Breast reconstruction restores the breast after a mastectomy (or lumpectomy). The procedure isn’t for everyone, but it is an option everyone has the right to consider. Those who choose to have reconstruction have several options ranging from breast implants to using their own tissue. The procedure is usually covered by insurance in the US thanks to a 1998 Federal Mandate.

Timing: 

Breast reconstruction can be performed at the same time as the mastectomy (“immediate reconstruction”), or any time later (“delayed reconstruction”). More than one surgery is often needed for the best cosmetic results. The term "immediate" can therefore be misleading; immediate reconstruction is started at the same time as the mastectomy but the entire reconstructive process often involves more than one surgery for the best results.

Immediate reconstruction provides the best cosmetic results. This is because it is easier to preserve the breast skin and to limit scarring. Patients also wake up from surgery with breasts and therefore avoid the experience of being without a breast. 

Immediate reconstruction does not increase the risk of cancer recurrence or prevent detection of a recurrence. It can occasionally slightly delay other breast cancer treatment such as chemotherapy but not significantly.

Reasons to delay breast reconstruction include patient preference, advanced breast cancer (stage III or IV), inflammatory breast cancer, other health factors, pregnancy, and lack of access to a reconstructive plastic surgeon. Some patients will also be told it is best to delay reconstruction if there is a plan for radiation, or if they have other health problems that should be "tuned up" first to decrease the risk of complications. Immediate breast reconstruction can still be performed in appropriate candidates when post-mastectomy radiation is planned, however, a coordinated team approach involving a radiation oncologist experienced in treating breast reconstruction patients is crucial in decreasing the risk of complications.

Some patients choose to delay reconstruction until all their cancer treatment has been completed. This allows as much time as they need to consider of all their options without the stress that the consideration of immediate reconstruction can generate in some people. There is no time limit; reconstruction can be delayed as long as you want. Some patients ultimately decide to stay flat once they have healed from the mastectomy. 

Types of Mastectomy:

There are several different types of mastectomy. In patients interested in reconstruction, a skin-sparing mastectomy (SSM) should be performed whenever possible, even if reconstruction will be delayed. SSM removes the breast tissue but saves the overlying natural breast skin envelope (except the nipple-areola). The reconstruction then “fills” the empty skin envelope. Preserving as much of the natural breast skin as possible will help the plastic surgeon achieve the best cosmetic result. Immediate reconstruction with skin-sparing mastectomy improves the final cosmetic results by minimizing scarring and preserving the overall breast shape. 

In many cases, a nipple-sparing mastectomy (NSM) can be performed. This preserves the nipple and areola as well as all the breast skin. Patients who need a significant breast lift for the best cosmetic results are not ideal candidates, though NSM can still be performed in these situations with appropriate planning as long as patients are open to having more than one surgery. When combined with immediate breast reconstruction in appropriate candidates, nipple-sparing mastectomy generally provides the best cosmetic results without compromising cancer care.

Skin-sparing or nipple-sparing mastectomies are still an option even if delayed reconstruction is planned. Most (if not all) of the saved breast skin can be used at the time of the reconstruction to decrease the amount of total scarring and improve the final breast shape. Unfortunately, patients needing post-mastectomy radiation usually lose some of the benefit of saving the breast skin envelope because of radiation-induced skin damage and contraction (shrinkage) of the skin.

Patients must be prepared to lose nipple and breast skin sensation after a mastectomy, even if the nipple and areola are preserved, and irrespective of whether they have reconstruction. In cases where some sensation is preserved or returns over time, the feeling is typically well short of what Mother Nature provided. Even though the sensation that typically returns after nipple-sparing mastectomy is rarely the same as before the mastectomy, preserving the nipple and areola can significantly improve the amount and degree of feeling that returns. In some cases the preserved nipple-areola will also still respond to tactile and temperature stimuli. Preserving the nipple-areola also does not mean breast feeding will be possible after mastectomy and reconstruction. Reconstructed breasts cannot produce breast milk since the breast gland that makes milk is removed as part of the mastectomy. 

Methods of Reconstruction:

Implant reconstruction is the most common method of breast reconstruction after mastectomy. This is usually performed as a multiple-step procedure starting with tissue expanders. Tissue expanders are temporary implants that are filled (expanded) with saline (salt water) over a few weeks in the doctor’s office. 

In appropriate candidates, implant reconstruction can be performed in a single stage (“direct to implant”) whereby the final implant is placed at the time of the mastectomy and the entire expansion process is avoided. Implant procedures limit scarring to the chest, involve shorter surgery and hospital stays, and are associated with quicker recovery (3-4 weeks) compared to “flap” procedures that use the patient’s own tissue for the reconstruction. Most board-certified plastic surgeons offer implant-based breast reconstruction.

Generally speaking, a reconstructed breast will look more natural after a flap (autologous) reconstruction, than after an implant. Breasts reconstructed with implants tend to have a more enhanced look. This is especially the case after delayed reconstruction.

"Flap" procedures involve removing tissue from one part of the patient’s body (abdomen, back, buttock or thigh) and transferring it to the chest. These surgeries recreate “natural”, warm soft breasts but also leave a scar on the part of the body from where the flap was removed. Flaps require longer surgery than implants, a longer stay in the hospital, and a longer recovery time (4-6 weeks off work). However, unlike implants, flaps do not rupture, leak, or harden, and do not need to be replaced. Flaps are permanent, change with your body over time, and do not require maintenance. 

Many plastic surgeons offer “pedicled” flaps like the latissimus and TRAM flaps that do not require microsurgery. These procedures can weaken your muscles from the area where tissue was taken. More advanced flap options, called "perforator flaps", preserve the patient's muscles, are associated with an easier recovery, and preserve the patient's muscle function and strength longterm. 

Some flaps also allow for sensory nerve reconstruction that helps restore feeling to the reconstructed breast. Perforator flap procedures, like the DIEP flap, require microsurgical expertise and are therefore not offered by all plastic surgeons. Unfortunately, many patients seeking one of these breast reconstruction options may need to travel to specialized centers for their surgery.

The nipple and areola can also be recreated in conjunction with any breast reconstruction technique, often as an office or outpatient procedure.

Radiation can impact your Reconstruction:

Radiation therapy is often recommended as part of breast cancer treatment. Patients undergoing lumpectomy receive radiation routinely once they’ve healed from surgery. Some mastectomy patients also need radiation after mastectomy depending on the characteristics of the tumor and staging. 

While radiation can complicate breast reconstruction, it does not preclude it. Radiation can cause toughening (fibrosis) and shrinking (contracture) of the patient’s tissue. The skin and underlying tissue loses its elasticity and can become very firm and rigid, making it difficult to expand. Skin color changes are also very common.

Flaps tolerate radiation much better than implants. Studies have shown that flaps have fewer complications than implants in patients receiving radiation after mastectomy and immediate reconstruction. Also, when radiation is planned, delayed reconstruction with flaps yields higher patient satisfaction, and fewer complications than immediate reconstruction with implants or flaps. Delayed reconstruction with implants in patients who have had mastectomy and radiation generally yields the poorest cosmetic results. 

Another option for patients who ultimately want a flap reconstruction but will be getting radiation is for a tissue expander to be placed at the time of the mastectomy. In this situation, the expander is simply used to preserve the breast skin envelope as much as possible until the radiation therapy has been completed. The expander is then replaced by the flap once the patient has recovered from the radiation. This "delayed-immediate" approach preserves as much of the breast skin and shape as possible without exposing the flap to the potentially damaging effects of radiation.

Risks:

Most people recover well after surgery with few major side effects, but there are some things to be aware of as all surgery has risks. Your specific risk will not only depend on the procedure you choose, but also your overall health. Other health conditions such as diabetes, high blood pressure, obesity, poor nutrition, and autoimmune disorders will increase your risk of complications after any procedure. Certain lifestyle choices like smoking also significantly increase your risk of wound healing problems and failure of your reconstruction. Please talk to your physician(s) about your individual situation and steps that can be taken to minimize your risk. Every opportunity should be taken to "tune things" up before surgery. 

While some options are better than others in certain situations, there is no “best technique” when it comes to breast reconstruction. The best option is the one that most suits the patient’s desires, needs, situation and overall medical health. Anyone interested in breast reconstruction should consult with a board certified plastic surgeon, preferably one specializing in breast reconstruction. Ideally, this should be before the mastectomies are scheduled so that the option of immediate reconstruction can be considered, or in the case of delayed reconstruction, the patient is more prepared about the process ahead.

Wound Dressings & Surgical Garments:

Surgeons use a variety of wound dressings. Some use adhesive dressings, others use soft gauze or bandages. You may have dissolvable stitches that don’t need to be removed, or non-dissolvable stitches that need to be removed 7 -14 days after surgery.  The use of surgical garments also varies - some surgeons will place you in a surgical bra after your surgery, others prefer not to have anything compressing the new breasts. Likewise, if you have an abdominal flap procedure (TRAM, DIEP or SIEA flap), you may or may not be placed in an abdominal binder. Be sure to ask your surgical team about the preferred dressing/garment routine before your surgery. If you will need a surgical bra, ask whether you'll be able to remove it to wash it, or whether you'll be given a spare bra so you'll always have a clean one available while the other is being washed.

Surgical Drains:

You may have wound drains after surgery, although not all surgeons use them. These are tubes that drain blood and fluid from the wound into a small plastic bottle or bag. You can walk around and move normally with the drains in place. Breast drains usually stay in for several days. Drains after flap surgery usually stay in a little longer, depending on the type of surgery. The drains are usually removed by a member of your surgical team once the drainage has slowed down significantly. You or your carer will be taught how to monitor (and measure) the drainage before you go home from the hospital. 

Content provided by PRMA Plastic Surgery | Center for Advanced Breast Reconstruction