What is Breast Reconstruction?

Breast reconstruction is a surgery to rebuild the breast to restore its shape and size. The nipple and the areola (dark area around the nipple) can also be reconstructed or even spared.

When one or both breasts are completely removed during mastectomy or altered by lumpectomy/partial mastectomy/segmental mastectomy, a woman will be faced with the choice to undergo reconstruction to restore her breasts or not to have additional surgery and leave her chest as is.

Women can opt for immediate reconstruction (at the same time as her mastectomy) or delayed reconstruction (at a later date). It is important to discuss reconstruction options with at least one breast or plastic surgeon before your mastectomy, to explore the opportunity to begin reconstruction at the same time as your mastectomy. Discuss cancer treatments you’ve had or will have as it may not be beneficial in some cases to have immediate reconstruction.

Generally, there are four surgical approaches to restore the shape of the breast:
  • Use of an implant (saline which is filled with a substance similar to salt water or silicone which is gel-filled)
  • Use of tissue from another part of your body (abdomen, back, thighs, etc.)
  • Use of an implant and tissue from your own body (combination)
  • Rearrangement of your own breast tissue after a lumpectomy

Click here to review a comprehensive table on different breast reconstruction options and its process, benefits, and considerations.
 

Implant Reconstruction


There are two common types of implants for reconstruction: a saline implant and a silicone-gel filled implant. Ask our surgeon if you can feel a sample of both types and try to talk with women who’ve had each type.

Implant procedures can be divided into two types:

  • Direct to Implant- surgery with an implant is done in one stage. At the same time as your mastectomy. After the surgeon removes the breast; an implant is placed under the chest wall muscle. Keep in mind, additional surgery may be needed for a revision or for nipple reconstruction.
  • Expander to Implant- done in two stages, the use of a tissue expander allows the body to create space enough and enough skin for an implant after a mastectomy. A tissue expander, similar to a balloon, is placed under the skin and muscle where the breast was removed. Saline is inserted into the expander at the time of the mastectomy and gradually over the next few weeks to up to six months, through a small valve in the implant. Women comment that expanders feel tight or “like rocks” while in place. When the breast area has stretched adequately a second surgery is performed to remove the expander and replace it with a permanent implant.

Concerns About Implants


Fears about silicone leakage have led the U.S. Food and Drug Administration (FDA) to evaluate breast implants. The FDA has determined that most silicone filled implants are safe for both reconstruction and cosmetic reasons. Discuss any concerns you have about implants with your doctor. You should know that implants may need to be replaced with surgery at some point in your lifetime. Implants can leak or tear, cause an infection, or develop scar tissue – but these things can be managed effectively with your doctor.

More on breast implant safety is available at:


Reconstruction with a Tissue Flap


This procedure uses tissue from your body- your abdomen, back, thighs, or buttocks- to rebuild the breast. When your own tissue is used to create a new breast, this is called autologous reconstruction.

Tissue flaps behave more like your own body than implants- for example, they shrink or expand when you gain or lose weight. Tissue flap procedures result in two scars- one at the breast and the other at the site where tissue was removed. It is possible that the tissue removed from your abdomen for a reconstructed breast can cause changes, for example, in the shape of your belly button. In some cases the abdomen may require support as it heals after a tissue flap procedure to decrease problems such as hernias or bulges. These are things you may want to ask your doctor more about.

Types of Tissue Flap Procedures:


  • TRAM (transverse rectus abdominis muscle) Flap- tissue from the abdomen (including skin, fat, blood vessels and at least one abdominal muscle) are used to rebuild the breast. In addition, an implant may be used to create a fuller shape. There are two types of TRAM flaps: 
                  -- A pedicle flap - where the tissue remains attached to its original blood supply and is tunneled under the skin to the breast area
                  -- A free flap- where the tissue is cut away completely from its original location and is attached to a new blood supply in the chest area. Free flap procedures use microsurgery techniques to connect blood vessels and ensure proper circulation to the site.
  •  Latissimus Dorsi Flap- a pedicle flap procedure where tissue and muscle from the upper back is tunneled under the skin to the breast area, creating a pocket for an implant
  • DIEP (Deep inferior epigastric artery perforator) Flap- a free flap procedure using fat and skin, but not muscle, from the lower abdominal area. A SIEA (Superficial inferior epigastric artery) Flap uses skin and fat from the lower abdominal area. The relocated tissue is attached to a new blood supply in the chest.
  • Gluteal free flaps- tissue from the buttocks, including muscle, is relocated to the breast area and connected to a new blood supply there in order to recreate the shape of the breast, IGAP (inferior gluteal artery perforator) Flap, and SGAP (Superior gluteal artery perforator) Flap are also done. If necessary, an implant can also be used to fill out the size of the new breast.
  • TUG (Transverse Upper Gracilis) Flap- builds a breast from a small muscle plus skin and fat from the upper inner thigh. It can be performed on one or both breasts at the same time or separately

Tissue Rearrangement


Oncoplastic surgery is the rearrangement of tissue in the affected breast and symmetry procedure on the unaffected breast. Oncoplastic surgery is good for women with large breasts who desire a decrease in size. Once the general surgeon has performed the lumpectomy and feels comfortable that the cancer is surgically removed, a plastic surgeon can rearrange tissue to correct the defect remaining from the lumpectomy and at the same time perform a reduction (mastopexy) on the other side. Radiation can be performed after reconstruction.

Cell Enhanced Lumpectomy Repair


Although lumpectomy and partial mastectomy are breast-conserving surgeries, a scar is created and a dimple or indent is left behind. A new option- cell enhanced breast reconstruction- is being explored in clinical trials to help correct these problems. Fat tissue, which is rich in stem cells, is adapted in a special process that enables it to be used at the lumpectomy site. Also, fat grafting is a technique that may improve tissue damage after radiation, and may improve breast reconstruction outcomes after radiation treatment.

Nipple and Areola Reconstruction


Nipple and areola reconstruction is a separate surgery and is usually the final step in breast reconstruction. Tissue from the reconstructed breast, opposite nipple, abdomen, eyelid, groin, inner thigh, or buttocks can be used to recreate a nipple. Because reconstructed nipples tend to shrink, they are initially made up to 50% larger than desired size. Tattooing can give the nipple a natural color to create an areola. For some women, a nipple- sparing mastectomy is an option. This type of surgery is performed when cancer is at an early stage located far from the nipple, or during a prophylactic mastectomy.

Concerns About Surgery

Like any major surgery, your surgeon should explain and discuss the complications and time commitments related to your procedure, as well as methods to prevent problems. Ask questions so that you fully understand the risks before making your choice.

Surgery, in general, can pose a number of risks (infection, bleeding, blood clots, pain, reactions to medications or general anesthesia, etc.). However, each person is unique and reacts differently -- ideally problems can be avoided or well managed. Stay on top of changes that you experience and stay in touch with your doctor if you are concerned about something that doesn't look or feel right.

These things can happen and can be corrected with the help of your surgeon:

  • Swelling, redness or infection
  • Painful scars or excess scar tissue distorting the new breast
  • Stitching that opens before healing
  • Problems with drains (pooling blood and fluid at the mastectomy site)
  • Necrosis (circulation problems causing the skin around the implant to die)
  • Saline leakage
  • Cosmetic problems