The type of breast reconstruction procedures available to you depends on your
medical situation, breast shape and size, general health, lifestyle, and goals.
You can have your breast reconstructed with a breast implant, a tissue flap
(your own tissues), or a combination of the two. If you have breast reconstruction,
with or without breast implants, you will probably undergo several reoperations
to improve symmetry and appearance.
For example, after your breast has healed from the original implant surgery,
you may want to build a new nipple and darken the areola (skin around the nipple).
This procedure can usually be performed on an outpatient basis. Ask your doctor
to explain the various ways this can be done, such as using a skin graft from
the opposite breast or by tattooing the area. Ask your doctor about the pros
and cons of each implant technique. If you decide to have reconstruction for
one breast, your doctor may suggest surgery on the other breast to achieve a
similar appearance.
The following issues should be considered for women with breast cancer:
- The physical and cosmetic results with breast implants may be affected by
chemotherapy, radiation therapy, or any other factor that significantly affects
the healing process.
- Skin necrosis may occur because blood circulation to the remaining tissue
has been changed by a mastectomy. Radiation treatment may also increase skin
necrosis.
- It usually takes more than one operation to achieve the desired cosmetic
outcome, especially if the reconstruction procedures include building a new
nipple.
- Breast reconstruction is an optional procedure and is not needed to treat
the cancer.
Breast Reconstruction with Breast Implants
The following information applies to reconstruction following mastectomy. However,
similar considerations apply to reconstruction for breast trauma or congenital
defects.
Your doctor will decide whether your health and medical condition makes you
an appropriate candidate for breast reconstruction with breast implants. Women
with larger breasts may require reconstruction with a combination of a tissue
flap and an implant.
Your doctor may recommend a breast implant, reduction mammoplasty (breast reduction),
or a mastopexy (breast lift), of your opposite, uninvolved breast to improve
symmetry with your reconstructed breast. Reduction mammoplasty involves removal
of breast tissue and skin. 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. If it is important to you not to alter the unaffected breast,
you should discuss this with your doctor because it may affect the breast reconstruction
procedures considered for your case.
The breast reconstruction process may begin at the time of your mastectomy
(immediate reconstruction) or weeks to years afterwards (delayed reconstruction).
Immediate reconstruction is one-stage or two-stage reconstruction.
- 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 insert a breast implant under the skin where breast tissue was removed.
- Two-stage reconstruction is more typical. The first stage is a breast tissue
expander placed, at the time of your mastectomy, to stretch your skin and
create a pocket for a breast implant. Tissue expansion typically lasts four
to six months. The tissue expander is then replaced several months later with
a breast implant. This is considered immediate reconstruction because the
tissue expander is placed at the time of mastectomy.
Delayed reconstruction is a two-stage reconstruction starting
with a breast tissue expander placed months or years later, which is then replaced
several months later with a breast implant. This is considered delayed reconstruction
because the tissue expander is placed after the mastectomy site has healed.
It is important to know that the one and two-stage references do not
mean the number of surgeries involved. You should expect that any type of breast
reconstruction will take several steps to complete. It could take months to
years before your reconstruction is complete.
Two potential advantages to immediate reconstruction are that your breast reconstruction
starts at the time of your mastectomy and that you may save money when you combine
the mastectomy with the first stage of the reconstruction. However, with immediate
reconstruction, there may be a higher risk of complications, such as rupture/deflation,
as well as longer initial operation and healing times.
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.
There are medical, financial, and emotional considerations to choosing immediate
versus delayed reconstruction. You should discuss the pros and cons with the
options available in your individual case with your surgeon, plastic surgeon,
and oncologist.
Breast Reconstruction with Tissue Flaps
The breast can be reconstructed by surgically moving a section of skin, fat,
muscle, and blood vessels from one area of your body to another. The tissue
may be taken from such areas as your lower abdominal area, upper back, or buttocks.
The most common types of tissue flaps are:
- the TRAM (transverse rectus abdominus musculocutaneous) flap that uses tissue
from the lower abdominal area
- the Latissimus Dorsi flap that uses tissue from the upper back.
Flap surgery has the advantage of using your own tissue to construct a new
breast. However, it is important for you to be aware that flap surgery, particularly
TRAM flap surgery, is a major operation and more extensive than your mastectomy
operation or breast implant surgery. It requires good general health and strong
emotional motivation. If you are very overweight, smoke cigarettes, have had
previous surgery at the flap site, or have any circulatory problems, you may
not be a good candidate for a tissue flap procedure. Also, if you are very thin,
you may not have enough tissue at the flap site to construct a breast mound.
Tissue flaps, in general, can be moved to the reconstruction site by one of
two methods. The first method is when the flap is left attached to the muscle
and blood vessels and tunneled under the skin to the reconstruction site. The
second method is when the flap is completely removed and then transferred to
the reconstruction site and reattached by microsurgery. More specifically, the
TRAM flap can be done by either of these two methods while the Latissimus Dorsi
flap procedure involves only the first method. In addition, for TRAM flap surgery,
your surgeon may also need to build you a new belly button after the lower abdominal
area is reshaped.
Flap surgery requires a hospital stay of several days and generally a longer
recovery time than breast implant reconstruction. While you can resume normal
daily activity after several weeks, some women report that it takes up to one
year to resume a normal lifestyle.
Flap surgery also creates scars at the site where the flap was taken and possibly
additional scars on the reconstructed breast. You may also have some temporary
or permanent decreased muscle strength at the flap site.
As a special note regarding the TRAM flap procedure, if you are considering
pregnancy after your reconstruction, you should discuss with your surgeon how
this procedure may affect your abdominal muscle strength. In addition, although
abdominal tissue feels like breast tissue to the touch, the nerves are cut during
the surgery, so there may be little feeling or sensitivity in your breast. Also,
you should know that a surgeon can take tissue from your abdomen only once.
If you later need a mastectomy of your second breast and want to have a tissue
flap procedure, then the tissue will have to come from another site, such as
your back.
