Breast reconstruction is surgery to recreate breasts after mastectomy. “Unilateral reconstruction” is recreation of one breast. “Bilateral reconstruction” involves both breasts. Reconstructive procedures have evolved tremendously in the last decade. In past years, reconstructive surgeons tried to restore a woman’s profile in clothes. Now the goal of many surgeons is to make a woman look as natural as possible whether clothed or not. Reconstruction can replace the look of breasts, but even the best surgeons and the newest techniques can’t replace all sensation lost when chest nerves are severed during mastectomy, completely eliminate breast scars, or restore the ability to breastfeed.
Today, although some women prefer not to have reconstruction, those who do have many options. Choosing a method of reconstruction is very personal. Each procedure has advantages and disadvantages. Not all surgeons perform all procedures, and often, surgeons recommend only the techniques they perform. The most important actions a woman considering reconstruction can take is to learn about her options, decide which is best for her, then consult with and choose a surgeon who is experienced and expert in the technique she prefers.
Reconstruction can be done almost anytime after mastectomy. “Immediate reconstruction” is performed with mastectomy, including prophylactic mastectomy, while you’re still asleep in the operating room. “Delayed reconstruction” can be performed weeks, months, or even years after mastectomy—sometimes treatment delays reconstruction, or a woman may choose not to be reconstructed at the time of her mastectomy and then change her mind some time later. When immediate reconstruction is performed, the breast skin is preserved and less conspicuous incisions are made for the best cosmetic result. When a woman doesn’t have immediate reconstruction, most of her breast skin is removed along with the breast tissue during mastectomy. The longer and wider mastectomy incision creates a slanting scar across her chest. Even though delayed reconstruction produces very good results, this mastectomy scar remains on the new breast (but it does fade considerably in time).
Most reconstruction involves two or more operations over several months. The initial surgery forms the breast mounds, breasts without nipples. This first stage is the most complex and involves the most recovery. Depending on the procedure used, a shorter revision surgery refines the shape and size of the new breasts and add nipples. With unilateral reconstruction, the opposite healthy breast may be modified at this time for better symmetry. Tattooing the area around the nipples simulates the areolas and completes the process.
Implant reconstruction uses saline or silicone breast implants to create breast shape and volume.
Both types are available in different volumes and shapes, so your surgeon can choose one that best fits your anatomy and desired size. Saline implants have a silicone shell filled with salt water. Breasts reconstructed with saline implants tend to feel firmer than silicone, which is softer and has a texture more like natural breast tissue. Silicone implants are filled with liquid or cohesive gel silicone. Their use is still controversial; while some fear implants may leak and spread silicone into the breast tissue or beyond, others consider the natural feel and weight of silicone implants is worth the risk. No matter which type implant is used, it is always placed under the pectoralis chest muscle (unlike breast augmentation, which usually places the implant between the breast tissue and muscle).
Generally, implant reconstruction involves two phases: first, temporary implants called expanders are placed in pockets formed under the chest muscles. Over several weeks the expanders are gradually inflated with saline to stretch the skin and muscles. During a second shorter surgery, the expanders are replaced with implants that best fit your anatomy and desired size.
Two single-step procedures may be options for small-breasted women. An adjustable hybrid expander-implant can be placed and gradually inflated. When fully expanded, it is sealed and remains in place, eliminating the need for exchange surgery. Another newer technique completely eliminates the need for expansion. Non-expansive breast reconstruction uses Alloderm, a synthesized skin product, to cover portions of the implant.
Implants aren’t permanent. Sooner or later they wear out and must be removed and/or replaced. Sometimes this occurs sooner if the implant leaks or is distorted by hard scar tissue that forms around it. Some women need their implants replaced within a year of reconstruction; others may have their implants for 15 years or longer. It is obvious when a saline implant deflates, because the breast collapses (think of a balloon losing air). Deflation of silicone implants is often undetected, because the implant retains its shape. For this reason, some experts recommend women have a yearly MRI to determine if their silicone implants are intact.
Implants are a good option for women who:
- don’t mind potentially having less projection
- haven’t previously had chest or breast irradiation
- don’t mind having to replace the implants at sometime in the future
- don’t want to endure a longer recovery from tissue flap surgery or scar another area of the body
The most natural breast reconstruction uses a woman’s own skin, fat, and sometimes muscle.
Breasts made with the body's own tissue feel and move more naturally than those reconstructed with implants. However, tissue flap procedures are more complex and recovery is sometimes more intense—this involves surgery at the chest and the donor site—but the overall reconstruction timeline is shorter. Unlike implants, flaps form full-size breasts during the initial operation. Additional surgery later refines the breast shape and creates the nipples.
Two distinct types of tissue flaps are performed. The older “attached flap” surgeries use skin, fat and muscle from the back (latissimus dorsi flap) or the abdomen (pedicle TRAM flap). A portion of tissue and muscle is tunneled under the skin from the donor site to the chest, where it is shaped into a breast. It remains connected to its original blood supply (so it is “attached”).
“Free flaps” are complete transplants. They take skin, fat, and a small portion of muscle surrounding the blood vessels. This is technically more demanding than implant surgery; the surgeon need special skill and operates with a surgical microscope. Free flaps can be taken from the abdomen (free TRAM) and the buttock (gluteal flap). The gold standard of breast reconstruction is a “perforator flap,” a type of free flap that allows the surgeon to spare the entire muscle. Fewer surgeons are qualified to do this exacting procedure. They must completely remove the tiny blood vessels feeding the flap from the surrounding muscle, and reconnect them in the chest. This is tedious, demanding and long surgery. Perforator flaps are taken from the abdomen (DIEP and SIEA flaps) or the buttock (GAP flap).
Flaps are a good option for women who:
- want the most natural reconstruction possible
- have previously had chest or breast irradiation
- don’t want to risk the problems inherent with implants or don’t want to endure the expansion process
- don’t want to surgically modify their opposite healthy breast for symmetry
One disadvantage of flaps is the risk for some or all of the flap tissue to die, this is known as necrosis. When necrosis occurs, the skin and/or fat at the mastectomy or donor site dies because of insufficient blood supply. It may appear as a hard lump or an area that feels thickened. A small area of necrosis may be left as is or surgically removed. Rarely, an entire flap dies. This is known as "flap failure" and when it does occur it is usually within the first few days after reconstruction. When flap failure occurs, the reconstruction must be entirely removed.
Once a reconstructed breast has settled into its final position (about three or four months after flap revision surgery or implant exchange surgery), new nipples can be recreated. For many women, adding nipples to their reconstructed breasts brings a sense of closure to the breast cancer experience. But this is an optional procedure; because reconstructed nipples remain erect, and do not react to cold or touch the way normal nipples do, some women forego this part of reconstruction.
Nipple reconstruction is an art, creating nipples that look exactly like the real thing. Most surgeons recreate nipples using skin of the new breast: a small flap of skin is freed on the front of the breast, fashioned into a nipple and sutured in place. Because reconstructed nipples tend to shrink, they are initially made up to 50% larger than the desired size. Another, more traditional procedure uses skin grafts to create the nipple and areola. Small pieces of skin are taken from the inner thigh, labia, or back of the ear (the skin in these areas tends to be darker) and are grafted onto the breast. These techniques tend to scar an additional part of the body, however, some surgeons prefer this type of nipple reconstruction.
Once the nipple is created, the area surrounding it is tattooed to simulate the areola. Your surgeon may perform the tattooing in his office, or he may have a specially-trained technician do the tattooing. Some surgeons refer their patients to professional tattoo artists who are experienced with reconstructive tattooing. Because a reconstructed breast has little or no sensation, most women feel the tattooing more as pressure than pain. There are a wide variety of pigments to choose from; sometimes one or more are combined to produce the desired result. Tattoos often fade in time and must be redone.
The Women’s Health and Cancer Rights Act (WHCRA) took effect in 1998. This federal law requires group health plans to pay for the following services after mastectomy:
- Breast prostheses.
- Breast reconstruction.
- Surgery to the other breast to achieve a symmetrical appearance.
- Treatment for complications from mastectomy or reconstruction.
Despite the law your initial request for reconstruction may be denied. If you belong to a managed care plan, your insurer will most likely approve your request for procedures performed in-network (with surgeons already contracted by the insurance company). You’ll have to prove why you want to go out-of-network; you may only have sufficient tissue for a GAP procedure, for example, which may not be performed in-network.
Your insurance company won’t pay for procedures it considers “medically unnecessary”. Unfortunately, some companies still consider prophylactic mastectomy to be medically unnecessary and routinely deny such requests, even for women with high hereditary risk for developing the disease. Denials may occur when a woman decides to remove both healthy breasts to reduce her breast cancer risk, or when a woman who is having unilateral mastectomy to treat breast cancer wants to have the opposite healthy breast removed also. If your request for prophylactic mastectomy and reconstruction is denied, ask your primary care physician, oncologist, and medical geneticist to write supportive letters explaining your high-risk status. As management of hereditary breast cancer risk matures, more insurers understand preventative mastectomies reduce risk as well as potential future costs of treating the disease.
To learn more about the WHCRA, contact the Department of Labor, Pensions, and Welfare Benefits Administration, 800-998-7542 or visit their website. Many states also have additional laws regarding reconstruction. Contact your state’s Department of Health or Insurance Commissioner for information.
Surgical drains are plastic devices used whenever surgery leaves the opportunity for fluid build-up, which could delay healing, cause discomfort or invite infection. Often surgical drains are placed at the time of surgery with mastectomy or as part reconstruction. The tubes remain temporarily after surgery, usually for a few days or weeks, and are removed once post-surgery fluid buildup has decreased.
Part of the drain is placed inside the body at the surgery site and can't be seen. This part consists of a soft plastic tube with holes for the fluid to drain out of. This part of a drain cannot be seen until it is removed.
The drainage tube with the holes connects with a longer tube--the Jackson-Pratt (JP) drain, which remains outside of the body. At the end of this tube is a bulb which has a lid on it that can be opened to drain the collected fluid. The amount of fluid build up is measured to determine when the drain can be removed. After the fluid is removed, the bulb is squeezed so that it creates a gentle vacuum and the top is placed back on. This allows gentle suction of fluid from the surgical site. (Picture of a surgical drain.)
Every surgery has potential risks; some are more serious than others. Some mastectomy risks can affect recovery. Others can affect the type of scarring and appearance of the breast reconstruction. Some possible risks include:
- Fluid build-up at the surgical site (seroma or hematoma)
- Delayed healing
- Blood loss
- Blood clots
- Pain (post-operative and long term pain syndromes)
- Loss of implant or flap
- tissue necrosis
- Rupture, rotation or movement of implant requiring removal
- Capsular contruction or hardening around implant
It is important to discuss possible surgical risks with your physician. Understand the seriousness and likelihood of these risks prior to surgery.
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