Breast reconstruction after mastectomy

You've been diagnosed with breast cancer, and your doctor has recommended mastectomy. Although your rational side knows that surgery makes sense — and may even save your life — you may be grappling with the emotional aspects of what it means to lose a breast.

Among your options is accepting your new appearance or wearing an artificial breast (prosthesis). Or you can choose breast reconstruction surgery.

What is breast reconstruction?

Breast reconstruction is a surgical procedure that restores shape to your breast after mastectomy. Different approaches to breast reconstruction include:

• Using breast expanders or implants
• Using your body's own tissue (autologous tissue reconstruction)
• Using a combination of tissue reconstruction and implants

Breast reconstruction is a complex procedure performed by a plastic surgeon. You may need two or more operations to achieve a correctly positioned and natural-appearing breast. However, your breasts probably won't be completely symmetrical afterward.

The breast reconstruction process can also entail reconstruction of your nipple, if you choose, including tattooing to define the dark area of skin surrounding your nipple (areola).

Finally, you may choose to have surgery on your opposite breast, even if it's healthy, so that it more closely matches the shape and size of your reconstructed breast.

Before surgery

Before a mastectomy, your doctor may recommend that you meet with a plastic surgeon. Consult a plastic surgeon who's experienced in breast reconstruction following mastectomy. Ideally, your breast surgeon and the plastic surgeon will work together to develop the best surgical treatment and breast reconstruction strategy in your situation.

Your plastic surgeon will describe your surgical options and may show you photos of women who have had different types of breast reconstruction. Your body type, health status and cancer treatment factor into which type of reconstruction will provide the best result. The plastic surgeon provides information on the anesthesia, the location of the operation and what kind of follow-up procedures may be necessary.

How is breast reconstruction done?

Breast reconstruction may be performed at the time of mastectomy (immediate reconstruction) or at a later date (delayed reconstruction). Breast reconstruction is rarely completed in one operation, so even if you choose immediate reconstruction, you'll likely face follow-up procedures later on.

Breast implants
A breast implant is a round or teardrop-shaped silicone shell, filled with salt water (saline) or silicone gel. A plastic surgeon places the implant behind the muscle in your chest (pectoral muscle) in a manner similar to what occurs during breast augmentation surgery.

Few women are able to go through a one-stage process — having the implant placed at the time of the mastectomy. Most women require a two-stage process, using a tissue expander before the permanent implant is placed.

Tissue expanders
Tissue expansion is a process that stretches your remaining chest skin and soft tissues to make room for the breast implant. The process takes place gradually, typically over several months.

Your surgeon places a tissue expander, similar to a balloon, under your pectoral muscle at the time of your mastectomy. The tissue expander has a small valve that your doctor can access by inserting a needle through your skin. Over the next few months your doctor or nurse injects saline into the valve, filling the balloon in stages. This gradual process allows the skin to stretch over time. You may experience moderate discomfort or a sensation of pressure as the implant expands.

After the tissue expansion process is complete, your surgeon performs a second surgery to remove the tissue expander and replace it with a permanent implant. Some tissue expanders are designed to be left in place permanently, so the second operation may be less extensive and require only local anesthesia.

Tissue reconstruction
Autologous tissue reconstruction is the most complex reconstructive option. Your surgeon transfers a section of skin, muscle, fat and blood vessels from one part of your body to your chest to create a new breast mound. In some cases, the skin and tissue need to be augmented with a breast implant to achieve the desired breast size.

One of two surgical methods is used:

• Pedicle flap surgery. The surgeon cuts some of the blood vessels nourishing the tissue to be transferred but keeps other blood vessels intact. Tunneling the tissue beneath your skin to your chest area, the surgeon then creates the new breast mound or pocket for the implant.
• Free flap surgery. The surgeon disconnects the tissue completely from its blood supply and uses microsurgical techniques to reattach the tissue flap to new blood vessels near your chest. Because of the intricate nature of reattaching blood vessels, free flap surgery typically takes longer to complete than does pedicle flap surgery.

Tissue expansion

Tissue expansion

During tissue expansion, a balloon inserted under your chest muscle is gradually filled with saline over a period of several weeks or months. The gradual inflation of the balloon stretches the skin and tissue over your chest to make room for an implant.

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Types of flap surgery by area of muscle and tissue used

The tissue for reconstructing your breast may come from your abdomen, back or — less commonly — your buttocks. Your surgeon determines which method is best for you based on your body type and your medical and surgical history.

• Abdomen (TRAM flap). Your surgeon removes tissue — including muscle — from your abdomen in a procedure known as a transverse rectus abdominal muscle (TRAM) flap. The abdominal portion of this procedure is similar to a tummy tuck (cosmetic abdominoplasty); however, the muscle is moved instead of tightened. The TRAM flap can be transferred as a free flap or a pedicle flap.

  A pedicle TRAM flap is the only procedure that uses your whole rectus muscle — one of the four major muscles in your abdomen. If your surgeon performs a free TRAM flap, only a portion of your rectus abdominal muscle is taken. In some instances, that portion of muscle may be very small. This is known as a muscle-sparing free TRAM procedure. Using less of your muscle for reconstruction may help you retain abdominal strength after surgery.

• Abdomen (DIEP flap). Another type of abdominal procedure is the deep inferior epigastric perforator (DIEP) flap. This newer procedure is almost the same as a muscle-sparing free TRAM flap, but skin and fat are the only tissues removed. Minimal abdominal muscle tissue is taken to form the new breast mound. A DIEP flap uses a free flap approach. An advantage to this type of breast reconstruction is that you'll retain more strength in your abdomen. If your surgeon can't perform a DIEP flap procedure for anatomical reasons, he or she might opt for the muscle-sparing free TRAM flap instead.
• Back (latissimus dorsi flap). Another surgical technique takes tissue — including skin, fat and muscle — from your upper back. This is called a latissimus dorsi flap. The tissue is tunneled under your skin to your chest. Because the amount of skin and other tissue is generally smaller than in a TRAM flap surgery, this approach may be used for reconstructing small and medium-sized breasts or for creating a pocket for a breast implant. Although it's not very common, some women experience muscle weakness in the back, shoulder or arm after this surgery.
• Buttocks (gluteal flap). A gluteal flap is a free flap procedure that takes tissue — possibly including muscle — from your buttocks and transplants it to your chest area.

Because adequate blood supply is critical to the survival of transplanted tissue in flap surgery, your surgeon may prefer not to perform a pedicled flap procedure if you're a smoker or you have diabetes, vascular disease or a connective tissue disorder. Also, obesity may preclude you from having a pedicled TRAM flap.

In general, autologous breast reconstruction is more extensive than is a mastectomy or implant reconstruction. Flap procedures result in larger incisions that take longer to heal, but the overall time to complete the breast reconstruction process may be shorter.

TRAM flap

TRAM flap

In a pedicled TRAM flap procedure, the surgeon cuts a section of skin, muscle, fat and blood vessels from your abdomen, tunnels the tissue underneath your skin to its new location and uses it to form a new breast mound.

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Latissimus dorsi flap

Latissimus dorsi flap

In this flap procedure, the surgeon takes tissue from the latissimus dorsi muscle in your back, tunnels it underneath your skin to its new location and uses it to form a new breast mound.

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Recovery

Depending on the type of breast reconstruction procedure performed, you may be tired and sore for weeks to months after your surgery. Your doctor can prescribe medication to control your pain. You may have drainage tubes in place for a short time after your surgery to remove excess fluids that collect in your breast tissue. The drainage tubes remain in place until the amount of fluid draining substantially decreases.

You'll also have stitches (sutures) in place after your surgery. They'll probably be absorbable sutures, though, so you won't need to have them removed. Scarring is permanent, but the scars generally fade over time.

Getting back to normal activities may take up to six weeks or more, depending on the type of procedure performed. Take it easy during this period. Your doctor will let you know of any restrictions to your activities, such as avoiding overhead lifting or strenuous physical activities. Don't be surprised if it seems to take a long time to bounce back from surgery — some women report that it took as long as a year or two before they felt completely healed and back to normal.

If you've only had one breast reconstructed, you'll need to have screening mammography done regularly on your other breast. Mammography isn't usually necessary on breasts that have been reconstructed, as the mastectomy removes most of your breast tissue. You may opt to perform breast self-exams on your natural breast and the skin and surrounding area of your reconstructed breast.

Nipple reconstruction

After you've had time to heal and your newly formed breast has settled into shape, you might consider nipple reconstruction.

The surgeon measures and marks a nipple location that's symmetrical to your other breast. The surgeon reconstructs your nipple using tissue from the breast itself or from skin taken from another part of your body, such as your inner thigh. Tattooing the skin makes it more closely match your natural nipple and areola.

Not all women choose to have nipple reconstruction. Whether or not you want to have this done is up to you.

Nipple reconstruction

Nipple reconstruction

After your breast has healed from reconstruction or mastectomy surgery, a plastic surgeon can reconstruct a new nipple and areola. The surgeon makes a star-shaped incision to form the new nipple and then adds a tattoo to shade in the new areola.

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Risks

Breast reconstruction carries the possibility of significant complications — whether you choose breast implants or tissue reconstruction. Breast implants aren't lifelong devices. There's a strong possibility of future surgery to replace or remove the implant. Also, with breast implants, you could experience complications such as infection, implant rotation and capsular contracture — scar tissue that forms and compresses the implant and breast tissue into a hard, unnatural shape. Correcting any of these complications may require additional surgery.

Tissue reconstruction is a major procedure. It prolongs your time in surgery and extends your recovery time by several weeks. In addition, poor wound healing, hernia, a collection of fluid (seroma), infection or tissue death — due to insufficient blood supply — are all possible complications.

Set realistic expectations

Make sure you have realistic expectations for the outcome of your surgery. Understand what breast reconstruction surgery can do for you, but also be aware of what it won't do for you.

What breast reconstruction can do:

• Give you a breast contour
• Provide improved symmetry to your breasts so that they look similar under clothing or a bathing suit
• Help you avoid the need for an external prosthesis

What breast reconstruction may do:

• Improve your self-esteem and body image
• Partially erase the physical reminders of your disease
• Require additional surgery to correct reconstructive problems

What breast reconstruction won't do:

• Make you look exactly the same as before
• Give your reconstructed breast the same sensations as your normal breast

Chances are your new breasts won't look exactly like your natural ones used to. However, the contour of your new breasts can usually be restored so that your silhouette will look similar to your silhouette before surgery.