What is Breast Reconstruction?
Breast reconstruction is a type of surgery for women who have had a breast removed (mastectomy). The surgery rebuilds the breast so that it is about the same size and shape as it was before. The nipple and the darker area around the nipple (areola) can also be added.
Most women who have had a mastectomy can have reconstruction. Women who have had only the part of the breast around the cancer removed (lumpectomy) may not need reconstruction. Breast reconstruction is done by a plastic surgeon. The choice to have breast reconstruction is yours to make.
Before you make the crucial decision talk to your breast surgeon and plastic surgeon well in advance to have all your doubts and questions answered.
Why have Breast Reconstruction?
Women choose breast reconstruction for many reasons:
- To make their breasts look balanced when they are wearing a bra
- To permanently regain their breast shape
- So they don't have to use a form that fits inside the bra (an external prosthesis)
You will be able to see the difference between the reconstructed breast and the remaining breast when you are nude. But when you are wearing a bra, the breasts should be alike enough in size and shape that you will feel comfortable about how you look in most types of clothes.
Your body image and self-esteem may improve after your reconstruction surgery.
Immediate or delayed Breast Reconstruction ?
Immediate breast reconstruction is done at the same time as the mastectomy. An advantage to this is that the chest tissues are not damaged by radiation therapy or scarring. This often means that the final result looks better. Also, immediate reconstruction means less surgery.
After the first surgery, there still may be a number of steps that are needed to complete the immediate reconstruction process. If you are 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.
What are the types of Breast Reconstruction?
Several types of operations can be done to reconstruct your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. (A tissue flap is a section of your own skin, fat, and muscle which is moved from your tummy, back, or other area of your body to the chest area.)
Implant procedures
The most common implant is a saline-filled implant. It is a silicone shell filled with salt water (sterile saline). Silicone gel-filled implants are another option for breast reconstruction. They are not used as often as they were in the past because of concerns that silicone leakage might cause immune system diseases.
One-stage immediate breast reconstruction may be done at the same time as mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant where the breast tissue was removed to form the breast contour.
Two-stage reconstruction or two-stage delayed reconstruction is done if your skin and chest wall tissues are tight and flat. An implanted tissue expander, which is like a balloon, is put under the skin and chest muscle. Through a tiny valve under the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over time (about 4 to 6 months).
After the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant.
There are some important factors for you to keep in mind if you are thinking about having implants:
• Implants may not last a lifetime. You may need more surgery to replace them later.
• You can have problems with breast implants. They can break (rupture) or cause infection or pain. Scar tissue may form around the implant (capsular contracture), or you may not like the way the implant looks.
Tissue flap procedures
These procedures use tissue from your tummy, back, thighs, or buttocks to rebuild the breast. The 2 most common types of tissue flap surgeries are the TRAM flap (or transverse rectus abdominis muscle flap), which uses tissue from the tummy area, and the latissimus dorsi flap, which uses tissue from the upper back.
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 they will never go away completely. There can also be problems at the donor sites, 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 are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers.
In general, flap procedures behave more like the rest of your body tissue. For instance, they may enlarge or shrink as you gain or lose weight. There is also no need to worry about replacement or rupture.
TRAM (transverse rectus abdominis muscle) flap
The TRAM flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). The tissue from this area alone is often enough to shape the breast, and an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) 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." There are 2 types of TRAM flaps:
- A pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area.
- In a free flap, the surgeon cuts the flap of skin, fat, blood vessels, and muscle for the implant free from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer than a pedicle flap. A free flap can result in a more natural shape.
Latissimus dorsi flap
The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast.
Nipple and areola reconstruction
You can decide if you want to have your nipple and the dark area around the nipple (areola) reconstructed. Nipple and areola reconstructions are optional and usually the final phase of breast reconstruction. This is a separate surgery that is done to make the reconstructed breast look more like the original breast.
It can be done as an outpatient after drugs are used to make the area numb (under local anesthesia). It is usually done after the new breast has had time to heal (about 3 to 4 months after surgery).
The ideal nipple and areola reconstruction requires that the position, size, shape, texture, color, and projection of the new nipple match the natural one. Tissue used to rebuild the nipple and areola also is taken from your body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks. A tattoo may be used to match the color of the nipple of the other breast and to create the areola.
Choosing your plastic surgeon
Once you decide to have breast reconstruction, you will need to find a plastic surgeon with experience in breast reconstruction. You could ask your oncosurgeon to suggest a plastic surgeon for you.
Questions to ask your plastic surgeon
It is very important that you get all of your questions answered by your plastic surgeon before having breast reconstruction. If you don't understand something, ask your surgeon about it. Here is a list of questions to get you started. Write down other questions as you think of them... The answers to these questions may help you make your decisions.
- How long will the implant last?
- What kinds of changes to the breast can I expect over time?
- How will aging affect the reconstructed breast?
- What happens if I gain or lose weight?
- Are there any new reconstruction options that I should know about?
Breast reconstruction and even mastectomy are not emergencies. It is more important for you to make the right decisions based on the correct information than to act quickly before you know all your options.