Breast Reconstruction

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Breast Reconstruction

Breast reconstruction can help restore the look and feel of the breast after mastectomy. Done by a plastic surgeon, breast reconstruction can be done at the same time as the mastectomy surgery ("immediate") or some time after the surgery ("delayed"). Many women now choose to do immediate breast reconstruction. However, exactly when a woman should have or can have reconstruction depends not only on her wishes but also on her situation and the follow-up care she might need after the surgery. Not all women are candidates for reconstruction at the same time as surgery. It is important for a woman to discuss her options with her breast surgeon, her oncologist and her plastic surgeon.

Although a reconstructed breast may never look or feel as natural as your original breast, this area of plastic surgery continues to improve, as do the cosmetic results. Having a breast reconstructed can help you feel less self-conscious about how you look and restore confidence in your sexuality. Reconstruction can also help you to worry less about your cancer because you will not be constantly reminded of it by your missing breast .

There are two basic types of breast reconstruction. One uses artificial implants (filled with saline or silicone) and one uses skin, fat and muscle from a woman's own body. There are benefits and drawbacks to each. Artificial implants require less extensive surgery than procedures using a woman's own body tissues, but the results can look and feel less natural . There is no one best reconstructive method and you should discuss all options with your plastic surgeon. It may be comforting to know that most women are satisfied with the method of breast reconstruction they chose and that there are relatively few complications with any of the current techniques .

Most procedures for breast reconstruction involve several steps. Whether performed at the same time as the mastectomy (immediate reconstruction), or at a later date (delayed reconstruction), the initial procedure for breast reconstruction will require a hospital stay. However, follow-up steps in the procedure may be done on an outpatient basis .

Smoking increases the risk of complications for all types of breast reconstructive surgery . Women who smoke should talk to their plastic surgeons about potential problems with wound healing and complications with flap procedures .

Implant
Inserting an artificial implant is a relatively short procedure that may not require extra hospital time if it can be done at the time of the mastectomy. The shape of the breast reconstructed with an implant, however, may not look or feel exactly like the natural, opposite breast, especially as a woman ages and her natural breast changes shape . For this reason, this procedure is better suited for women with small or medium-sized breasts with little or no sagginess . However, it is possible to have surgery to augment or reduce the size of the opposite breast to create a more symmetrical appearance.

There are two basic types of breast implants available to women after a mastectomy: saline and silicone. Although there was concern in the past over the safety of silicone implants, to date, there is no proven evidence that they are associated with lupus, immune system disorders, connective tissue disease or rheumatoid arthritis . Therefore, women should consider silicone implants a viable option to saline implants.

For both saline and silicone implants, the outer cover of the implant (also called the implant sac) is made of a solid form of silicone. Many other types of implanted medical devices, such as heart valves, are made of this form of silicone. The two types of implants differ in the substance used to fill the implant sac. Saline implants are filled with saline, a saltwater solution similar to that found in IV fluids. Silicone implants are filled with silicone gel, a semi-solid substance made from silicone.

In general, inserting a saline implant is a two- or three-step procedure. The process often begins with the insertion of a tissue expander beneath the skin and chest muscle. The tissue expander is a modified saline implant with a valve that allows volume to be added after the initial surgery. A simple injection of saline through the skin into the valve fills the implant. During repeated office visits over a period of four to six months, the skin-muscle envelope is slowly stretched until desired size of the final implant is reached. The next step of the process is an out-patient procedure in an operating room where the expander is removed and replaced with a permanent implant (saline or silicone). A few women decide to keep the expander in place for an extended period of time in order to be able to change the size of the reconstructed breast at a later time by increasing or decreasing the amount of saline in the implant without having to remove the implant.

The procedure for inserting a silicone implant is similar to that for a saline implant. However, it usually involves fewer steps because the implant sac is pre-filled with a specified amount of silicone gel. Thus, the size of the reconstructed breasts cannot be changed without surgical replacement of the implant.

Some women do not need tissue expansion and can have an implant (saline or silicone) directly inserted. However, this depends on whether the size of the available skin-muscle envelope at the time of the mastectomy is large enough to cover the desired final implant. These cases are exceptions rather than the rule.

A newer, recently developed reconstructive technique takes full advantage of the entire skin envelope available at the time of the mastectomy but does not require the use of the chest muscles to cover and hold an implant in place ,. This technique creates a hammock for the implant or expander underneath the mastectomy skin envelope using donated tissues (called "acellular dermal matrix") instead of the woman's own chest muscle. Similar procedures have been used in the past for various other reconstructive procedures in the human body. The procedure is less invasive and the length of the operation is shorter, but it is dependent on the quality of the mastectomy skin envelope. You should talk with your reconstructive surgeon to determine whether or not you are a good candidate for this procedure.

Reconstruction of the nipple is either performed at the same time the permanent implant is inserted in the operating room or as an independent third step in the office.

There are advantages and disadvantages to each type of implant. These are summarized in the table below. However, you should discuss your options with a plastic surgeon in order to select the type most appropriate for you.

Breast Implants and Radiation Therapy
Radiation therapy following mastectomy can cause complications with both implant and natural tissue reconstruction. If implants are the preferred method of reconstruction and radiation therapy will be used after mastectomy, immediate rather than delayed breast reconstruction is recommended . Skin that has received radiation and is later stretched to fit an implant is at high risk for complications and a poor cosmetic result . Results are better when the procedures to expand the skin are completed before radiation therapy begins.

Breast Implants and Mammography
It is important for women who have breast implants to notify their health care provider before getting a mammogram (standard X-ray film or digital) so that special adjustments to the mammography machine can be made.

Natural Grafts/Tissue Flap Surgery
Reconstruction using skin and tissue flaps (grafts) from a woman's own body tend to look and feel more like the natural breast. However, the procedures are more complicated than with artificial implants and this usually prolongs the hospital stay. They also leave scars in the area of the body where the tissue was taken. In some flap procedures an entire muscle needs to be removed for the reconstruction of the breast. This can result in weakness in this particular area of the body and might have a negative impact on certain physical or athletic activities. The most common of today's natural graft procedures use tissue from the back, the abdomen (tummy) or the buttocks.

The latissimus dorsi muscle flap procedure removes a large muscle in the back along with skin and underlying fatty tissue and uses these tissues to reconstruct the breast. The inclusion of fatty tissue helps create a more natural looking breast. However, the flap itself is usually only about one inch thick, and even with the added fatty tissue, this procedure usually requires an artificial implant in addition to the natural tissue in order to make the reconstructed breast match the size of the unaffected breast. Even so, because much of the reconstructed breast is formed with natural tissue, the look and feel of the breast will still be more natural than with an implant alone.

The transverse rectus abdominis myocutaneous (TRAM) flap is another popular form of breast reconstruction involving natural tissues. This procedure uses skin, muscle tissue and fatty tissue from the lower abdomen to reconstruct the breast. A TRAM flap creates a very natural looking breast and usually does not require the use of an implant as long as a woman has enough excess skin and fatty tissue in her lower abdomen. However, it does have some drawbacks. Once the procedure has been performed, it cannot be repeated. And, women who do not have excess tissue in the abdominal area may not be candidates for the procedure. Moreover, the surgery is complicated and invasive and leaves a large scar across the lower abdomen. Since the lower abdominal muscle is used to form the reconstructed breast, its absence will cause some weakness in this area of the body. Women who are athletic or physically active should consider this aspect of the procedure. If post-mastectomy radiation therapy is planned, the TRAM flap procedure is generally postponed until several months after radiation therapy has been completed as it may affect the cosmetic appearance of the reconstructed breast.

Another procedure used for breast reconstruction and recently growing in popularity is the deep inferior epigastric perforator (DIEP) flap. The DIEP flap procedure, like the TRAM flap procedure, uses skin and fatty tissue from the lower abdomen to form the reconstructed breast. Unlike the TRAM flap technique, the DIEP flap procedure keeps the abdominal (tummy) muscle intact, which speeds recovery and preserves abdominal strength after the procedure. The procedure is more complicated than the latissimus dorsi muscle flap and TRAM flap procedures, and therefore usually requires two surgeons well trained in microvascular techniques. The DIEP flap procedure also tends to take longer to perform than other natural graft procedures, which can increase the risk of complications during surgery. Though increasingly popular, it's still unclear whether the benefits of this procedure outweigh the risks when compared to other techniques . The DIEP flap procedure should only be performed by a surgeon who is well-trained and experienced with this technique.

Not unlike the DIEP flap, the superior gluteal artery perforator (S-GAP) flap procedure uses skin and fatty tissue to reconstruct the breast, but taken instead from the upper part of a buttock. Because no buttock muscle tissue is used, athletic ability after surgery is not usually affected . S-GAP flap reconstruction may be a good option for women with more fatty tissue in their buttocks area than in their abdomen . If the procedure leaves a woman's buttocks noticeably dissimilar in size, liposuction can be used to remove fat from the opposite buttock to create a more even look. Similar to the DIEP flap procedure, S-GAP flap procedure is more complicated compared to the other types of tissue flap surgeries and requires a surgeon well trained in microvascular techniques . S-GAP flap takes longer to perform than other types of natural tissue grafts, even longer than the DIEP flap procedure . The longer length of the surgery may increase the risk of complications. If an S-GAP flap reconstruction is not successful, a different reconstruction procedure can usually be performed on the breast at a later time .

Skin-Sparing Mastectomy
If a woman is having breast reconstruction immediately after her mastectomy, the breast surgeon may try to keep intact as much of the skin of the breast as possible. In this procedure — called a skin-sparing mastectomy — the tumor and margins are removed, as are the nipple, areola, fat and other tissue that make up the breast. What remains is much of the skin that surrounded the breast. This skin can then be used to cover a tissue flap or artificial implant.

The major benefit of the skin-sparing mastectomy is that it avoids using skin from other parts of the body for reconstruction, since that skin can have a different color, texture and thickness compared to the natural breast skin. With skin-sparing mastectomy, the reconstructed breast tends to look and feel more similar to the opposite, unaffected breast. Although it's been suggested that skin-sparing mastectomy may increase the risk of cancer recurrence, most studies to date have not found an increased risk with the procedure ,.

Natural Tissue Reconstruction and Radiation Therapy
Radiation therapy following mastectomy can cause complications with both implant and natural tissue reconstruction. For women undergoing a natural tissue reconstruction and who will receive radiation therapy after their mastectomy, it is better to delay reconstruction until after radiation therapy is completed . This reduces the chances that the cosmetic look of the reconstructed breast will be affected by the radiation therapy .

Nipple-Areola Reconstruction
The nipple and areola are usually the last stage of breast reconstruction. Recreating the nipple and areola gives the reconstructed breast a more natural appearance and can help hide scars. These procedures do not usually require an overnight stay in the hospital. The nipple can be recreated with tissue from the reconstructed breast itself after the skin on the breast has healed and had a chance to expand over the new tissue or implant. The areola may also be created by tattooing the area or by grafting skin from the groin area. Skin in the groin area has a similar skin tone to the skin on the areola and the graft scar can be concealed in the bikini line .

After Breast Reconstruction
Most women feel tired and sore for two to three weeks after reconstruction. Overhead lifting, strenuous sports and sexual activity should be avoided for three to six weeks following reconstructive surgery. However, most women can resume normal activity levels within six weeks . You should talk to your health care provider about specific recommendations following your surgery.

It is important to remember that while breast reconstruction can improve appearance and boost self-confidence, the reconstructed breast will not have the same sensation or the exact appearance and feel of a natural breast. Most of the scarring will fade over time, but some scars may never completely disappear .
It is not surprising that most women undergoing breast reconstruction experience a period of emotional adjustment. Feeling anxious or depressed is very common and it may be useful to talk to other women who have undergone breast reconstruction, orwith a mental health professional ,.

Insurance Coverage for Reconstructive Surgery
Although many states require health insurance providers to pay for reconstructive surgery following mastectomy, unfortunately at this time, no federal laws mandate this coverage. However, the Women's Health and Cancer Rights Act of requires that all health insurance providers and health maintenance organizations (HMOs) that pay for mastectomy also pay for breast reconstruction. Many states have enacted laws that go further requiring all health insurers to cover reconstructive surgery as well as prostheses and lymphedema therapy. As coverage varies from state to state, it is important to check with your state insurance commissioner's office or your health insurance provider to find out which services are covered by your state's laws and your health plan.

© 2009 Susan G. Komen for the Cure®