Breast Reconstruction

Some women with breast cancer have treatment that includes removal of one or both breasts. These procedures are referred to as a mastectomy or a double mastectomy. In addition, some women who are at high risk of developing breast cancer choose to reduce their risk by having a preventive (prophylactic) double mastectomy.

These women, along with some women who have a lumpectomy (breast conservation) to treat their cancer, may decide to explore breast reconstruction — surgery to rebuild the breast to restore its shape and size. Not all women choose to have breast reconstruction; some prefer to leave their chest or breast as is.

The reconstruction procedure may also include creating a new nipple and areola (dark area around the nipple). In other cases, depending on where the tumor is, a woman may be able to have a “nipple-sparing” surgery.

Breast reconstruction can begin at the same time as the mastectomy. This is referred to as “immediate reconstruction.” Or, the reconstruction can begin at a later date. This is called “delayed reconstruction.” It is important to discuss reconstruction options with at least one breast or plastic surgeon before your mastectomy, so that you can decide if you want to have reconstruction and, if so, when you want to have the procedure begin.

The four surgical approaches typically used to restore the shape of the breast are:

• Use of an implant. The implant can be filled with saline (a substance similar to salt water) or a silicone gel.
• 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

Breast reconstruction is not the right choice for every woman. You may see reconstruction as a tool to help you feel whole again, or you may feel like you would be fine without having the additional surgeries. It’s also possible that you will learn that breast reconstruction is not an option because of the stage of your cancer or due to other health issues. Before considering reconstruction, it’s important to take a moment to prioritize what’s important to you when considering whether to have breast reconstruction after cancer.

Ask your breast or plastic surgeon to show you pictures of the results of the different types of reconstruction that you are considering or show you how mastectomy scars look without reconstruction. These visual images may help you have a better idea of what you will look like after the surgery. The most important thing to remember is that there is no right decision. The only decision that is right is the one that is right for you.

If you are interested in reconstruction, you’ll want to make sure that you learn about all of your options by meeting with at least one breast or plastic surgeon. If you want to have reconstruction begin at the same time as you have your mastectomy, you will need to discuss this with surgeon before you have your mastectomy. Your surgeon will also need to be in contact with your medical oncologist and your radiologist to make sure immediate reconstruction will work well with your overall treatment plan.

Learn About Types of Breast Reconstruction

There are two types of implants used for reconstruction: a saline implant and a silicone-gel filled implant. Ask your surgeon for a sample of both types. This will allow you to feel them and get a sense their similarities and differences. There are two methods of implant reconstruction:

• Direct to Implant: This surgery 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. Additional surgery may be needed for aesthetic reasons or for nipple reconstruction.
• Expander to Implant: This surgery is done in two stages. During the mastectomy, the surgeon puts in a tissue expander under the skin and muscle where the breast was removed. The tissue expander is like a balloon, and it allows your body to slowly create space under your skin for an implant. Saline is inserted into the expander at the time of the mastectomy and more is gradually added through a small valve in the implant every few weeks, for up to six months. Women have said that the 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

The U.S. Food and Drug Administration (FDA) has determined that most silicone filled implants are safe for breast reconstruction or enhancement. Discuss any concerns you have about implants with your doctor. Also, your doctor should explain to you that any implant—whether it is made from saline or silicone—may need to be replaced with surgery at some point in your lifetime. That’s because implants can leak or tear, cause an infection, or develop scar tissue. All these problems can be managed effectively by your doctor.

More on breast implant safety is available at:

• FDA (Food and Drug Administration)
• National Cancer Institute: Breast Implant Study Fact Sheet

Timing of Reconstruction

Your breast or plastic surgeon may recommend immediate reconstruction (during your cancer surgery) or delayed reconstruction (after you have healed from your cancer surgery. Some women delay their reconstruction for months, or years.

There are several factors to take into account when thinking about whether to begin reconstruction at the same time as your mastectomy or delay it for a later date. If radiation therapy is or was part of your treatment plan, you should ask about the best timing for reconstruction to reduce damage to the reconstructed breast (radiation reduces the elasticity of skin tissue and can impact reconstruction). Also, if you smoke, most surgeons will require that you stop before you begin reconstructive surgery, which will require you to have delayed reconstruction.

Advantages to immediate reconstruction include potentially more chest tissue to support reconstruction because there is no surgical scarring or damage from radiation therapy (unless you had that earlier in your life), less surgery and exposure to general anesthesia, ability to recover from everything at the same time, and less dramatic physical changes after a mastectomy.

Advantages to delayed reconstruction including giving you more time to adjust emotionally to a cancer diagnosis, recover from your mastectomy, and research your reconstruction options. For women who smoke, are overweight, or have diabetes, their health care team may ask them to wait on breast reconstruction to avoid surgical risks and complications. Your doctors may also advise you to wait for reconstruction because the added healing time may delay your ability to start systemic treatment.

Planning for Surgery

Before surgery, your health status will be assessed. Tell your doctor or nurse about all medicines that you take, including prescription drugs, over-the counter medicines, and vitamins and herbal supplements. You may need to stop some or all of your medicines.

Exercise, get plenty of rest, and eat well so that you will be as healthy as possible before surgery. If you smoke, you should stop. Some surgeons will not perform breast reconstruction procedures on smokers because surgical wounds may not heal as well; this can also delay other forms of treatment you may need.

Your recovery period can be more comfortable if you think about and prepare for your needs before you return home. Planning meals in advance or lining up assistance from family or friends, for example, is helpful. You will not be able to lift heavy items (a rule of thumb is nothing heavier than an old phonebook) so gallon jugs of milk or large bags of pet food should be put in smaller containers. In most cases, you will not be able to raise your arms above your head right away, so soft, oversize or front button-down shirts will be most comfortable. This discomfort will go away over time with exercise.

The first phase of the healing process for reconstructive surgery takes at least 4–6 weeks and you might feel tired and sore. When a woman opts for immediate reconstruction, she may recover 4-6 weeks faster than a woman who opts for delayed reconstruction. More than one operation may be required to complete the process or achieve the result you want.