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Breast Reconstruction

Breast reconstruction is a type of surgery for women who have had all or part of a breast removed.

The surgery rebuilds the breast mound to match the size and shape of the other breast. The nipple and areola can also be added.

Hospital Stay: Hospital Stay: 3 days
Duration: Duration: 1-6 hrs
Cost Estimate: Cost Estimate: 6000 USD - 7500 USD These are indicative prices in Indian Hospitals

Women choose breast reconstruction for many reasons after mastectomy:

  • To make their chest look balanced when they are wearing a bra or swimsuit
  • To permanently regain their breast shape
  • So they don’t have to use a form that fits inside the bra (an external prosthesis)
  • To be happier with their bodies and how they feel about themselves

Surgery

Breast reconstruction often leaves scars that can be seen when you’re naked, but they often fade over time. Newer techniques have also reduced the amount of scarring. When you’re wearing a bra, the breasts should be alike enough in size and shape to let you feel comfortable about how you look in most types of clothes.

Breast reconstruction has been shown to improve body image and self-esteem when compared to no reconstruction. There are often many options to think about as you and your doctors talk about what’s best for you. The reconstruction process sometimes means more than one operation.

Immediate or delayed breast reconstruction

Immediate breast reconstruction is done, at the same time as the mastectomy. The benefit of this is that breast skin is often preserved, which can produce better-looking results. Women also do not have to go without the shape of a breast.

While the first step in reconstruction is often the major one, many steps are often needed to get the final shape. If you’re planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take.

Delayed breast reconstruction means that the rebuilding is started later. This may be a better choice for some women who need radiation to the chest area after the mastectomy. Radiation therapy given after breast reconstruction surgery can cause problems like delayed healing and scarring.

Decisions about reconstructive surgery also depend on many personal factors such as:

  • Overall health
  • The stage of breast cancer
  • The size of natural breast
  • The amount of tissue available
  • Whether you want reconstructive surgery on both breasts
  • The type of procedure
  • The size of the implant or reconstructed breast
  • Desire to match the look of the other breast

Types of breast reconstruction

Several types of operations can be done to reconstruct the shape of your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of both. (A tissue flap is a section of your own skin, fat, and in some cases muscle which is moved from another area of your body to your chest.)

Implant procedures

Types of implants

Implants have a silicone shell filled with either silicone gel or salt water (saline).

Silicone gel-filled implants are one option for breast reconstruction. Most of the recent studies show that silicone implants do not increase the risk of immune system problems, and the FDA (Food and Drug Administration) has approved silicone implants since 2006.

Some newer types use thicker silicone gel, called cohesive gel. The thickest ones are sometimes called “gummy bear” implants and are made of highly cohesive silicone. They are more accurately called form-stable implants, meaning that they keep their shape even if the cover is cut or broken.

Alternative breast implants that have different shells and are filled with different materials are being studied, but you can only get them when they are available in clinical trials.

Types of implant surgery

One-stage immediate breast reconstruction is also called direct-to-implant reconstruction. For this, the final implant is put in at the same time as the mastectomy is done. After the surgeon removes the breast tissue, a plastic surgeon places a breast implant. The implant is usually put beneath the muscle on your chest. A special type of graft or an absorbable mesh is used to hold the implant in place, much like a hammock or sling.

Two-stage reconstruction means that a short-term tissue expander is put in after the mastectomy. The expander is a balloon-like sac that’s slowly expanded to the desired size to allow the skin flaps to stretch. It’s used when the surgeon believes that the mastectomy skin flaps are not healthy enough to support a full-sized implant right away. Through a tiny valve under the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over a period of about 2 to 3 months. After the skin over the breast area has stretched enough, a second surgery will remove the expander and put in the permanent implant. Some expanders are left in place as the final implant.

The two-stage reconstruction is sometimes called delayed-immediate reconstruction because it allows time for other treatment options. If radiation therapy is needed, the final placement of the implant is put off until radiation treatment is complete. If radiation is not needed, the surgeon can start right away with the tissue expander.

Considerations about implants

Keep these important factors in mind if you are thinking about having implants to reconstruct the breast and/or to make the other breast match the reconstructed one:

  • You may need more surgery to remove and/or replace your implant later. In fact, up to half of implants used for breast reconstruction have to be removed, modified, or replaced in the first 10 years.
  • You can have problems with breast implants. They can break or cause infection or pain. Scar tissue may form around the implant, which can make the breast harden or change shape, so that it no longer looks or feels like it did just after surgery. Most of these problems can be fixed with surgery, but others might not be reversible.
  • MRIs may be needed every few years to make sure silicone gel implants have not broken.
  • Routine mammograms to check your remaining breast for cancer will be more difficult if you have a breast implant there – you’ll need more x-rays of the breast, and the compression may be more uncomfortable.
  • An implant in the remaining breast could affect your ability to breastfeed, either by reducing the amount of milk or stopping your body from making milk.

Tissue flap procedures

These procedures use tissue from your tummy, back, thighs, or buttocks to rebuild the breast shape. The most common types of tissue flap procedures are from the lower abdomen called TRAM – transverse rectus abdominis muscle flap or DIEP – deep inferior epigastric perforator flap, and the latissimus dorsi flap, which uses tissue from the upper back. Other tissue flap surgeries described below are more specialized, and may not be done everywhere.

These operations leave 2 surgical sites and scars – one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but never go away. There can be donor site problems such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue’s blood supply, flap procedures can cause more problems in smokers, and in women who have uncontrolled diabetes, vascular disease or connective tissue diseases.

In general, flaps require more surgery and a longer recovery. But when they work well, they look more natural and behave more like the rest of your body. There’s also no worry about implant replacement or rupture.

  • Abdominal flaps: TRAM and DIEP

    The TRAM (transverse rectus abdominis muscle) flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). Some women have enough tissue in this area to shape the breast, so an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower belly, or a “tummy tuck.”
    The DIEP (deep inferior epigastric perforator) flap uses fat and skin from the same area as the TRAM flap but does not use the muscle to form the breast shape. This results in less skin and fat in the lower belly, or a “tummy tuck.” This method uses a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest. As in the free TRAM surgery, a microscope is needed to connect the tiny blood vessels. There’s less risk of a bulge or hernia because no muscle is taken.

  • Latissimus dorsi flap

    The latissimus dorsi flap tunnels muscle, fat, skin, and blood vessels from your upper back, under the skin to the front of the chest. This provides added coverage over an implant and makes a more natural-looking breast than just an implant alone. It can sometimes be used without an implant. It’s a very reliable flap and can even be used in women who smoke. Though it’s not common, some women have weakness in their back, shoulder, or arm after this surgery.

  • Gluteal free flap

    The Gluteal free flap or GAP (gluteal artery perforator) flap is newer type of reconstruction surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It might be an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons, but it’s not offered in many areas of the country. The method is much like the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest. Like all of the free flaps, a microsurgery is needed to connect the tiny vessels.

  • Inner thigh or TUG flap

    A newer option for those who can’t or don’t want to use TRAM or DIEP flaps is a surgery that uses muscle and fatty tissue from along the bottom fold of the buttock extending to the inner thigh. This is called the transverse upper gracilis flap or TUG flap, and it’s only available in some specific centers. Because the skin, muscle, and blood vessels are cut out and moved to the chest, a microscope is used to connect the tiny blood vessels to their new blood supply. Women with thin thighs don’t have much tissue here, so the best candidates for this type of surgery are women whose inner thighs touch and who need a smaller or medium-sized breast. Sometimes there are healing problems due to the location of the donor site but they tend to be minor and easily treated.


Nipple and areola reconstruction

You can decide if you want to have your nipple and the areola reconstructed. Nipple areola reconstructions usually are the final phase of breast reconstruction. This is a separate surgery done to make the reconstructed breast look more like the original breast. It can be done as an outpatient procedure after the area is numbed with local anesthesia. It’s usually done after the new breast has had time to heal, approximately about 3 to 4 months after surgery.

Ideally, nipple and areola reconstruction matches the position, size, shape, texture, color, and projection of the new nipple to the natural one. Tissue used to rebuild the nipple and areola is taken from your body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks. In some cases, doctors build up the areola and nipple area with donor skin that’s had the cells removed. Tattooing may be used to match the color of the nipple and areola of the other breast.

Some people opt to have just the tattoo, without nipple and areola reconstruction. A skilled plastic surgeon may be able to use pigment in shades that make the flat tattoo look 3-dimensional.

Nipple-sparing procedures

In a nipple-sparing mastectomy or areola-sparing mastectomy, the nipple and/or areola are left in place while the breast tissue under them is removed. Women who have a small cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple, might be able to have nipple-sparing surgery.

Possible risks

Some risks of reconstruction surgery are:

  • Bleeding
  • Fluid build-up in the breast or the donor site, with swelling and pain
  • Growth of scar tissue
  • Infection
  • Tissue death/necrosis of all or part of the flap, skin, or fat

Many women who have a mastectomy-surgery to remove an entire breast to treat or prevent breast cancer, have the option of having more surgery to rebuild the shape of the removed breast.

Breast reconstruction surgery can be either immediate or delayed. With immediate reconstruction, a surgeon performs the first stage to rebuild the breast during the same operation as the mastectomy. A method called skin-sparing mastectomy may be used to save enough breast skin to cover the reconstruction.

With delayed reconstruction, the surgeon performs the first stage to rebuild the breast after the chest has healed from the mastectomy and after the woman has completed adjuvant therapy.

A third option is immediate-delayed reconstruction. With this method, a tissue expander is placed under the skin during the mastectomy to preserve space for an implant while the tissue that was removed is examined. If the surgical team decides that the woman does not need radiation therapy, an implant can be placed where the tissue expander was without further delay. However, if the woman will need to have radiation therapy after mastectomy, her breast reconstruction can be delayed until after radiation therapy is complete.

Breasts can be rebuilt using implants (saline or silicone) or autologous tissue (tissue from elsewhere in the body).

Implants can be inserted underneath the skin and chest muscle that remain after a mastectomy, usually as part of a two-stage procedure.

In the first stage, the surgeon places a device called an expander under the chest muscle. The expander is slowly filled with saline during visits to the doctor after surgery. In the second stage, after the chest tissue has relaxed and healed enough, the expander is removed and replaced with an implant. The chest tissue is usually ready for the implant 3-4 months after mastectomy.

Expanders can be placed as part of either immediate or delayed reconstructions. An optional third stage of breast reconstruction involves recreating a nipple on the reconstructed breast.

In autologous tissue reconstruction, a piece of tissue containing skin, fat, blood vessels, and sometimes muscle is taken from elsewhere in a woman’s body and used to rebuild the breast. This piece of tissue is called a flap. Different sites in the body can provide flaps for breast reconstruction.

  • TRAM flap: Tissue, including muscle, that comes from the lower abdomen. This is the most common type of tissue used in breast reconstruction.
  • DIEP flap: Tissue that comes from the abdomen as in a TRAM flap, but only contains skin and fat.
  • Latissimus dorsi flap: Tissue that comes from the middle and side of the back.

More rarely, flaps are taken from the thigh or buttocks.

After the chest heals from reconstruction surgery and the woman has completed adjuvant therapy, a surgeon can reconstruct the nipple and areola. Usually, the new nipple is created by cutting and moving small pieces of skin from the reconstructed breast to the nipple site and shaping them into a new nipple. A few months after nipple reconstruction, the surgeon can recreate the areola. This is usually done using tattoo ink. However, in some cases, skin grafts may be taken from the groin or abdomen and attached to the breast to create an areola.

Skin-sparing mastectomy that preserves a woman’s own nipple and areola (called nipple-sparing mastectomy) is performed by some surgeons on select women who are at low risk of cancer recurrence.

Most women can choose their type of breast reconstruction method based on what is important to them. However, some treatment issues are important to think about. For example, radiation therapy can damage a reconstructed breast, especially if it contains an implant. Therefore, if a woman knows she needs radiation therapy after mastectomy, that information may affect her decision.

Sometimes, a woman may not know whether she needs radiation therapy until after her mastectomy. This can make planning ahead for an immediate reconstruction difficult. In this case, it may be helpful for the woman to talk with a reconstructive surgeon in addition to her breast surgeon or oncologist before choosing the type of reconstructive surgery.

Other factors that can influence the type of reconstructive surgery a woman chooses include the size and shape of the breast that is being replaced, the woman’s age and health, the availability of autologous tissue, and the location of the breast tumor.

Each type of reconstruction has factors that a woman should think about before making a decision.

Reconstruction with Implants

Surgery and recovery

  • Enough skin and muscle must remain after mastectomy to cover the implant
  • Shorter surgical procedure than for reconstruction with autologous tissue; little blood loss
  • Recovery period may be shorter
  • Many follow-up visits may be needed to inflate the expander and insert the implant

Possible complications

  • Infection
  • Pooling of blood (hematoma) within the reconstructed breast
  • Extrusion of the implant (the implant breaks through the skin)
  • Implant rupture (the implant breaks open and saline or silicone leaks into the surrounding tissue)
  • Formation of hard scar tissue around the implant (known as a contracture)

Other considerations

  • Can be damaged by radiation therapy
  • May not be adequate for women with very large breasts
  • Will not last a lifetime; the longer a woman has implants, the more likely she is to have complications and to need to have her implants removed or replaced
  • Silicone implants may provide a more natural-looking breast shape than saline
  • The Food and Drug Administration (FDA) recommends that women with silicone implants undergo periodic MRI screenings to detect possible “silent” rupture of the implants

Reconstruction with Autologous Tissue

Surgery and recovery

  • Longer surgical procedure than for implants; more blood loss
  • Recovery period may be longer
  • Pedicled flap reconstruction is a shorter operation than free flap but requires more donor tissue
  • Free flap reconstruction uses less donor tissue than pedicled flap reconstruction but is a longer, highly technical operation requiring a surgeon with experience re-attaching blood vessels

Possible complications

  • Necrosis (death) of the transferred tissue
  • Blood clots
  • Pain and weakness at the site from which the donor tissue was taken
  • Obesity, diabetes, and smoking may increase the rate of complications

Other considerations

  • May provide a more natural breast shape than implants
  • Less likely to be damaged by radiation therapy than implants
  • Leaves a scar at the site from which the donor tissue was taken

Any type of breast reconstruction can fail if healing does not occur properly. In these cases, the implant or flap will have to be removed. If an implant reconstruction fails, a woman can sometimes have a second reconstruction using autologous tissue. If an autologous tissue reconstruction fails, a second flap cannot be moved to the breast area, and an implant cannot be used for another reconstruction attempt due to the lack of chest tissue available to cover the implant.

Any type of reconstruction increases the number of side effects a woman may experience compared with those after a mastectomy alone. A woman’s medical team will watch her closely after surgery for complications, some of which can occur months or even years later.

Women who have autologous tissue reconstruction may need physical therapy to help them make up for weakness experienced at the site from which the donor tissue was taken, such as abdominal weakness. A physical therapist can help a woman use exercises to regain strength, adjust to new physical limitations, and figure out the safest ways to perform everyday activities.

Studies have shown that breast reconstruction does not increase the chances of breast cancer coming back or make it harder to check for recurrence with mammography.

Women who have one breast removed by mastectomy will still have mammograms of the other breast. Women who have had a skin-sparing mastectomy or who are at high risk of breast cancer recurrence may have mammograms of the reconstructed breast if it was reconstructed using autologous tissue. However, mammograms are generally not performed on breasts that are reconstructed with an implant after mastectomy.

A woman with a breast implant should tell the radiology technician about her implant before she has a mammogram. Special procedures may be necessary to improve the accuracy of the mammogram and to avoid damaging the implant.

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