surgery Performed?
If enough existing skin is left following the mastectomy procedure, the surgeon can create a pocket beneath the skin and underlying muscle and place an implant. If the skin needs to be stretched to form the new breast, the first step is the placement of a deflated tissue expander beneath the skin and muscle. This can be done either immediately following the mastectomy or at a later date. For breast reconstruction most surgeons place the implant below the chest muscle for better implant coverage.
The tissue expander has a port through which, over a period of two to four months, saline solution can be introduced every one-to-two weeks to increase its size and gradually expand the skin over it to accommodate an implant. Once the desired size is reached, the skin is kept at that level for one to two months to maximize the expansion.
Once the expansion is complete, the expander can be removed in a minor surgical procedure and replaced with the permanent implant. Often, the surgeon can follow the same incision as the mastectomy in order to minimize new scarring. This is performed as an outpatient procedure, or with a one-night hospital stay.
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What Are Important Issues for Tissue-Flap Breast Reconstruction?
Breast reconstruction with a tissue flap is a procedure that transfers skin and muscle tissue from elsewhere on the patient's body to create the new breast mound. An advantage of this approach is that it can result in a reconstructed breast that looks and feels more natural than one reconstructed with an implant.
Also, a flap procedure can be performed in conjunction with the mastectomy procedure, so that you can have your reconstructed breast immediately — possibly a significant psychological advantage.
A drawback of the tissue-flap approach is that it leaves scars in the areas from which the tissue has been removed, whether the abdomen, the back or the buttocks. On the abdomen, the scar will usually be across the lower abdomen, similar to a "tummy tuck."
In addition, abdominal tissue-flap breast reconstruction can be done once, but not a second time. It can be done on both breasts at one time, but if it is done on one it cannot be done on the second breast at a later time. That would have to be performed as an implant procedure.
Tissue-flap surgery is a more extensive procedure than implant surgery, and, as major surgery, simply may not be suitable for some people.
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How is Tissue-Flap Breast Reconstruction Performed?
In many cases, it is preferable to move living tissue from another part of the body to the chest area to help create a breast mound. This is particularly true if there is not enough tissue to cover an implant, if the chest has previously been irradiated, or for certain patient body types.
- The latissimus dorsi muscle flap brings skin and muscle from the back to the chest area. Usually, an implant is inserted under the flap to give sufficient volume.
- Another technique, the transverse rectus abdominus muscle (TRAM) flap involves using muscle, skin and fat from the abdomen to the chest. This combines a modified "tummy tuck" with reconstruction, and usually an implant is not needed. The flap is tunneled under the skin and over the ribs to the chest area. Some surgeons prefer to detach the tissue and re-establish the blood supply using microsurgical techniques.
- A third type of reconstruction uses muscle, skin and fat from the buttock (gluteal flap) or the thigh (lateral thigh flap) transplanted microsurgically to the chest. These techniques are used less frequently.
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How is Nipple and Areola Reconstruction Accomplished?
Nipple and areola reconstruction often is delayed for several months to allow the reconstructed breast mound to heal and settle. It's usually performed as a day-surgery operation under local anesthesia. Tissue for the nipple can be taken from a number of locations — formed from local skin flaps, from tissue taken from the opposite nipple or from sources such as an earlobe or toe. A darker color can be achieved through medical tattooing.
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What Should I Do to Prepare for Breast Reconstruction Surgery?
Since every case is different — both in medical concerns and the patient's desires — you want to be certain to talk frankly with your surgeon about your expectations and likely outcomes for your surgery. Don't be afraid to ask questions.
You and your surgeon should talk about issues that may affect your operation, such as your medical and anatomical issues (how much skin and muscle will remain following your mastectomy), which options for reconstruction are feasible for you and desired by you, where to take tissue from in a flap procedure, timing in terms of immediate or delayed, the need for follow-up procedures, the prospect of scars and the type of anesthesia to be used.
You should prepare for your surgery by making sure you don't take certain vitamins or aspirin, ibuprofen or other blood-thinning analgesics for at least two weeks before your procedure. Any herbal remedies you use may need to be discontinued. If you smoke, you should also stop for at least three weeks before and three weeks after your surgery, as nicotine interferes with blood supply and can adversely affect the healing of your incisions (and the final appearance of your scars). You will probably be asked not to eat or drink after midnight of the night before your surgery.
Since mastectomy is usually performed under general anesthesia (in which case you will be asleep throughout the procedure), immediate breast reconstruction surgery will be under that same administration of anesthesia, as part of the same operating session. Later reconstruction surgery will probably be under general anesthesia, as will subsequent procedures, such as replacement of the temporary expander with the permanent implant. In any event, you must have a family member or friend available to drive you home after you are discharged.
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What Can I Expect Following Surgery?
If your breast reconstruction surgery is performed in conjunction with mastectomy, you can expect your recovery from the mastectomy to coincide with your recovery from breast reconstruction. Following breast reconstruction either immediately or delayed, you can expect to remain in the hospital for one or two days following an implant reconstruction procedure, and four to five days following a tissue-flap reconstruction procedure.
Initially during your hospitalization, you will be restricted from activities requiring strength, such as raising yourself up or getting out of bed unassisted. After a day or so, you will likely be able to sit up in a chair and after one to two days to walk unassisted. You should expect to experience some pain, but these can be managed with medications prescribed by your doctor. Continue to avoid aspirin, ibuprofen or other blood-thinning medications and vitamins until your incisions have completely healed.
If you have had immediate reconstruction or flap surgery, you may have small drainage tubes inserted at the locations of your incisions to prevent fluid from accumulating, and these will be removed within a week. Your stitches will be removed in seven to 14 days.
Once you are discharged, you should avoid strenuous physical activity such as lifting or exercising for several weeks, as this may interfere with healing. You should expect to be able to return to work or normal activity in four to six weeks. Scars left from the incisions will remain swollen and red for several months, but will usually fade over time
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What Can I Expect from Breast Reconstruction?
Breast reconstruction can help you in the process of recovering your life and your sense of wholeness following breast cancer and the mastectomy that it made necessary. Each year, breast reconstruction helps more than 80,000 women feel better about themselves in recovering from breast cancer.
Breast reconstruction cannot erase the trauma you have experienced from having breast cancer, and it is not intended to. Hopefully, it is a positive tool to help you in your recovery.
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Frequently Asked Questions
Are Breast Implants Safe?
The implants used for breast reconstruction surgery are bag-like capsules made of silicone and filled with a soft, pliable material to give them form. While a silicone gel was a popular filling for several decades, the filling of choice today is a saline (or salt water) solution.
A reality of breast reconstruction is that breast implants are not guaranteed to last forever. Some may leak or burst, due either to trauma or — more likely — to the natural pressures of body movements over time. Because of concerns among patients with silicone-gel-filled implants that leakage of the gel was causing health problems such as immune-related diseases, the use of silicone-gel implants today is restricted by the U.S. Food and Drug Administration to patients participating in clinical studies.
The safety of saline solution implants has never been in question. If saline solution were to leak from the implant, the implant might deflate over a period of hours or days, but the solution would be harmlessly absorbed by your body. Another operation would be required to replace the implant.
In addition, although implants may make mammograms more difficult to read, a mammogram will no longer be necessary on the reconstructed side of the mastectomy. There is no evidence whatever associating saline solution breast implants with recurrence of breast cancer.
Will I Still Have Feeling in My Breast Following Reconstruction?
Sensation is never normal after mastectomy or after reconstruction. Some patients do regain some sensation but many have none.
Will Breast Reconstruction Affect My Need for Breast Cancer Screening?
You should continue a program of monthly breast self examination following breast reconstruction. The normal breast should be monitored as well as the reconstructed breast. A mammogram is not necessary on the side of the mastectomy, but will still be necessary for the normal breast.
Does Breast Reconstruction Increase the Possibility of Recurrence of My Cancer?
Breast reconstruction has no connection with recurrence of cancer, either in the breast, the lymph nodes or at distant sites.
Will Breast Reconstruction Affect Treatment for Any Future Breast Cancer?
Breast cancer that may recur following breast reconstruction should be as treatable by radiation, chemotherapy or surgery as it would be in the absence of a reconstruction. However, the reconstruction might need to be removed.
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For Additional Information
You can find additional information about breast reconstruction surgery at web sites sponsored by government agencies, societies and healthcare institutions. It should perhaps be noted that the World Wide Web is open to many sources posting questionable information and promises, and you are encouraged to seek information from established, reputable organizations.
Likely sources include:
The American Society of Plastic Surgeons
(www.plasticsurgery.org)
The U.S. Food and Drug Administration Center for Devices and Radiological Health
(www.fda.gov/cdrh/breastimplants/bisurgery.html)
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