Breast Reconstruction Surgery

Contents

• What Is Breast Reconstruction Surgery?
• When Is It Performed?
• Types Of Surgeries
• How Long Does Recovery Take?
• Do I Still Need To Monitor For Cancer?
• What Risks And Complications Are There?
• Choosing A Plastic Surgeon
• How Much Does It Cost?

Tissue Expanders

Tissue Expander Followed by Insertion of Implant

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Breast Cancer Guide

What Is Breast Reconstruction?

This is a type of surgery which rebuilds the breast after a mastectomy (image). The idea of the surgery is to recreate the breast so that it looks the same size and shape as it used to be. The nipple and darker area around it (areola) can also be reconstructed later. Most women who have had a mastectomy choose to undergo this surgery. They have a desire to look 'normal' and feel that an artificial replacement (prosthesis) will not help them achieve this. Women who have had part of their breast removed (lumpectomy surgery) may or may not choose reconstruction; it depends on how much tissue was removed. Surgery may also be performed for non-cancer reasons. For example damage to a breast which occurs in childhood (such as a burn) can cause the breast not to full develop, which may only be noted in puberty. All breast reconstruction procedures are carried out by a plastic surgeon and different surgical techniques can be employed. The main challenge is to make the breast look as natural as possible, with some droop and a normal crease. If the woman just wants something to look normal underneath her clothes, than a mound may be sufficient. Adding the nipple and areola is considered optional. Also, some surgery on the healthy breast may be required to lift it or reduce the size so that it matches the new breast. If you are considering breast reconstruction surgery it is a good idea to discuss the procedure with a plastic surgeon before your mastectomy. This allows some time for planning and thought.

When Is It Performed?

The surgery can be performed at any time; some women choose to have it at the same time as their cancer surgery, while others may wait. Many factors will influence a woman's decision about timing. For example, radiation treatment given after breast reconstruction surgery can cause complications, which is why some women are advised to wait until their treatment plan is completed. Other issues to think about include:

1. Do you want more surgery?
2. Not all surgery is a total success, no matter what the plastic surgeon says. You may not like the result.
3. Healing may be slowed by other procedures such as radiation, chemo, smoking, diabetes and some medicines.
4. Surgery can restore the breast but it will not bring back feeling.
5. The healthy breast may also require surgery, such a breast enlargement/reduction or a lift to match the new breast.

If you are considering the procedure, there is plenty of information available on the pros and cons. The FDA has a hotline and information which they can post out to you on the subject. Call: (800) 532 4440 or (301) 827 4420. And, the Y-Me Breast Cancer Support Program puts women into contact with other survivors for emotional support and advice, call: 1 800 221 2141. Additionally check out breast cancer books for published information.

Types Of Surgeries

Implants

If a woman has enough skin remaining in the breast area after a mastectomy, the surgeon may simply be able to slip an implant in under the chest muscle to create a mound. This is the most straight forward type of surgery. The implant may even be inserted during the mastectomy. The most common type of implant is filled with saline (sterile salt water). Silicone gel filled implants are still an option for breast reconstruction patients (if the surgeon is participating in cancer clinical trials), but not for women undergoing plastic surgery for cosmetic purposes. Although there have been some concern over silicone leakages, recent studies show there is no evidence of increased cancer in women with silicone implants compared to those without. One thing experts do agree on is that no implant is a long-term solution and all types have to be changed every 10 to 15 years. After the procedure, the new breast will appear pert and upright. This may look at odds with the other breast which can have a more natural drooped appearance. It may require some cosmetic procedure such as breast enlargement/reduction or lift.

Tissue Expanders

If the woman does not have enough skin after a mastectomy, then a tissue expansion procedure must be used. This technique relies on the fact that skin can be stretched naturally on its own if done so over a period of time (this happens naturally in pregnancy for example). During a tissue expansion procedure a small device called an expander is inserted under the skin and gradually over time it is inflated like a balloon to expand the skin. A doctor can inflate the balloon gradually, a process which is not painful. Once the desired pocket space of skin has been created, the doctor over-inflates the expander and leaves it that way for a few weeks. This is supposed to help the breast achieve a natural droop before the permanent implant is surgically inserted.

Useful: See Breast Cancer Treatment Options.

Tissue Flap Procedures

Sometimes a surgeon will recommend using tissue from another part of the body to rebuild a breast. This is because it can give a more natural appearance than an implant. Skin, fat and muscle tissue can be removed from the buttocks, thighs, tummy or back and molded into the new breast. This tissue will age naturally over time, which means it will also stay ‘in tune’ with the other breast. However flap surgeries are lengthier procedures and require expert surgeons. The operation leaves 2 scars - one in the breast and the other at site of excision, although these will fade over time. The most common types of flap operations are:

TRAM Flap
Transverse rectur abdominus myocutaneous (TRAM) flap, also called the tummy tuck surgery. To be eligible for this surgery the woman needs to have ample fat in the tummy area to remove. Of course there are other bonuses, as well as a new breast she also ends up with a flatter stomach. During the surgery a flap of tissue is cut from the tummy. One side remains attached to its original blood supply and site. The flap of skin is then tunneled under the skin to the breast site where it is stitched into place. The remaining tummy wound is then stitched together. Although this procedure yields the most natural results, not all women are eligible. It is not offered to diabetics, smokers or those with circulation disorders. The DIEP (deep inferior epigastric artery perforator) flap is a newer version of the TRAM flap and is becoming increasingly popular. It uses more skin and fat from the same area in the tummy (rather than muscle) and the flap is completely removed. It requires microsurgery to then connect the tiny blood vessels of the flap to the breast area. However, as the transplanted tissue does not carry its own blood supply there is increased risk that it will not 'take'.

LATS Flap
The latissimus dorsi flap moves a patch of tissue from the upper back and funnels it under the armpit to the breast area. However as the latissimus muscle is not overlaid with fat, this procedure usually also requires an implant. It is the least common option and some women complain of weakness in their back, shoulder or arm after surgery.

SGAP Flap
The superior gluteal artery perforator (SGAP) flap, is also known as the gluteal free flap. A new type of surgery it uses tissue from the buttocks. It is an option for women who do not have enough fat in the tummy area or want to avoid incisions there. Similarly to a DIEP flap, the tissue is completed removed and requires microsurgery to reattach.

AlloDerm

This is a new product which some plastic surgeons are beginning to use. It is made of donated human skin which can support natural tissue growth and healing. Manufactured by LifeCell, the donated skin has its epidermis and cells removed so that there are fewer chances of tissue rejection and graft failure. In breast reconstruction surgery AlloDerm may be used alongside expanders and implants. It has also been used in conjunction with nipple reconstruction. Long-term studies are still needed with the product, but so far research is encouraging.

Nipple Reconstruction

Whichever reconstruction procedure is used to create the breast mound, the surgeon also has a choice of which technique to use to recreate the nipple and the dark area around it (areola). For example the nipple can be created by dividing the healthy nipple or by transplanting part of the earlobe. More commonly however the surgeon chooses to wrap flaps of skin around themselves to recreate the appearance of a nipple. After the nipple has healed and settled a tattoo gun is used to inject natural pigments into the surrounding skin. Generally, nipple reconstruction is carried out 3 to 4 months after breast surgery.

How Long Does Recovery Take?

Cancer surgery recovery, specifically the the time taken to heal will depend on the type of surgery performed. If reconstruction is performed at the same time as mastectomy, the recovery will be rolled into the overall cancer surgery treatment. If reconstruction is performed later, then healing time will depend on whether or not artificial materials are used. Generally surgeries which involve artificial materials like implants are quicker to carry out and quicker to heal. Yet this is not a reason to reject using your own tissues. Women who have implants or use a tissue expander can be back to work within a week of surgery. Women who have a TRAM flap will take a few weeks longer and may be restricted in their activities. However, in both instances when the woman recovers she should be able to return to all normal activities.

Do I Still Need To Monitor For Cancer?

Yes. If you choose a reconstruction after cancer you will still need to be monitored for breast cancer recurrence, just the same as a woman who does not choose reconstruction. The long term breast cancer survival rates are the same for both categories. Always follow your doctor’s advice on a regular mammogram and breast self examination. If cancer does come back it is likely to occur in the tissue left over after the mastectomy, not the new transplanted tissue. If there is recurrence, the newly reconstructed breast will not interfere with chemotherapy or radiation therapy. It should also be noted that research shows new breasts will not mask or hide the return of cancer.

What Risks And Complications Are There?

All reconstructive surgery is major and has therefore has associated risks, namely:

• Bleeding.
• Infection.
• Problems associated with anesthesia.
• Fluid build-up with pain and swelling.
• Growth of scar tissue.
• Necrosis: tissue death in part of or the entire flap, skin or fat.
• Problems at the donor site, such as numbness.
• Loss of nipple and breast sensation.
• Fatigue or extreme tiredness.

Choosing A Plastic Surgeon

Always choose a board certified plastic surgeon. The American Society of Plastic Surgeons (ASPS) can provide you with a list of qualified surgeons in your area. Your breast surgeon will also be able to recommend someone suitable.

How Much Does It Cost?

Most insurance companies will cover the cost of reconstruction surgery which is performed as a result of mastectomy. This is thanks to the Women's Health and Cancer Rights Act (1998) which requires them to do so. For the uninsured, the average fee ranges from $5,000 to $10,000.

Related Articles on Breast Cancer

For more female diseases, see the following:

• Breast Cancer Prevention
• Breast Cancer Risks Factors
• Breast Biopsy

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