Breast Reconstruction

Breast reconstruction is a surgical procedure used to restore a woman's breast to a normal shape and size after mastectomy (entire breast removed) or after lumpectomy (part of the breast is removed). This can be achieved by either using the patient's own tissue or using implants (prosthetics). If the nipple and areola (darker area around the nipple) are also removed during the mastectomy, then both can be reconstructed following completion of breast “mound” reconstruction.

Although breast reconstruction is considered to be an integral part of the healing and recovery process, it is not appropriate for everyone. Reconstructive efforts should not interfere or complicate the treatment of breast cancer. The primary goal of the initial surgery is to treat breast cancer and at the same time plan for a reconstruction if the patient is a good candidate.

First and foremost, everyone should be aware of the of the Women's Health and Cancer Rights Act of 1998 which mandates insurance carriers to cover the cost of restorative procedures following mastectomy. Restoration after cancer treatment does not necessarily include surgery. For some women it may be as simple as just wearing an external prosthesis or a form-fitted bra. Reconstructive surgery is another option for restoring one's femininity and womanhood, but it is clearly more involved.

The decision to have breast reconstruction is one that is highly personal and one that should be made by the patient without any outside influence from others. Sometimes reconstruction becomes secondary as one is learning how to cope with the diagnosis and treatment. Reconstruction is considered if the patient does not have any medical conditions that would significantly complicate the healing process (such as diabetes, obesity, smoking, high blood pressure, and history of chest wall radiation). Although breast reconstruction can improve a woman's self-image following a mastectomy or lumpectomy, it is likely that there will be some emotional adjustments in order to accept the results of breast reconstruction. Although breast reconstruction procedures can result in a natural looking breast, a candidate should be prepared to accept that a reconstructed breast may never look like or have the sensation of their natural breast.

When considering restorative options, a woman's first decision is whether or not she is interested in a reconstructive procedure. If so, then one has to consider the next question of whether reconstruction should be done at the time of the mastectomy or be delayed until the breast cancer treatment is completed. At times, even if a patient desires to have immediate (at time of mastectomy) reconstruction, their surgical team may recommend that a delayed procedure, which may carry less of a risk and less interference with the cancer treatment.

Risks associated with any surgical procedure vary and are dependent on patients' existing medical problems. Some patients are at much higher risk for complications from anesthesia, especially patients who have diabetes, obesity, and/or high blood pressure. Patients who actively smoke are likely to have major complications post-surgery, particularly wound complications after reconstruction. Patients who have had prior lumpectomy and radiation therapy to the chest are also at a higher risk for wound complications. Being at risk for higher rates of complications does not mean that the patient will never have reconstructive surgery, but it may be that the surgical team may elect to delay reconstructive surgery. Some lifestyle modifications may also be recommended while preparing for the delayed reconstructive surgery. The goal is to set the patient up for success with this process, as reconstructive surgery is a major undertaking and may require multiple procedures.

As with other surgical treatments, there are always risks from anesthesia. Breast reconstruction complications may include bleeding, infection, and complications in the healing of the incision site. The risks of infection and seroma formation (fluid collection in the breast pocket) are higher with patients undergoing immediate reconstruction compared to those who are delayed, but the psychological benefits may outweigh the risks for some patients.

In a patient who requires flap surgery, there is a risk of loss of sensation in the flap and the donor site. The use of implants carries the risk of firmness in the breast, known as capsular contracture, and risk of implant rupture. Fortunately, past concerns in the 1990s that silicone implants led to certain systemic diseases have been dismissed. Research conducted by the Institute of Medicine has shown that the use of silicone implants does not pose additional health risks, such as autoimmune or other systemic diseases, or complicate breast health or healing.

No matter which technique is used to reconstruct a breast, a woman's chest skin will change over time with age, weight, and hormonal changes. Therefore, the shape of the breast will also change over the years and revision procedures may be needed if the patient desires them.

If the patient is a good candidate for immediate reconstruction, optimally, it should be performed concurrently with a skin-sparing or even a nipple-sparing mastectomy. Nipple-sparing mastectomy should be considered if the patient is a good oncological and reconstructive candidate. The breast and plastic surgeon team will determine the safety of a nipple-sparing mastectomy. Immediate reconstruction allows the surgeon to replace the breast tissue with an implant while the skin is still pliable and makes it possible to recreate the original natural shape of the breast.

The two types of breast reconstruction are implant of a prosthetic device and the use of one's own tissue to reconstruct the breast (autologous reconstruction). According to The American Society of Plastic Surgeons statistics, 75% of women in the U.S. have prosthetic reconstruction and 25% have autologous reconstruction.

Implant reconstruction: This procedure replaces the patient's tissue with a saline or silicone implant. Depending on the patient's chest wall characteristics, the implant may be placed immediately at the time of the mastectomy. However, in a majority of patients, a temporary implant known as an “expander” will be placed into the pocket of empty space of the mastectomy breast. The expander's role is to keep the future pocket for the implant open as the skin heals from the mastectomy. Expansions will be performed to create a breast mound that is generally smaller than the final implant. Patients often find this process helpful as they can progressively decide what size of implant they may want to have. Some surgeons also utilize Botox to paralyze the chest muscle, in order for the expanders to be more comfortable for the patient and overall have less pain. (Patients are responsible for the cost of the Botox as insurance carriers do not reimburse for the procedure since it is considered an off-label use of the product.) Once the patient's breast is fully expanded, then the choice between three types of implants can be made. One choice includes saline implants which have a silicone shell on the surface with saline inside. The second choice includes round silicone implants which have the same external shell except for they are filled with “cohesive silicone” on the inside. The third choice includes the next generation of silicone implants (5th generation), known as the “highly cohesive silicone” implants or as the “gummy bear” implants. The highly cohesive nature of the gel makes the implant more stable giving it a more anatomical look.

Autologous reconstruction: This group of procedures includes procedures where one's own tissue is used. The options of tissue that can be used include tissue from the following areas: abdomen, back, upper or lower buttock, and inside of the thighs. Another type of reconstruction that has been recently utilized is a series of procedures that utilize the patient's own processed fat to create a breast. This procedure is termed “fat injection” and is sometimes used in a combination with implant-based or autologous reconstruction.

Radiation therapy can change the breast reconstruction options that are available for a woman. Some may decide not to have the surgery if there is concern about monitoring the chest wall for recurrence. If the plan for chest radiation is known prior to the mastectomy, the surgical team may recommend a delayed reconstruction. On the other hand, some surgeons now also place a temporary implant, the expander, into the pocket prior to the radiation therapy. All of these efforts are to minimize complications after the final reconstructive procedure since the risk of complications is now higher after the breast is radiated. Radiation therapy changes the skin often causing the skin to “shrink wrap” and be very difficult to stretch.

Like any surgery, recovery varies after breast reconstruction surgery. Healing will continue for several weeks and one should follow the surgeon's instructions during this period. It is important not to lift, strain, or exert excessive force around the surgical area during the recovery period. The plastic surgeon will give the instructions that will include how to care for the surgical site, possible warning signs to watch for, and which medications to take to increase healing and reduce the risk of infection. It is generally recommended to take sufficient time off work to allow for the healing to take place. In addition, good nutrition is important as the body is working overtime to heal the surgical areas. Physical therapy is a crucial component of healing phase and it is recommended for all the types of procedures that are performed. Knowing the limitations of physical activity is important and continuous support of the new chest with a supportive bra for 2 to 3 months following the reconstruction is essential. The body heals over a period of time. Unusual breast sensations, twitching, and some discomfort are part of the entire healing process that can take a couple of years.

Whether reconstructive surgery is performed or the patient has chosen to wear an external prosthesis, self breast exams continue to be very important in monitoring the reconstructed breast or chest. Monthly self-breast exams should be performed on both chest/breasts and the armpits. If there is a concern or anything appears abnormal, an immediate consultation with breast or plastic surgeon is warranted. Monthly self-breast exams must continue for the rest of one's life as mastectomy does not eliminate the risk of breast cancer recurrence. Moreover, self-breast exams can detect a recurrence early when it is more treatable. Additional screening may be ordered if there is a suspicious mass or nodule that is felt. The screening may include an ultrasound or even an MRI.