Breast Reconstruction Surgery

Breast reconstruction surgery restores breast appearance for women who have had their breast (s) removed to treat breast cancer. A plastic surgeon rebuilds the breast so it is about the same size and shape as it was before the mastectomy. The nipple and the darker area surrounding the nipple (the areola) can also be surgically reconstructed.

Some women will have breast reconstruction done at the same time as the mastectomy, while others may wait a requisite period of time. With immediate breast reconstruction, the chest tissue is undamaged by radiation therapy or scarring. Also, immediate reconstruction means the woman needs to undergo one less surgery. On the other hand, delayed breast reconstruction may be advisable if radiation to the chest area is needed after the mastectomy. Radiation therapy that follows breast reconstruction can increase complications after surgery.

The reconstruction process may require one or more operations. The final surgery is typically the nipple and the areola reconstrution .

Not every woman with breast cancer chooses or even needs breast reconstruction. For example, many women opt for breast conservation surgery (lumpectomy or segmental mastectomy), which removes less breast tissue than a mastectomy; these women generally do not need breast reconstruction.

However, a number of women who go this route thinking that they won’t need reconstruction end up with asymmetrical breasts due to the volume of tissue removed or changes caused by radiation therapy. As a result, these women end up needing breast reconstruction surgery anyway.

Some of the key factors affecting breast reconstruction candidacy include:

• Instructions to take or avoid certain vitamins and medicines. For example, it is often prudent to avoid aspirin, anti-inflammatory drugs and herbal supplements, as they can increase bleeding risk.

• Undergoing lab testing.

• Having a complete medical evaluation.

Breast implant surgery can be done under local anesthesia or under general anesthesia. Breast implant surgery can last from one to several hours depending on whether the implant is inserted behind (submuscular) or in front of (subglandular) the chest muscle and whether surgery is performed on one or both breasts.

Scarring is a natural outcome of surgery, and your doctor can describe the location, size, and appearance of the scars you can expect to have. For most women, scars will fade over time to thin lines, although the darker your skin, the more prominent the scars are likely to be. You should ask your doctor about the types of surgical procedures, where your scar will be, and what to expect after surgery.

Options in Breast Reconstruction

The type of breast reconstruction procedure available to you depends on your medical situation, breast shape and size, general health, lifestyle, and goals. Women with small or medium sized breasts are the best candidates for breast reconstruction.

Breast reconstruction can be accomplished by the use of a breast implant, your own tissues (a tissue flap), or a combination of the two. A tissue flap is a section of skin, fat and/or muscle which is moved from your stomach, back or other area of your body, to the chest area and shaped into a new breast.

Whether or not you have reconstruction with or without breast implants, you will probably undergo additional surgeries to improve symmetry and appearance.

Breast Reconstruction with Breast Implants:

Women with larger breasts may require reconstruction with a combination of a tissue flap and an implant. Your surgeon may recommend breast implantation of the opposite, uninvolved breast in order to make them more alike or he/she may suggest breast reduction (reduction mammoplasty) or a breast lift (mastopexy) to improve symmetry. Mastopexy involves removing a strip of skin from under the breast or around the nipple and using it to lift and tighten the skin over the breast. Reduction mammoplasty involves removal of breast tissue and skin.

Timing of Breast Implant Reconstruction:

The following description applies to reconstruction following mastectomy, but similar considerations apply to reconstruction following breast trauma or for reconstruction for congenital defects. The breast reconstruction process may begin at the time of your mastectomy (immediate reconstruction) or weeks to years afterwards (delayed reconstruction). Immediate reconstruction may involve placement of a breast implant, but typically involves placement of a tissue expander, which will eventually be replaced with a breast implant.

It is important to know that any type of surgical breast reconstruction may take several steps to complete.

Two potential advantages to immediate reconstruction are that your breast reconstruction starts at the time of your mastectomy and that there may be cost savings in combining the mastectomy procedure with the first stage of the reconstruction. However, there may be a higher risk of complications such as deflation with immediate reconstruction, and your initial operative time and recuperative time may be longer.

A potential advantage to delayed reconstruction is that you can delay your reconstruction decision and surgery until other treatments, such as radiation therapy and chemotherapy, are completed. Delayed reconstruction may be advisable if your surgeon anticipates healing problems with your mastectomy, or if you just need more time to consider your options.

Surgical Considerations to discuss:

Discuss the advantages and disadvantages of the following options with your surgeon and your oncologist:

• Immediate Reconstruction:

One-stage immediate reconstruction with a breast implant (implant only)

Two-stage immediate reconstruction with a tissue expander followed by delayed reconstruction several months later with a breast implant.

• Delayed Reconstruction:
Two-stage delayed reconstruction with a tissue expander followed several months later by replacement with a breast implant.

Breast Implant Reconstruction Procedures

One-Stage Immediate Breast Implant Reconstruction:

Immediate one-stage breast reconstruction may be done at the time of your mastectomy. After the general surgeon removes your breast tissue, the plastic surgeon will then implant a breast implant that completes the one-stage reconstruction.

Two-Stage (Immediate or Delayed) Breast Implant Reconstruction:

Breast reconstruction usually occurs as a two-stage procedure, starting with the placement of a breast tissue expander, which is replaced several months later with a breast implant. The tissue expander placement may be done immediately, at the time of your mastectomy, or be delayed until months or years later.

Tissue Expansion

During a mastectomy, the general surgeon often removes skin as well as breast tissue, leaving the chest tissues flat and tight. To create a breast shaped space for the breast implant, a tissue expander is placed under the remaining chest tissues.Tissue Flap Procedures
The tissue expander is a balloon-like device made from elastic silicone rubber. It is inserted unfilled, and over time, sterile saline fluid is added by inserting a small needle through the skin to the filling port of the device. As the tissue expander fills, the tissues over the expander begin to stretch, similar to the gradual expansion of a woman’s abdomen during pregnancy.Tissue Flap Procedures
The tissue expander creates a new breast shaped pocket for a breast implant.Tissue Flap Procedures
Tissue expander placement usually occurs under general anesthesia in an operating room. Operative time is generally one to two hours. The procedure may require a brief hospital stay, or be done on an outpatient basis.
Typically, you can resume normal daily activity after two to three weeks.Tissue Flap Procedures
Because the chest skin is usually numb from the mastectomy surgery, it is possible that you may not experience pain from the placement of the tissue expander.Tissue Flap Procedures
However, you may experience feelings of pressure or discomfort after each filling of the expander, which subsides as the tissue expands. Tissue expansion typically lasts four to six months.
Breast Reconstruction with Implants

After the tissue expander is remover, the breast implant is placed in the pocket. The surgey to replace the tissue expander with a breast implant is usually done under general anesthesia in an operating room.

Breast Reconstruction without Implants: Tissue Flap Procedures

The breast can be reconstructed by surgically moving a section of skin, fat, and muscle from one area of your body to another. The section of tissue may be taken from such areas as your abdomen, upper back, upper hip, or buttocks.

The tissue flap may be left attached to the blood supply and moved to the breast area through a tunnel under the skin (a pedicled flap), or it may be removed completely and reattached to the breast area by microsurgical techniques (a free flap). Operating time is generally longer with free flaps, because of the microsurgical requirements.

Flap surgery requires a hospital stay of several days and generally a longer recovery time than implant reconstruction.

Flap surgery also creates scars at the site where the flap was taken and possibly on the reconstructed breast.

However, flap surgery has the advantage of being able to replace tissue in the chest area. This may be useful when the chest tissues have been damaged and are not suitable for tissue expansion. Another advantage of flap procedures over implantation is that alteration of the unaffected breast is generally not needed to improve symmetry.

The most common types of tissue flaps are the TRAM (transverse rectus abdominus musculocutaneous flap) which uses tissue from the abdomen and the Latissimus dorsi flap which uses tissue from the upper back.

The TRAM Flap (Pedicle or Free)

During a TRAM flap procedure, the surgeon removes a section of tissue from your abdomen and moves it to your chest to reconstruct the breast. The TRAM flap is sometimes referred to as a “tummy tuck” reconstruction because it may leave the stomach area flatter.

A pedicle TRAM flap procedure typically takes three to six hours of surgery under general anesthesia; a free TRAM flap procedure generally takes longer.

The Latissimus Dorsi Flap with or without Breast Implants

During a Latissimus Dorsi flap procedure, the surgeon moves a section of tissue from your back to your chest to reconstruct the breast. Because the Latissimus Dorsi flap is usually thinner and smaller than the TRAM flap, this procedure may be more appropriate for reconstruction a smaller breast.

The Latissimus Dorsi flap procedure typically takes two to four hours of surgery under general anesthesia.

Nipple and Areola Reconstruction

Nipple and areola reconstructions are the final phase of breast reconstruction. This separate surgery is done to make the reconstructed breast more closely resemble the original breast. Usually done on an outpatient basis with local anesthesia, nipple and areola reconstruction is generally performed once the new breast has had time to heal, which may be three or four months after surgery.

The tissue used to rebuild the nipple and areola is taken from your own body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh or buttocks.

Risks of Breast Reconstruction

• Bleeding

• Scars

• Differences in the size and shape of the two breasts

• Delayed or incomplete healing due to previous surgery, chemotherapy, radiation, smoking, alcohol, diabetes…

• Tissue necrosis of all or part of the flap.

• The need for additional surgeries to correct problems.



What if my natural breast does not match my reconstructed breast?

The ultimate goal of reconstruction is to create a breast that is symmetrical with the remaining natural breast. Sometimes, getting the reconstructed and natural breasts to match is difficult unless surgery is performed on the natural breast, too. For some patients, this may involve placing an implant in the natural breast to make it larger by augmentation or making the natural breast smaller or less droopy by reducing the tissue and/or lifting the breast skin .

What if I am considering a lumpectomy or breast conservation instead of mastectomy?

If you are considering breast conservation rather than a mastectomy, reconstructive options may be available to improve the cosmetic result. Breast conservation surgery usually involves removing a portion of breast tissue where the cancer is located, followed by radiation therapy. The removal of breast tissue can often leave an indentation or dimple on the breast. This dimple may not be seen until after radiation treatment.

Does reconstruction change the risk of my cancer returning? Does it make cancer detection harder?

The risk of breast cancer recurrence depends on the stage of disease, biologic characteristics of the cancer and additional breast cancer treatments. Reconstructive surgery has not been shown to increase the risk of the cancer returning or make it harder to detect if cancer does return.

What if I may need chemotherapy?

Breast reconstruction should not delay chemotherapy treatments. Usually your medical oncologist will wait until you have healed from your mastectomy and reconstruction before starting chemotherapy. If you have complications such as wound healing problems or infection, chemotherapy may be delayed.

What if I may need radiation?

You may want to delay breast reconstruction until you are finished with radiation therapy. Radiation may damage your reconstruction and affect your final cosmetic result. If you require radiation, your surgeons may recommend that you use your own tissue for delayed reconstruction, either alone or with an implant. Implant-only reconstruction is not recommended, since radiation often results in implant complications . If you may need radiation treatment, a tissue expander can be placed during the mastectomy to preserve the skin “pocket.” It provides a breast mound while you are waiting to hear if you need radiation.