Breast Cancer Reconstruction Surgery

During breast reconstruction surgery, a plastic surgeon rebuilds the breast(s) of a woman who has undergone mastectomy (the surgical removal of breasts due to breast cancer) or suffered a traumatic injury to this area.

The benefits of breast reconstruction include improved body image and self-esteem, as well as the lack of need for a prosthesis to replace the missing breast. According to an article in Plastic and Reconstructive Surgery, 98 percent of women who had a breast reconstruction after their mastectomy would do so again.

The reconstruction process, which may entail more than one operation, typically involves placement of a saline or silicone implant and reconstruction of the nipple and areola (the darker pigmented skin surrounding the nipple).

Women who have had a mastectomy may have their breast reconstruction done at the same time as the mastectomy or several months down the road. Breast reconstruction can often be performed with the mastectomy if the chest tissue is undamaged by radiation therapy and scarring. This is preferable because it means one less surgery. However, delayed breast reconstruction may be better if postsurgical radiation to the chest area is part of the planned treatment, because radiation therapy can increase complications after surgery.

Am I a Candidate for Breast Reconstruction?

Not every woman with breast cancer needs breast reconstruction. Women who have opted for a lumpectomy or other type of breast-conserving surgery may not need reconstruction. On the other hand, some women who think they won't need reconstruction become prime candidates due to significant breast asymmetry resulting from removal of large volumes of breast tissue, or as a result of changes stemming from radiation therapy.

There are several key considerations when it comes to breast reconstruction surgery. First, your general health should be good enough to make you an acceptable candidate for this surgery. Your plastic surgeon will also take into consideration the stage of your breast cancer, how you were treated and your choice of reconstructive procedure. Other factors are your natural breast size, the size of the implant or reconstructed breast, your interest in matching the appearance of the opposite breast, your desire for bilateral reconstructive surgery, the availability of tissue to cover the new breast, and insurance coverage for the unaffected breast and other related surgical costs.

Types of Breast Reconstruction

There are several types of breast reconstruction surgery. Options include creating a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of both.

Breast reconstruction with breast implants can be performed with either saline or silicone implants. Some women prefer silicone-gel-filled implants for their more natural feel. There are pros and cons to each type of implant. Comparisons of both implants are available in our article on saline implants vs. silicone implants and should be discussed with your plastic surgeon.

You and your surgeon may also want to consider checking out current breast reconstruction clinical trials involving new types of breast implants that may be beneficial for breast reconstruction.

The implant is placed behind breast tissue or above the breast muscle, under breast skin that was saved during the mastectomy. Some women can have the implant placed immediately if they have relaxed muscle tone and stretchy skin and their cancer surgeon is able to do a skin- and tissue-sparing mastectomy. Women with tight chest skin and muscles, however, may need to have an expandable implant inserted that is gradually filled with saline over several weeks. Alternatively, a tissue expander is used to create enough room in the chest to accommodate a permanent implant, which is inserted surgically during a second operation.

Breast reconstruction with tissue flap uses tissue that is harvested from other parts of your body to reconstruct the breast. Common donor sites include the back, buttocks, stomach and thighs. The two most common types of tissue flap surgeries are the TRAM (transverse rectus abdominis muscle) flap, which uses tissue from the stomach, and the latissimus dorsi flap, which uses tissue from the upper back. Two related procedures are the deep inferior epigastric artery perforator (DIEP) flap and the gluteal free flap.

The TRAM flap procedure can be done in one of two ways. The first involves leaving a stem or stalk of tissue called a pedicle attached to its original blood supply and then tunneling it under the skin to the breast area. The alternative option is called a free flap and involves the surgeon transplanting a flap of skin complete with fat, blood vessels and muscle from its original location and reattaching it to blood vessels in the chest area.

During the latissimus dorsi muscle flap procedure, the surgeon removes a large muscle in the back, along with skin and underlying fatty tissue. This flap is used to reconstruct the breast. The inclusion of fatty tissue helps create a more natural-looking breast, which is rounded out with an implant.

The deep inferior epigastric artery perforator (DIEP) flap procedure is similar to the TRAM flap in that the fat and skin are harvested from the same area; however, no muscle is used to form the breast. This "free" flap procedure removes the donor tissue completely and reattaches it in the chest area. An added bonus of the DIEP flap procedure is a tightening of the lower abdomen, or "tummy tuck."

The gluteal free flap surgical procedure creates a new breast shape from tissue taken from the buttocks. It is an option for women who cannot use a graft from their abdomens because they are too thin.

All tissue flap operations require two surgical sites, meaning there will be scars where the flap was harvested and on the reconstructed breast. Because blood vessels are involved, tissue flap breast reconstruction procedures are usually not an option for smokers or women with diabetes, connective tissue disease or vascular disease, as these conditions can all damage blood vessels.

Nipple and Areola Reconstruction

The nipple and areola are recreated during the final phase of breast reconstruction. Although nipple and areola reconstruction can sometimes be done at the same time as flap surgery, it is usually postponed until a few months later, giving the new breasts time to heal. The procedure is done under local anesthesia on an outpatient basis.

As with flap surgery, the tissue used to rebuild the nipple and areola is taken from your own body. Favored harvest sites include the opposite nipple and the ears, eyelids, groin, upper inner thigh or buttocks. Tattooing can be used to create the areola and to repigment the tissue so that it matches the nipple color to that of the other breast.

Preparing for Breast Reconstruction Surgery

Once you have decided to undergo breast reconstruction surgery, your breast surgeon and your plastic surgeon will give you specific instructions on how to prepare, including:

• What to eat and drink, and what to avoid
• Directions to stop smoking and drinking alcohol for at least two weeks prior to surgery
• A list of medications and vitamins that should not be taken in the days leading up to surgery, including aspirin, anti-inflammatory drugs and herbal supplements, all of which can increase the risk of bleeding
• Lab tests that need to be completed prior to surgery
• A complete presurgical medical examination

What to Expect Following Breast Reconstruction Surgery

Expect to feel tired and sore for several weeks after your implant reconstruction. Flap procedure patients may take a bit longer to fully recuperate because the surgery is more involved than breast implant surgery. Your surgeon can prescribe medications to deal with the discomfort.

Most breast reconstruction patients who have no complications are discharged from the hospital within a few days, usually with a surgical drain to help remove excess fluids from the site while it heals.

Refrain from vigorous activities for six to eight weeks after surgery. If implants were used without flaps, your breast reconstruction recovery time may be shorter. In either case, follow your plastic surgeon's instructions for the postsurgical period and report any breast reconstruction complications that arise to him or her immediately.

Breast Health After Breast Reconstruction

Women with breast cancer who are facing mastectomy and the option of breast reconstruction surgery should consult with their breast surgeon and a board-certified plastic surgeon to establish a team approach to their surgery and recovery, and develop a follow-up plan.

Risks of Breast Reconstruction

• Problems with anesthesia
• Excessive bleeding during or after surgery
• Scarring
• Complications at the donor sites for flap procedures, including abdominal hernias and muscle damage or weakness
• Asymmetry of the breasts
• Healing problems due to numerous factors, including previous surgery, chemotherapy, radiation, smoking, alcohol consumption, diabetes, prescribed medications and other factors
• Loss of normal breast sensation (temporary or permanent)
• Lymphedema (swelling in the arm)
• Infection
• Necrosis (tissue death) of all or part of the flap
• Extreme fatigue
• Overall dissatisfaction with the cosmetic results
• Future revision surgery to correct complications or undesired results

Breast cancer survivors should know that post-mastectomy reconstruction rarely, if ever, masks a cancer's return, so it is not considered a risk to future health.

Will Insurance Cover My Breast Reconstruction Surgery?

The costs of breast reconstruction after mastectomy or injury are usually covered by health insurance policies. However, it is important to confirm coverage with your insurer prior to surgery and to understand any limits on your coverage.

Choosing a Plastic Surgeon for Your Breast Reconstruction

Your first step in choosing a plastic surgeon for breast reconstruction is to find one who is board certified and experienced in the newest technology and techniques. Your oncologist or primary care physician should be able to give you a referral. If you're comfortable doing so, you can also ask for a referral from friends or relatives who have undergone breast reconstruction.