If you or someone you care about is considering reconstruction of the breast, we hope this breast reconstruction information will be helpful to you. Although this web site is not a substitute for a full office consultation with a plastic surgeon, we hope it gives you an overview of your options for Post-Mastectomy Breast Reconstruction and what you can expect in terms of surgical procedures and long-term results.
BREAST RECONSTRUCTION AFTER CANCER
Having a mastectomy for breast cancer can be a traumatic experience. We want to make sure you are aware of all the options available for restoration of the breasts and to reassure you about the positive results and benefits of breast reconstruction.
Modern breast reconstruction began in the 1960s with the development of the silicone breast implant. Four decades of research have resulted in a variety of breast reconstruction techniques and surgical procedures that are safer and more reliable than ever.
WHO IS A CANDIDATE FOR BREAST RECONSTRUCTION?
Most women who have had a mastectomy and are in otherwise good health, are candidates for breast reconstruction. Factors that influence the selection of a reconstruction technique include:
- The type of mastectomy performed
- The use of radiation and/or chemotherapy
- Medical history
- Location and quality of the surgical scar
- Quality of the chest wall skin and muscle
- The condition of any scars on the abdominal wall and back
There are many approaches to breast reconstruction, so a patient who desires breast reconstruction is likely to be a candidate for at least one of these techniques. Many patients will benefit from a combination. As a candidate for reconstructive breast surgery, you will want to discuss all the appropriate options fully with your plastic surgeon.
WHAT IS THE TIMELINE FOR RECONSTRUCTION?
Reconstruction at time of mastectomy: Patients who are aware, prior to their surgery, of the possibility of breast reconstruction often elect to have the procedure started at the time of the mastectomy, with approval from the surgeon and oncologist. About three-fourths of our patients elect to begin breast reconstruction when the mastectomy is performed. Since the general surgeon must perform a complete mastectomy and also leave sufficient remaining healthy tissue to be used in the reconstruction, the plastic surgeon and general surgeon must work closely together.
The most obvious advantage of immediate reconstruction is that it allows you to avoid an additional hospital admission. Psychologically, mastectomy patients who have immediate breast reconstruction also experience less post-mastectomy depression, because their positive body image is retained. They also have the opportunity to balance the diagnosis of breast cancer against information about the positive aspects of breast reconstruction. Mastectomy patients who begin immediate reconstruction, however, sometimes have unrealistically high expectations about the results because they cannot see what the post-mastectomy results would be without reconstruction.
While patients who already have had a mastectomy cannot choose to have immediate reconstruction, they still are candidates for many of the same reconstructive techniques later on. Waiting has its own advantages. Not only is the surgical wound completely healed with delayed reconstruction, but the patient has had time to adjust psychologically, to complete any chemo or radiation therapy, to explore all the appropriate reconstruction options available and to schedule reconstructive surgery conveniently.
Radiation and Chemotherapy
Both radiation therapy and chemotherapy can influence the type and timing of breast reconstruction. Radiation therapy affects the quality of the skin and may rule out or lend itself more easily to certain reconstructive procedures. Patients who are having chemotherapy may have to postpone the start or completion of reconstructive surgery until the chemotherapy is completed.
BREAST RECONSTRUCTION: THE PROCESS
For most patients, breast reconstruction will require two to three surgical procedures. The first, and most involved, procedure is the primary reconstruction of the breast mound or breast shape, which may be done in any of several ways. The second procedure usually consists of additional work on the breast shape or the placement of the permanent implant. Any procedures needed to make the opposite breast more similar to the affected breast also would be done at this time. The final step usually is the nipple/areolar reconstruction. Location of the nipple/areolar area is critical to breast appearance and must be done after all other reconstructive stages are completed.
Breast implants have been available for breast reconstruction and augmentation since the early 1960s. More than two million women in the United States have had breast implants inserted. Both the implants and the techniques for placement are highly refined and have been proven to be both safe and successful over the years. Today there are a variety of implants in terms of type, filling solution and surface texture. During your office consultation, we will provide you with a complete package of information on the history, technology, safety and types of implants.
Some patients are good candidates for simple implant placement, either at the time of the mastectomy or later. The implant technique is done by developing a pocket under the chest wall muscle (pectoralis muscle) to protect the implant and to provide soft tissue coverage over the implant. The primary advantage of this implant technique is its simplicity. Many mastectomy patients unfortunately have insufficient tissue for this procedure.
Tissue Expander Technique
This is the most common breast reconstruction technique in current use. It provides more control over breast size and shape, and a better chance of obtaining a soft breast reconstruction. Initially, an expandable implant is placed under the skin and muscle at the time of the mastectomy, or later if delayed reconstruction is chosen. Initially, the tissue expander is filled with a sterile saline solution. This stretches the skin and provides some initial size and shape. Over a period of several months, sterile water is gradually added to the implant through a small valve attached to the implant. This procedure takes about five minutes in the physician’s office. The tissue expander can be filled as often as necessary until the reconstruction site matches the optimal breast volume.
When the tissue over the chest wall is fully expanded, the permanent breast implant can he placed by re-opening the mastectomy surgical scar and exchanging the tissue expander for the permanent implant. Additional work may be done to improve the shape of the breast at this stage. Both stages of the tissue expander technique are relatively simple procedures that require, at most, an overnight hospital stay.
Latissimus Dorsi Musculocutaneous Flap Technique
In this procedure, a block of skin and muscle from the patient’s back is used to replace the skin and muscle removed during the mastectomy. This technique makes a one-stage breast mound reconstruction possible for most patients because it does not require tissue expansion. The latissimus dorsi flap usually does not carry much tissue bulk with it, so a small implant is often inserted behind the flap to regain the desired breast shape and size.
In addition to one-stage breast mound reconstruction, the additional tissue brought by the latissimus dorsi flap provides most patients with adequate tissue for a full breast reconstruction. This is an advantage for patients who have extremely tight chest wall skin, those who have had a full radical mastectomy with missing pectoralis muscle, and those who have had radiation following a mastectomy. This is, however, a more involved procedure than tissue expansion and it requires more surgery and hospitalization time. It also results in an additional scar on the back.
Transverse Rectus Musculocutaneous Flap
This technique reflects a major advance in breast reconstruction. It uses the lower abdominal skin and fat to rebuild the breast. The primary advantage of the abdominal flap technique is that the entire breast mound can generally be reconstructed from the patient’s own tissue, without the need for an implant. Most patients have adequate abdominal skin and fat to allow for the reconstruction of one breast.
In this procedure, the surgeon elevates a large block of tissue from the lower abdominal area but leaves it attached to one of the two rectus muscles in the abdominal wall. This tissue is then tunneled under the skin up to the area where the breast will be reconstructed. It is then sculpted and fashioned to form a breast mound. When abdominal incision is closed, the result is similar to an Abdominoplasty (tummy tuck). This approach not only avoids a major second stage surgery for reconstruction, but also results in a soft breast consistency, similar to breast tissue.
Not all patients are good candidates for this procedure, particularly those who are excessively overweight, heavy cigarette smokers or who have had multiple abdominal surgeries and abdominal scars. Because the abdominal flap technique is a more extensive operation, it does carry slightly higher wound healing risks and requires longer hospitalization and recuperation.
The majority of mastectomy patients who have breast reconstruction surgery also have nipple/areolar reconstruction. Nipple reconstruction gives the breast a natural appearance. It is a relatively simple procedure that is done on an outpatient basis under either sedation or a light general anesthetic. Nipple reconstruction may involve using local tissue from the reconstructed breast or sharing tissue from the opposite normal nipple. This tissue sharing procedure provides the best color and texture match with the opposite breast. It is necessary, however, for the patient to have adequate nipple tissue on the opposite breast and be willing to have the opposite nipple used.
The more common procedure is to create a nipple from a small flap of tissue on the reconstructed breast mound once the markings for the location have been completed. The areolar area (the pigmented skin surrounding the nipple) is reconstructed with a skin graft from one of several sites. Donor sites for areolar grafts will vary with each patient depending on color match and patient preference. Generally a site that has some degree of color match with the opposite breast areolar area will be selected. The most common sources for the skin graft are the groin crease, the lower abdominal wall skin and, sometimes, the extra skin along the outside of the mastectomy scar.
Once the nipple/areolar reconstruction is completed and healed, the color match with the opposite breast will be reviewed. If the color match is not exact, as is usually the case, a simple tattooing procedure is done in our office to gain the best color match. This tattooing is a relatively painless and simple procedure and, for some patients, may be substituted for the areola grafting procedure. Finally, in some patients, a small implant may be placed under the completed nipple/areolar reconstruction for additional projection.
Approximately 30 percent of breast reconstruction patients have surgery on the opposite breast in order to maximize symmetry. When there is a significant difference between the size of the reconstructed and the opposite breast, many women choose to have the opposite breast reduced. Opposite-Breast Reduction is done in exactly the same way as ordinary breast reduction. The primary disadvantage of opposite-breast reduction is the additional surgical procedure and the resulting incisions and small scars on the reduced breast. Fortunately, breast reduction can be combined with second-stage reconstruction or nipple/areolar reconstruction.
Opposite-Breast Mastopexy: In this breast-lifting procedure, the breast volume is not altered, but the breast ptosis, or droop, is corrected by lifting the breast to give it a more youthful shape and higher position on the chest wall. This procedure is particularly helpful for mastectomy patients who have lost a significant amount of weight or who have had multiple pregnancies.
Opposite-Breast Augmentation: Some mastectomy patients, especially younger ones who are small-breasted, elect to have opposite-breast augmentation to achieve a slightly fuller breast volume that can match the reconstructed breast.
All three of these procedures – opposite-breast reduction, mastopexy and augmentation – will be discussed with you in detail prior to breast reconstruction. However, final decisions on the use of one or more of these procedures may be delayed until the first stage of breast reconstruction has been completed, and you and your physicians can better evaluate how much asymmetry may exist.
WHAT TO EXPECT
Expectations for results in breast reconstruction will vary with each patient. Our goal is to create a soft breast that has good shape and is reasonably symmetrical with the opposite breast. This is easier to achieve for some patients than others. The results depend upon the way the individual patient heals, the type of mastectomy, the reconstruction technique chosen and the patient’s existing tissue and opposite breast. All mastectomy patients should expect to lose some sensation over the chest wall, underarm and inner arm areas. While reconstruction will not improve sensation in these areas, it should not lessen it. Most patients can expect a breast volume that approximately matches the opposite breast, although there are some limitations on the size of a reconstructed breast.
Symmetry is a primary goal in breast reconstruction, but can only be obtained in some patients by altering the opposite breast. About 30 to 40 percent of mastectomy patients will choose opposite-breast surgery in order to match the shape and volume of the reconstructed breast. This improves appearance and sense of balance and makes the fitting of clothes and dressing easier. Some patients also find that a slight degree of asymmetry is acceptable and will choose not to alter the opposite breast. Some elect not to follow through with nipple/areolar reconstruction.
ABOUT COMPLICATED RECONSTRUCTIONS
Almost any mastectomy patient, however, can pursue breast reconstruction. This includes patients who have had prior radiation therapy, some other breast surgery complication or a congenital breast deformity. Each of these situations presents its own special complications, but most have solutions.
The choices of reconstruction techniques are narrowed for patients who have had prior irradiation of the skin. In these cases, a flap technique usually provides optimal results.
Patients who have non-malignant breast disease with a resulting subcutaneous mastectomy, present one of the greatest challenges for breast reconstruction, even though neither the skin nor the nipple/areolar area have been removed. An implant or a tissue expander technique provide best results when a subcutaneous mastectomy has been performed.
FEES AND INSURANCE
Breast reconstruction following a mastectomy generally is covered by health insurance policies. Coverage usually includes all phases of breast reconstruction including the nipple/areolar reconstruction. Unfortunately, not all insurance companies will cover opposite-breast surgery, particularly opposite-breast augmentation and mastopexy. Most companies do cover opposite-breast reduction. Coverage and pre-approval varies with each insurance company or HMO and for different policies – even from the same company. It is important that you call your insurance provider beforehand for information on your individual insurance coverage for breast reconstruction following mastectomy.
SELECTING A PLASTIC SURGEON
Breast reconstruction following a mastectomy has been a major advance in the treatment of patients with breast cancer. With today’s mastectomy and plastic surgery techniques, almost all mastectomy patients can have breast reconstruction and enjoy the physical and psychological benefits that usually accompany this restorative procedure.
It is strongly recommended that any patient considering breast reconstruction seek a fully-trained plastic surgeon who is certified by the American Board of Plastic Surgery and has significant experience in breast reconstruction for mastectomy patients. We invite you to call us for a free consultation anytime.
We hope we have answered many of your questions about the options for breast reconstruction and we encourage you to talk to us about these procedures. We will do everything we can to help you make an informed decision about the ideal breast reconstruction approach for you.