What is breast reconstruction?

Breast reconstruction is intended to recreate a breast mound after a mastectomy, or occasionally after lumpectomy, to restore your breast contour. The nipple and areola can also be reconstructed. Most women will have various breast reconstruction options.

Why have breast reconstruction?

Women may choose to have breast reconstruction for unique and personal reasons. Patients with realistic goals are happiest with their results. Common motivations for breast reconstruction include:

• To have a more natural breast shape and diminish the sense of physical loss and deformity that may follow mastectomy.
• To create a symmetrical breast appearance in clothing or bathing suits.
• To eliminate the need to wear an external prosthesis in a bra.

The reconstructed breast may not look exactly like your natural breasts and will usually not have fully normal sensation. 

Many women experience an improved body image and self-esteem after breast reconstruction, but not all. Some women may be disappointed with the appearance of the reconstructed breast and may have difficulty with the reconstructive process. Reconstruction usually requires a sequence of surgeries, rather than a one-time operation.  

There are several issues to consider when exploring the option of breast reconstruction: 

Timing of reconstruction.

Breast reconstruction can be either immediate (started at the time of the mastectomy) or delayed (started at a later date). Both immediate and delayed reconstruction can give good outcomes after careful individual consideration.

Immediate reconstruction begins the reconstructive process at the time of the mastectomy and may decrease the number of operations needed.  Some women feel better waking to a breast mound after their mastectomy and knowing that they have started the reconstructive process. Good outcomes from immediate reconstruction require a breast surgeon and plastic surgeon who are experienced in working as a team, favorable tissue quality and blood supply, and absence of significant risk factors, such as smoking, obesity, malnutrition, or diabetes.

Reconstruction may be delayed for weeks to years after mastectomy. This may be a better option for women who will choose chest wall radiation therapy after mastectomy and is usually the preferred timing for women who are having a tissue flap-based reconstruction, are smokers, who have diabetes, who have questionable blood supply to mastectomy skin, or who are uncertain about how they wish to proceed.  

Your breast surgeon and plastic surgeon can do an evaluation and make recommendations that are individualized about the type and timing of breast reconstruction. These will take into consideration your type and stage of cancer, your overall health, the size and shape of your natural breasts, the likelihood of needing radiation therapy after total mastectomy, your smoking history, whether or not you have diabetes or history of healing problems, your weight and body size, and the type of reconstruction best suited to you.

Methods of reconstruction.

The method that is best suited in your circumstances requires individualized consideration and planning. Whatever you decide, the full reconstructive process may take 6 – 12 months. The two primary types of reconstruction are implant-based and tissue- or flap-based. Both methods, through different means, achieve the goals of creating a “skin envelope” of the desired breast size and shape, creating a substitute for the missing breast tissue. In some situations a hybrid reconstruction is performed: a combination of tissue from elsewhere on the body with an expander and/or implant.

With implant based reconstruction, the first step is placement of a device called a tissue expander behind the chest wall muscles. Over time the expander is injected with salt water to develop the new breast to good form and size. The tissue expander can then be replaced with an implant filled with either salt water (saline) or silicone gel. The nipple areolar complex can be reconstructed as an additional procedure.

Tissue based procedures (TRAM, DIEP, Latissimus, and others) refer to breast reconstruction that is performed using skin, fat, and possibly muscle from elsewhere on the body (abdomen, back, buttock, thigh) to substitute for the breast tissue. The re-located tissue may require connection of the flap blood vessels to a chest area blood supply.

There are pros and cons to both implant-based and tissue-based reconstruction and the choices can be discussed with you in detail.

Other things to think about.

• Some women find that planning immediate reconstruction adds another layer of complexity to the cancer treatment decisions they already have to make. They may prefer to put off decisions about reconstruction until after their cancer treatment is completed. There is never any harm done or option lost by a delayed reconstruction.
• Reconstructive surgery cannot always create perfect breasts and results may be disappointing. Reconstruction creates a substitute breast. It may never look or feel like your natural breast.
• Reconstructed breasts usually do not have normal sensation.
• Some women may be candidates for nipple-areola complex preservation, which may enhance the cosmetic outcome. The preserved nipple will not have sensation or erectile function. If the tissue behind the nipple shows abnormal tissue, the nipple may need to be removed with another procedure. Even when nipple preservation is attempted, remaining blood supply can be diminished by mastectomy to a degree that the nipple may not survive the operation.
• There may be healing problems following mastectomy and some of the retained breast skin may lose its blood supply and subsequently need to be removed. This can affect the length, complexity, and cosmetic outcome of the reconstructive process.
• Surgery may be needed on the opposite breast to achieve symmetry. This could a reduction, lift, or enlargement of the breast with an implant.
• Having both breasts removed does not guarantee symmetry following reconstruction.
• Even when immediate reconstruction is planned, findings during surgery – such as a positive sentinel lymph node, the need for lymph node dissection, or clinical signs of poor tissue blood supply, – may alter the procedure and result in cancellation of the reconstruction.  If that happens, a delayed reconstruction should still be an option.

Some initial questions to discuss as you are making treatment decisions:

What are my options for breast reconstruction and which would give me the best outcome? 
Am I a candidate for nipple sparing mastectomy?
Would immediate reconstruction be an option or would you recommend delayed reconstruction?
What is the impact on reconstruction if I need to have radiation therapy after mastectomy?
What operations might I be a candidate for that you don’t personally do?
Can I see examples of work you’ve done in the past on patients like me?