All About Breast Reconstruction
You may be considering reconstruction of the breast either at the time of or following a mastectomy. 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, it will give you an overview of your options for postmastectomy breast reconstruction and will explain what you can expect in terms of surgical procedures and long-term results.
The fear of breast cancer is a common one for women. Not only is the risk of breast cancer in the general population relatively high, but the appearance and health of the breasts are important to women, both functionally and psychologically.
Having a mastectomy for breast cancer can be a traumatic experience for a woman particularly if she is not aware of all the options available for restoration of the breasts. Breast reconstruction can restore the appearance of the breasts, alleviate anxiety, improve body image and self-esteem, and simplify practical matters such as clothing selection and dressing.
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.
Please choose from the links below to read more about Breast Reconstruction, or scroll down the page to read all of our on-line information:
- Candidates For Reconstruction
- Types Of Mastectomies
- Radiation And Chemotherapy
- When To Begin Reconstruction
- Reconstruction Techniques
- Nipple/Areolar Reconstruction
- Opposite-Breast Surgery
- Expectations
- Unusual Or Complicated Reconstructions
- Fees And Insurance
- Selecting a Plastic Surgeon
We also have information on Cosmetic Breast Surgery.
Candidates for Breast Reconstruction
Almost any woman who is in otherwise good health and has had a mastectomy of any type is a candidate 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
- Age
- Medical History
- Location and Quality of the Surgical Scar
- Quality of the Chest Wall Skin and Muscle
- Condition and any Scars of the Abdominal Wall and Back
Please scroll down the page to read more about each of the issues listed above.
Types of Mastectomies
The type of mastectomy you have will influence the type of breast reconstruction that may be best for you.
Partial Mastectomy
A partial mastectomy removes a wide segment of breast tissue around the breast tumor. Some partial mastectomies require the removal of larger segment of breast tissue and are called quadrantectomies.
Subcutaneous Mastectomy
A subcutaneous mastectomy removes most of the breast tissue without removing any skin or the nipple. This type of mastectomy may be indicated for the treatment of some benign and malignant breast diseases.
Simple Mastectomy
A simple mastectomy removes the breast tissue, some overlying skin and the nipple/areolar area. Lymph nodes usually are not removed in a simple mastectomy.
Modified Radical Mastectomy
A modified radical mastectomy is similar to a simple mastectomy but removes the axillary (underarm) lymph nodes.
Radical Mastectomy
A radical mastectomy removes the overlying skin and nipple as well as the breast tissue and chest muscle. Once a common procedure, radical mastectomies are rarely performed today.
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.
When to Begin Reconstruction
Reconstruction at Mastectomy
Patients who are aware, prior to their surgery, of the possibility of breast reconstruction often elect to have the reconstruction started at the time of the mastectomy, with the approval of her surgeon and oncologist. About 75 percent of our breast reconstruction patients elect to begin reconstruction when the mastectomy is performed.
In general, there is no increased risk of surgical complications when reconstruction is started at the time of the mastectomy. The plastic surgeon and general surgeon must work closely together, however, to reduce the possibility of complications, since the general surgeon not only must perform a complete mastectomy but also must leave sufficient remaining healthy tissue to be used in the reconstructIon.
The most obvious advantage of immediate reconstruction is that it allows the patient to avoid an additional hospital admission. Psychologically, mastectomy patients who have immediate breast reconstruction also suffer less postmastectomy depression, because their body image remains more intact and because they have been able 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 do not see what the postmastectomy results would be without the reconstruction.
Delayed 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 on a delayed basis, which also can have its advantages.
Not only is the surgical wound completely healed with delayed reconstruction, but the patient also has had time to adjust psychologically, to complete any chemotherapy or radiation therapy that may be required, to become well informed about the reconstruction options available and to schedule reconstructive surgery conveniently.
Reconstruction Techniques
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 either 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.
Implant Techniques
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 have improved significantly in recent 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.
While the implant technique's advantages are its simplicity and the potential for a single-stage breast mound reconstruction, it also has drawbacks. Most mastectomy patients have insufficient tissue overlying a simple implant and may tend to have a relatively small breast reconstruction that may become tight or firm.
Tissue Expander Techniques
The tissue expander technique is a more recent development and has been available only since the early 1980s. It is the most common breast reconstruction technique in current use. Many mastectomy patients have a tissue expander implant placed prior to the placement of the permanent implant to stretch overlying skin. This provides a more adequate breast size and shape and a better chance of obtaining a soft breast reconstruction.
In this technique, an expandable implant is placed under the skin and muscle at the time of the mastectomy, or later if a delayed reconstruction is chosen. Initially, the tissue expander is filled with a sterile saline solution that provides some initial size and shape so the patient may begin the reconstruction process with some volume in the implant.
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 many times as necessary until the reconstruction site matches the anticipated breast volume.
When the tissue over the chest wall is fully expanded, the permanent breast implant can he placed by reopening 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 only a limited hospital stay, usually overnight.
Latissimus Dorsi Musculocutaneous Flap Technique
The latissimus dorsi musculocutaneous flap is one of two breast reconstruction techniques that can be done using some of the patient's own tissue. With this procedure, a block of skin and muscle from the patient's back is used to replace 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, however, so a small implant may be needed behind the flap to gain reasonable breast shape and size.
In addition to one-stage breast mound reconstruction, the additional tissue the latissimus dorsi flap brings also 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.
The disadvantages of this technique are that it is a more involved procedure than the tissue expansion technique, requiring more operative and hospitalization time, and that it involves an additional scar on the back, to which some patients object.
Transverse Rectus Musculocutaneous Flap
The second of the new reconstruction techniques using some of the patient's own tissue is the transverse rectus musculocutaneous flap technique (TRAM). This major advance in breast reconstruction uses the lower abdominal skin and fat to rebuild the breast.
The primary advantage of this abdominal flap technique over the latissimus dorsi flap is that the entire breast mound can be reconstructed from the patient's own tissue, usually without the need for an implant behind it. Most patients have adequate abdominal skin and subcutaneous (under the skin) fat to allow for the reconstruction of one breast, and sometimes both.
With this technique, 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 then is tunneled under the skin up to the area where the breast will be reconstructed. There it is sculpted and fashioned to form a breast mound. The abdominal incision is closed, giving the patient a result that is very similar to having an abdominoplasty (tummy tuck).
The abdominal flap lets the plastic surgeon rebuild the entire breast shape, using the patient's own tissue. This not only avoids a major second stage surgery for the reconstruction but also gives the patient a breast that will remain soft and have a consistency similar to breast tissue. It also is possible to reconstruct a full breast with the abdominal flap and to gain a normal amount of breast ptosis (breast droop) because of the quality of the tissue used.
As with other breast reconstruction techniques, the abdominal flap technique does have some trade-offs. First, it is a significantly longer operation than the implant or expansion technique and requires a longer hospital stay and recuperation. Abdominal flap patients, however, usually can have nipple reconstruction or minor revisions done secondarily on an outpatient basis, thus requiring only one hospitalization.
Not all patients are good candidates for this procedure, particularly those who are excessively overweight, who are heavy cigarette smokers, or who have had multiple abdominal surgeries and abdominal scars, which may rule out using the rectus muscle. Because the abdominal flap technique is a more extensive operation, it does carry slightly higher wound healing risks, which will be carefully explained during your plastic surgery consultation.
A Technique for Almost Everyone
As you can see, almost any mastectomy patient who desires breast reconstruction will be a candidate for one of these techniques and many patients have the opportunity to choose from several techniques.
As a candidate for reconstructive breast surgery, you will want to discuss each of these options fully with your plastic surgeon so you can be more involved in choosing the most appropriate technique for you.
Nipple/Areolar Reconstruction
The majority of mastectomy patients who have breast reconstruction surgery also have nipple/areolar reconstruction. Nipple reconstruction gives the reconstructed breast a much more natural appearance. Nipple/areolar reconstruction 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, that the patient have adequate nipple tissue on the opposite breast and be willing to have the opposite nipple used.
The other, much more common procedure for nipple reconstruction 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) may be reconstructed by using 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 the plastic surgeon's 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 to gain additional projection.
Opposite-Breast Surgery
Approximately 30 percent of breast reconstruction patients also choose to have a surgical procedure on the opposite breast to achieve the greatest degree of symmetry possible. This decision is one that should be made with the agreement of your general surgeon or oncologist.
Opposite-Breast Reduction
The most common opposite-breast procedure is breast reduction to reduce the volume of the opposite breast in a large-breasted woman. There are limitations on the size that can he achieved in the reconstructed breast, and this may be particularly true for implant-type reconstructions. 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 for breast hypertrophy (excessive development). The primary disadvantage of opposite-breast reduction is the additional surgical procedure and the resultant incision and small scars on the reduced breast. Fortunately, breast reduction can be combined with second-stage reconstruction or with any additional stages such as nipple/areolar reconstruction.
Opposite-Breast Mastopexy
Opposite-breast mastopexy is a 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 patients who are small-breasted, elect to have opposite-breast augmentation to achieve a slightly fuller breast volume that the reconstructed breast can match.
All three of these procedures - opposite-breast reduction, mastopexy and augmentation - will be discussed with you in detail by your plastic surgeon 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, when you and your physicians can better evaluate how much asymmetry may exist.
Expectations
Expectations for results in breast reconstruction will vary with each patient.
The plastic surgeon's 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, to improve a feeling of balance, and to make the fitting of clothes and dressing easier. Opposite-breast reduction is the most common such procedure. Some patients also find that a slight degree of asymmetry is acceptable and will choose not to alter the opposite breast; others elect not to follow through with nipple/areolar reconstruction.
All these are individual choices, and each patient should make this choice for herself, with information and advice from her plastic surgeon, at each step of the reconstruction process.
Unusual or Complicated Reconstructions
Most postmastectomy breast reconstruction patients have had a modified radical or simple mastectomy. However, almost any mastectomy patient who has a breast deformity can have 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 problems, but most have solutions.
Most patients who have had prior irradiation of the skin and then undergo a mastectomy will be able to have breast reconstruction, although the choices of reconstruction techniques are narrowed because the health of the post-radiation skin is not optimal. In these cases, a flap technique usually is recommended.
Patients who have nonmalignant breast disease and 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. Subcutaneous mastectomy patients can have immediate or delayed reconstruction, usually employing an implant or a tissue expander technique.
Fees and Insurance
Breast reconstruction following a mastectomy almost always is covered by health insurance policies. In fact, in some states, insurance companies and health maintenance organizations (HMO) are required by law to cover this procedure.
Coverage usually includes all phases of breast reconstruction, including multiple stages and the nipple/areolar reconstruction. Unfortunately, not all insurance companies will cover opposite-breast surgery, particularly opposite-breast augmentation and mastopexy. More companies do cover opposite-breast reduction.
Coverage and pre-approval requirements will vary with each insurance company or HMO and for different policies from the same company. It is important that you call your insurance provider beforehand for information on your individual insurance coverage.
Selecting a Plastic Surgeon
We strongly recommend that any patient considering breast reconstruction seek a fully-trained plastic surgeon who is certified by the American Board of Plastic Surgery and who has a significant degree of experience in breast reconstruction for mastectomy patients.
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 can enjoy the renewed physical and psychological well-being that usually accompany this restorative procedure.
We hope this web site has answered many of your questions about the options for breast reconstruction. We encourage you to talk with a plastic surgeon about these procedures and to ask any additional questions you may have so you can make an informed decision about the appropriateness of breast reconstruction for you.
