Treatments

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