Breast health

Mastectomy and breast reconstruction

Breast reconstruction is a surgical procedure to rebuild the contour of the breast, along with the nipple and areola (the pigmented area surrounding the nipple) and is intended to create breast symmetry when the woman is wearing a bra: the size and shape of the reconstructed breast will closely resemble the unaffected breast. Of course, when a woman is nude, the reconstructed breast will appear different from the unaffected breast.¹

Breast reconstruction is possible for the majority of patients following mastectomy. Patients who undergo modified radical mastectomy to remove the breast may begin breast reconstruction soon after surgery to remove the breast if not during the same operation. Breast cancer patients who have received chemotherapy following mastectomy may have to delay reconstruction until after chemotherapy is finished.²

Though many women are not interested in breast reconstruction, many breast specialists favor reconstructive surgery as an important option worthy of consideration, largely because new medical techniques and devices make it possible for them to recreate a breast that comes close in form and appearance to matching a natural breast. What's more, because breast reconstruction is frequently possible immediately following mastectomy, patients wake up with a breast mound already in place, sparing them the anguish of seeing themselves with no breast at all.³

What are the pros and cons of breast reconstruction?

Note, however, that breast reconstruction is by no means a simple procedure. You should note that as with any surgery, breast reconstruction carries advantages and disadvantages, and you should carefully consider all the options with your doctor before deciding what's best for you.

Advantages	Disadvantages
Patients do not wake up to the shock of losing a breast. Patients may avoid additional reconstructive surgery. Most doctors agree that optimal results occur when the cancer surgeon (oncologist) and the plastic surgeon plan the operation together.	Patients may find it hard to weigh all of their breast reconstruction options while also dealing with their recent breast cancer diagnosis and treatment options. If the cancer is more advanced than initially thought, breast reconstruction may interfere with treatment such as chemotherapy or radiation therapy.

Women who need radiation therapy after breast surgery may be advised to delay breast reconstruction. Although rare, it is possible for radiation after insertion of saline implants or muscle flap procedures (see Types of Breast Reconstruction, below) to distort the breasts. Radiation therapy, in most cases, can be administered to patients after breast reconstruction without any significant adverse effects.

Who's a candidate for breast reconstruction?

Breast reconstruction is a viable option for many mastectomy patients and many have breast reconstruction at the same time the breast is removed. The best candidates, however, are women whose breast cancer, as far as can be determined, has been eliminated by mastectomy.

Nevertheless, there are valid reasons to wait before undergoing breast reconstruction. For many patients, it is emotionally difficult to have to weigh all the options while also trying to cope with the diagnosis of breast cancer. Other women are reluctant to undergo any more surgery than is absolutely necessary. Some patients may be advised to wait, particularly if the breast is being rebuilt using a complicated procedure known as muscle flap reconstruction (see below). This is to allow the mastectomy wound and adjacent area sufficient time to heal. Women with other health conditions such as obesity or high blood pressure and women who smoke may also be advised to wait.⁴

Types of breast reconstruction

You can begin discussing breast reconstruction with your doctor as soon as you are diagnosed with breast cancer. Most doctors will agree that the best results occur when the surgeon and plastic surgeon work together to develop a strategy that will place you in the best possible condition for reconstruction.

After carefully examining you, your surgeon will explain which reconstruction options are most appropriate for you, based on your age, health, anatomy, tissues, and goals. You should be able to speak frankly with your surgeon, and he or she should be willing to fully describe your options and the risks and limitations of each. He or she should also explain the anesthesia he or she will use, the facility where the surgery will take place, and the costs of the operation. While reconstruction is intended to improve your appearance and help restore your self-confidence, you should remember that it is an improvement—not perfection.⁵

Breast reconstruction usually involves more than one operation. The first of these, whether done at the same time as mastectomy or later on, is usually performed at a hospital. Additional procedures may be performed at a hospital or, depending on the extent of the surgery required, at an outpatient facility. When making preparations for your surgery, you should ensure you have someone who can take you home and help ensure you are comfortable at home and well looked after for a few days.⁶

Saline breast implants

Insertion of saline breast implants is generally a two-part process. During the first implant operation—usually a 45-minute procedure—a tissue expander similar to a balloon is placed in the intended breast area beneath the skin and chest muscle. Following a day in hospital, patients are discharged and instructed to visit their doctor so that he or she may then periodically fill the expander with a salt-water solution. Once the skin has sufficiently stretched, the surgeon will perform a second procedure in which he or she will replace the tissue expander with a permanent saline implant. This second operation normally takes place within three to four months following the insertion of the tissue expander. In cases where a tissue expander is not needed, the surgeon will proceed directly to permanent implant surgery. Nearly half of saline implants require some type of modification or modification after 5 to 10 years.⁷

With implants, there is the remote possibility that an infection will develop, typically within the first two weeks following surgery. In some cases, the implant may need to be removed for several months until the infection clears. Once the infection is fully cleared, a new implant can be inserted.⁸

The most common complication associated with breast reconstruction involving implants is what's known as capsular contracture, a condition in which the scar or capsule around the implant begins to tighten, squeezing down on the implant and causing the breast to feel hard. This type of contracture can be treated with additional surgery designed to "score" or remove the scar tissue. In some cases, patients with capsular contracture will need to have their implant removed or replaced.⁹

Muscle flap reconstruction

Muscle flap reconstruction involves using a patient's own tissue—usually taken from the back, stomach or buttocks—to rebuild the contour of the breast. Such operations leave scars both at the tissue donor site and on the reconstructed breast. Recovery will take longer than with an implant.

In what's known as Transverse Rectus Abdominis Muscle (TRAM) Reconstruction, the surgeon takes some abdominal skin, fat, and a small piece of muscle under the skin to the intended breast area. Usually, the donated tissue remains attached to its original site, retaining its blood supply. The flap is tunneled beneath the skin to the chest, creating a pocket for an implant, or in some cases, creating the breast mound itself, without need for an implant.¹⁰

Similar to TRAM reconstruction, a Latissimus Dorsi Reconstruction involves taking muscle and skin from a patient's back to the intended breast area, creating a pocket into which an implant is inserted.¹¹

Lasting between 4 to 5 hours (as opposed to the 45 minutes required for saline implant reconstruction), muscle flap reconstruction usually requires that patients stay in the hospital three to four days. Although recovery time from muscle flap reconstruction is slower than for saline implant reconstruction, the end result usually looks and feels more natural. In some cases, patients have the added benefit of an improved abdominal contour.

Because muscle flap reconstruction involves blood vessels, it is not a viable treatment option for:

• women who smoke
• women with diabetes
• women with vascular or connective tissue diseases such as lupus or vasculitis

How will I look following breast reconstruction?

It's natural to be concerned about your breast's appearance following surgery, particularly since many breast cancers involve the nipple and/or areolar region. You may worry about your breast's looking strange, especially if your surgeon removes your nipple during mastectomy. You may also notice that your reconstructed breast may feel firmer than your natural breast. It may look rounder or flatter, too, and it may not have the same contour as it did before your mastectomy. It will not exactly match your opposite breast. Take comfort in knowing that these differences will be apparent only to you—for most patients, breast reconstruction significantly improves their appearance and quality of life following mastectomy.¹²

Once your breast volume has been rebuilt—either with a tissue expander or through muscle flap reconstruction—a nipple may be recreated. Because you need to allow the new breast area ample time to heal, nipple reconstruction usually takes place within two to six months following initial breast reconstruction. Tissue for the newly created nipple may be taken from the newly created breast, the opposite (natural) breast, or from the ear. Tissue for the pigmented region around the nipple, or areola, can be taken from the inner thigh. In some cases, tattooing may be done to ensure the pigmentation matches that of the natural breast.¹³

You should also know that reconstruction has no known effect on the recurrence of breast cancer, and it doesn't generally interfere with chemotherapy or radiation treatment should cancer recur.

Are there complications associated with breast reconstruction?

Although rare, the following complications may occur during breast reconstruction:

• bleeding
• excessive scar tissue
• infection
• adverse reactions to anesthesia
• if lymph nodes are removed during mastectomy, patients can experience temporary to permanent limitations of arm and/or shoulder movement due to lymphedema
• numbness in the upper-arm skin

Because nicotine interferes with the body's natural healing processes, women who smoke may experience slower healing and/or more conspicuous scars. Only occasionally are these complications severe enough to warrant additional surgery.¹⁴

Even if a woman's breast reconstruction involves nipple reconstruction and a skin graft to match the pigment of the areola to the natural breast, it is no longer possible to breastfeed from the reconstructed breast because it lacks the proper glandular tissue and ducts necessary to produce milk.¹⁵

Can I still get mammograms following reconstruction?

Even if you've had breast reconstructions, it's still important that you continue to receive yearly mammograms on your natural breast. However, unless there is a clinical concern (for example, a new breast lump is found), screening images of the area where your breast was removed should not be necessary. If you've had implants, your mammography technician will need to take several mammography views in order to see both the breast tissue and the implant. As a result, diagnostic mammography is strongly recommended for women who have undergone breast reconstruction surgery. In addition to pinpointing the exact size and location of breast abnormalities, a diagnostic mammogram also involves imaging the surrounding breast tissue and lymph nodes. (Refer to Imaginis.com for additional information on Breast Implant Imaging.)¹⁶

You should also continue to practice monthly breast self-examination and have regular clinical breast examinations.

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1. Breast Reconstruction. Imaginis Corporation. (1997–2004)
2. Mastectomy. Imaginis Corporation. (1997–2004)
   Breast Reconstruction. Imaginis Corporation. (1997–2004)
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9. Breast Reconstruction. Imaginis Corporation. (1997–2004)
   Breast Reconstruction Following Breast Removal. American Society of Plastic Surgeons. (2004)
10. Breast Reconstruction. Imaginis Corporation. (1997–2004)
    Breast Reconstruction Following Breast Removal. American Society of Plastic Surgeons. (2004)
11. Breast Reconstruction. Imaginis Corporation. (1997–2004)
12. Breast Reconstruction Following Breast Removal. American Society of Plastic Surgeons. (2004)
13. Breast Reconstruction. Imaginis Corporation. (1997–2004)
14. Breast Reconstruction. Imaginis Corporation. (1997–2004)
    Breast Reconstruction Following Breast Removal. American Society of Plastic Surgeons. (2004)
15. Breast Reconstruction. Imaginis Corporation. (1997–2004)
16. Breast Reconstruction. Imaginis Corporation. (1997–2004)