Breast Reconstruction

Breast Reconstruction

Also called: Breast Reconstruction Surger

Summary

Each year, nearly 180,000 women in the United States are diagnosed with breast cancer, according to the American Cancer Society (ACS). Earlier detection techniques and better mammography have led to earlier discovery of breast cancer and better options for breast reconstruction.

In the United States, the standard treatment for breast cancer for the past 25 years has been modified radical mastectomy, which is the total removal of the breast. Today, improved diagnostic and treatment methods enable more women to choose a lumpectomy (partial mastectomy) rather than a total removal of the breast.

However, for women who have large tumors and cancer that has spread to the lymph nodes, or those women who have more than one tumor in the same breast, a modified radical mastectomy is usually the recommended surgical treatment. For these women, the decision is whether or not they choose to have breast reconstruction following the surgery. Breast reconstruction can be immediate (at the time of mastectomy) or it can be done later after the patient has completed cancer treatment. 

When reconstruction is necessary, a woman may choose among the various forms of reconstruction. These options include saline implants, silicone implants or an autologous flap reconstruction (using skin, tissue and possibly muscle from the patient’s abdomen, back or buttocks).

Each option has its own benefits and risks. A woman should discuss the options carefully with a qualified physician – usually a plastic surgeon – as not every breast cancer patient is a candidate for every type of reconstructive surgery. Today there are a wide variety of options available to women who want to create a new and natural-appearing breast, offering the breast cancer patient both physical and emotional healing.

About breast reconstruction

Breast reconstruction is the surgical restoration of a woman’s breast following a mastectomy (removal of the breast). Many women receive significant psychological and emotional benefits from having breast reconstruction.

Reconstruction can take place at the time of mastectomy (immediate reconstruction) or later (delayed reconstruction), after any chemotherapy or radiation treatments are completed. Women today have several options when it comes to breast reconstruction, including:

  • Using breast expanders for skin expansion and implants
  • Using the patient’s own tissue from the lower abdomen, buttocks or back (autologous tissue reconstruction)
  • Using a combination of tissue reconstruction and implants

Breast reconstruction is a complicated surgical procedure done by a plastic surgeon. It is not uncommon for a patient to require two or more surgeries to achieve the optimal results of symmetry and correct positioning of the reconstructed breast.

The procedure involves not only reconstructing the breast, but also reconstructing the nipple followed by tattooing the new nipple to create a more natural-looking areola (area around the nipple).  Sometimes, the healthy breast is also adjusted to more closely match the shape and size of the reconstructed breast.

Many women diagnosed with breast cancer find it difficult to emotionally deal with the loss of a breast, despite the fact that the surgery may save their lives. Following a mastectomy, women have the option of breast reconstruction surgery or prosthesis (artificial breast).

The option of no reconstruction at all does exist but many women chose some form of breast reconstruction. For many years, women have had the option of using an external prosthesis. The prostheses are basically pads or breast forms that can be worn in bras or under clothing. They come in a variety of styles and have improved considerably over time. The main disadvantages are that they are not ‘part of the body’ and have limitation in use, especially with bathing suits.

There were more than 56,000 breast reconstructive surgeries performed in 2006, according to the American Society of Plastic Surgeons (ASPS). This represents a 31 percent decrease in the number of reconstructive procedures from 2000. The ASPS notes the decline in breast reconstruction may be related to health insurance issues. Many women cannot afford the insurance copayment and are unable to complete breast reconstruction due to cost.

Types and differences of breast reconstruction

There are many breast reconstruction alternatives from which to choose. Therefore, it is important for patients to discuss their individual options with their physicians, including the medical oncologist and plastic surgeon before reconstruction. A plastic surgeon performs breast reconstructive surgery and works closely with the patient’s cancer care team.  The breast reconstruction can be immediate (at the time of mastectomy) or it can be done later after the patient has completed treatment.

Prior to a mastectomy, the plastic surgeon will explain that the two most common types of breast reconstruction in the United States – implants and autologous tissue flaps:

  • Implants. In implant reconstruction, a temporary tissue expander is placed under the skin and muscle where the breast was located at the time of mastectomy. The expander is similar to a balloon with a small valve placed beneath the skin. During follow-up visits, the physician will periodically inject sterile saline (salt water) via a small tube. The expander stretches the muscles over a period of weeks or months until the breast area is stretched enough to accommodate an implant.

    Just as the uterus stretches the lower abdominal wall during pregnancy, the chamber stretches with saline and forms an extra amount of skin tissue. In a second procedure, the tissue expander is removed and replaced with a permanent saline implant. At that time, a symmetrizing (equalizing) contralateral (opposite side) breast procedure can be performed. This helps to ensure the proper position and also helps match the reconstructed breast to the other healthy breast. Not all women require breast tissue expansion before receiving an implant. For these candidates, the permanent implant is inserted during the first step.

    The implants that are selected can be filled with saline or silicone. There is a common belief that silicone breast implants are unsafe and should be banned. Some controversy remains as to whether silicone implants cause autoimmune disease. Several large scientific studies have not found such a connection. Many women still choose implants that consist of a silicone shell filled with a saline solution instead of silicone. However, saline implants do not feel as natural as silicone gel implants.

    In 1992, silicone implants were removed from the market in the United States by the U.S, Food and Drug Administration (FDA) due to safety concerns, particularly about the potential link between implants and autoimmune conditions. Use of silicone implants were restricte and only approved for reconstructive surgery in women. They could not be used for breast augmentation. In addition, the women could receive silicone implants only if they were enrolled in an investigational exemption study.

    However, in 2006, the FDA lifted a 14-year ban on silicone breast implants. Two companies were granted approval for silicone breast implants. The implants were approved for women of any age undergoing breast reconstruction and in women age 22 and older for breast augmentation. All other silicone-filled breast implants are considered investigational by the FDA. If a woman wishes to receive one of the non-approved implants in the United States, she must be enrolled in a clinical study.
  • TRAM flap. Another common procedure is the TRAM flap, which was pioneered in the early 1980s. TRAM is an acronym for transverse rectus abdominus muscle. The transverse refers to the skin orientation, which is transverse, or horizontal. The rectus abdominus muscle and skin are used for the flap to create the new breast. 

    This procedure relocates abdominal fat with the lower abdominal skin attached to the rectus abdominus (stomach) muscle. The flap is removed, but the feeding artery and vein remain, and the site from which the tissue is removed is sewn closed. The flap is tunneled under the skin and pulled up into the mastectomy site. Since the blood vessels are not cut, there is a blood supply that remains in the flap. One option in the TRAM flap procedure involves removing the breast tissue, but leaving the skin in position. At the time of a planned mastectomy, very small, keyhole-type skin excisions of the breast can be made, allowing access to the axilla (armpit). The nipple and breast tissue are removed, but the actual skin of the breast remains. This contrasts with traditional TRAM flaps in that the skin of the lower abdominal wall is not used. Instead, the fat and muscle are placed beneath the original skin of the breast, which produces a very natural contour and recreates the illusion of having breast tissue.

    In addition, there are three variations of flap procedures:

    • Latissimus dorsi flap. For women who do not have adequate lower abdominal skin or who have had previous surgeries, but desire a flap procedure, there is another option: the latissimus dorsi flap, which is an older procedure that has been used for years. It is similar to the TRAM flap, but requires the placement of an implant underneath the flap. The disadvantages of the procedure are that there is an oblique (slanted) scar on the back. It also requires harvesting the large latissimus dorsi muscle, which is muscle from the patient’s back on the opposite side of the mastectomy. The benefit is that the latissimus dorsi is a very hearty muscle and seems to respond very well after surgery. Additionally, there is no lower abdominal wound that needs to heal. These procedures cannot construct large breasts, but can make medium-sized breasts.

    • DIEP flap. Another type of abdominal flap is the DIEP (deep inferior epigastric perforator) flap. This is a newer alternative to the TRAM flap and similar in many ways. Unlike the TRAM, however, a flap of only skin and fat (not muscle) are removed. The advantage is that muscle strength is retained in the abdomen. The disadvantage is that the surgery may take longer to perform.

    • Gluteal flap. Another option is the buttocks (gluteal) flap. This is a free-flap procedure that uses muscle from the buttocks and transplanting it to create a breast mound.

Regardless of which flap procedure is used, the type of surgery is more complicated than reconstruction using a tissue expander and implant. There will be scars from the donated site as well as on the breast. In addition, the recovery time is longer with flap procedures.

Before, during and after the reconstruction

The plastic surgeon should explain the advantages and disadvantages of each type of breast reconstruction, including the option of having no reconstruction at all. In addition, the surgeon should describe the surgery in detail and show the patient photos of women who have had the various types of reconstruction. This will allow the patient to view the various options and also have more realistic expectations going into the procedure in order to make an informed decision.

During the surgery, general anesthesia is almost always used. Many breast reconstruction cases require more than one procedure. While the first surgery normally requires general anesthesia, some follow-up procedures may be done using a local anesthetic.

After surgery, it is normal for the patient to be tired and sore for a week or possibly two following implant reconstruction. The recovery period can be several weeks for those undergoing a flap procedure. Depending on the type of breast reconstruction, a hospital stay of 1 to 6 days is normal.

Many women will be discharged with a surgical drain in the breast that is used to remove excess fluids from the breast area. Patients will be instructed on the care of these drains as well as their surgical sites. The drains are usually removed within the first few weeks following surgery. The physician and nurses will also provide information to the patient about recommended exercises and any restrictions on activities.

Most breast reconstruction patients need a series of follow-up procedures after the initial surgery. These can include surgery to reconstruct the nipple and tattooing to simulate the darker skin of the areola. Surgery may also be performed on the natural breast to match the size, shape or lift of the reconstructed breast.

The sexual impact of breast reconstruction should also be considered. While reconstruction creates the shape of a breast that can look normal, it does not restore normal breast sensation. The nerve that leads to sensation in the nipple is cut during surgery. Thus, all feeling beyond slight pressure is usually lost. Over time, the reconstructed breast may regain some feeling, but it will not be the same as normal breast sensation.

Potential benefits and risks with reconstruction

Whether a woman chooses implants or an autologous flap procedure, there are benefits and risks for each that should be thoroughly discussed with her physicians. It is important to research each procedure and discuss any concerns or questions with a qualified plastic surgeon and oncologists who are experienced in breast reconstruction and breast cancer treatment.

For a woman who chooses implants, whether they are filled with silicone gel or saline, there are some disadvantages:

  • Hard envelopes of scarring can occur around the implant
  • Reconstructed breast can feel overly firm
  • Breast area can be quite tender
  • Implants may interfere with future mammograms and breast self-examinations

The advantages of a flap procedure include:

  • Implant is usually not needed
  • Usually a single operation can create a soft breast composed of a patient’s own tissue
  • Women who carry extra weight in the abdomen can achieve a tummy tuck (abdominoplasty) as well as breast reconstruction

The disadvantages of reconstruction with a flap include:

  • Longer time in surgery and recuperation
  • Greater risk in delay of healing
  • Breast area and skin flap removal are involved in healing

The question becomes which patients are the best candidates for a flap. Several criteria are used in screening women for a flap procedure. There are a few contraindications, meaning conditions in which this type of surgery would not be advised, including: 

  • Previous abdominal surgery (e.g. appendectomy or gallbladder incision). Since the newer surgeries utilize less invasive laparoscopic techniques, this factor is less of an issue.
  • Diabetes. Individuals with diabetes do not heal as well and are considered higher risk for infection and complications.
  • Smoking. Smokers tend to absorb nicotine in their lungs, which is a vasoconstrictor. The nicotine can cause the smaller blood vessels in the breast, which keep the flap alive, to constrict. The constriction jeopardizes the health of the breast.
  • Lack of fatty tissue in the abdomen. Without adequate tissue, there is not enough skin to use in the procedure.
  • Obesity. Too much fat and subcutaneous tissue makes it too difficult to use the skin for the flap.

Some women opt for the TRAM flap over implants because the procedure includes an abdominoplasty and also because they avoid some of the potential drawbacks of having an implant. It is a U.S. Food and Drug Administration (FDA) requirement to tell all prospective patients who consider saline or silicone implants that there is a risk of deflation, infection, hardness of the area and that the implants may have to be changed, which would require an additional surgical procedure.

Other potential risks of breast reconstruction include the possibility of:

  • Rupture or deflation of an implant
  • Additional surgery to replace a damaged implant
  • Needing to replace an implant at a future date
  • Infection
  • Implant rotation under the skin
  • Capsular contracture (scar tissue that forms and compresses the implant, making it hard and unnatural looking)
  • Poor wound healing
  • Tissue death (the flap dies due to insufficient blood supply)

Lifestyle considerations with reconstruction

Women who are extremely active and want to avoid spending long periods recuperating tend to opt for the placement of tissue expanders leading up to implants. For most, this fits well into an active lifestyle, as implant surgery may be performed on an outpatient basis or with an overnight hospital stay. Even though patients have soreness and tenderness in the chest, they are able to return to their normal routines in a shorter period of time.

Before considering a flap procedure, athletically active women may want to be aware of the effect of cutting the rectus abdominus muscle. Because 10 percent of the initiation of an abdominal sit-up is begun using the rectus abdominus muscle, such women may find that it will take considerably more time after the surgery before they can exercise as usual. However, there are three other muscles that can be conditioned to carry the load of the rectus abdominus.

It may take up to six weeks for a woman to recover from a flap reconstructive surgery. The recovery may be even longer if the reconstruction was performed at the same time as her mastectomy. Patients should follow the physician’s instructions regarding stretching exercises and normal activities. In some cases, women may be referred to a physical or occupational therapist to help with muscle and arm function following a mastectomy. In general, women should refrain from overhead lifting and strenuous activities for three to six weeks following surgery.

Breast reconstruction can provide a cosmetically similar breast. However, the reconstructed breast has no nursing or sexual function.

Following reconstruction, there are normally several visits to the plastic surgeon to monitor the progress and healing at the surgery sites. Once the incisions have healed properly, subsequent follow-up visits most likely will be handled by the patient’s oncologist who will offer recommendations on the scheduling of any other tests, including clinical breast exams and the need for mammography.

Questions for your doctor

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about breast reconstruction:

  1. Should I have breast reconstruction at the same time as my mastectomy?
  2. If not, how long should I wait for the reconstruction?
  3. Which is the best type of reconstruction for me?
  4. What are the benefits and risk of this reconstruction?
  5. How will breast reconstruction affect my cancer treatment plan?
  6. If I use skin expansion, how long will the expanders be in place?
  7. Do you recommend saline or silicone implants?
  8. If I choose a silicone implant that is not approved, can I be enrolled in a clinical study?
  9. If I have a flap procedure, from where will you remove the tissue?
  10. How long will the surgery last and where will it be performed?
  11. How long will I need to be hospitalized?
  12. What will I have for scars and how large will they be?
  13. What is involved with the recovery process?
  14. What type of follow-up procedures will be necessary?
  15. What complications indicate the need for medical attention following surgery?
  16. What are my restrictions following the surgery?
  17. Will I have any sensation in my reconstructed breasts?
  18. Can you show me photographs of your reconstruction work in women?
  19. Can you recommend a support group?
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