WHAT IS NATURAL BREAST RECONSTRUCTION?
Natural breast reconstruction generally describes procedures that use the woman’ own tissue (from her abdomen) to reconstruct a breast after mastectomy. These procedures are commonly referred to as flap procedures. The flap refers to the skin and fat tissue that is transferred and reshaped into a breast. Either a section of muscle is also removed to provide the blood supply for the new breast (e.g. TRAM flap or lat flap) or the muscle is spared with a perforator flap procedure (free TRAM).
As opposed to breast implants, naturally reconstructed breasts are made of natural tissues and they generally feel like natural breast tissue (i.e. warm, soft). Unlike when implants are placed behind breast tissue in a breast enlargement surgery, implant placement for breast reconstruction is typically behind a thin layer of skin (and possibly muscle). The results of implant breast reconstruction can therefore be very firm.
Although the reconstructed breasts from flap procedures may retain tiny micro-clips remaining on the newly established blood vessels, there is no foreign component that may leak or contract and require replacement.
WHY DO WOMEN CONSIDER BREAST RECONSTRUCTION?
Each woman seeking breast reconstruction has her own individual reason for it. Many find a sense of comfort knowing that breast reconstruction is an available treatment option. Some women appreciate being able to return to a physical appearance similar to that before the breast cancer surgery.
Women describe a sense of emotional healing, restoration of self-confidence/femininity, joy and peace of mind after breast reconstruction. Some women choose breast reconstruction because they feel it allows them to return to as “normal” an appearance and lifestyle as possible. Some women find the mastectomy scar constantly reminds them of the breast cancer. Other women prefer not to wear an external prosthesis (artificial breast) for a variety of reasons.
WHO CAN HAVE BREAST RECONSTRUCTION?
Most women of any age who are in fairly good health and require a mastectomy. Women at high risk for breast cancer who have their breasts removed as a preventative measure (prophylactic mastectomies). Women with congenital defects.
WHAT ARE CONTRADICTIONS FOR BREAST RECONSTRUCTION?
Women with severe lung disease, advanced diabetes, or those who have had a recent heart attack or are heavy smokers.
Women who smoke are at risk for serious complications, as it affects blood flow to the skin and underlying tissues. Women who smoke are also more prone to infection and delayed healing. Thus smokers considering this surgery are advised to discontinue smoking at least three months before and one month after the surgery.
When cancer has spread beyond the breast region, women need to consider whether the pain and discomfort of breast reconstruction surgery will interfere with the quality of their perhaps shortened life.
Women may not be suitable candidates for this surgery if their emotions, motivation or personal circumstances make it difficult for them to cope with additional surgery and healing.
WHEN CAN BREAST RECONSTRUCTION BE PERFORMED?
In the past, breast reconstruction was delayed for a period of time to allow women to recover both emotionally and physically after mastectomy surgery. Now breast reconstruction is often done at the time of mastectomy (immediate reconstruction). However, it can be done months or years after mastectomy (delayed reconstruction).
Ideally, women facing mastectomy should learn about their options for breast reconstruction from their general surgeons or medical oncologists before breast cancer surgery. Some doctors believe that it is better to delay reconstruction when chemotherapy and radiation treatment are necessary after the surgery or when a patient is at high risk for wound healing complications (women who are smokers, diabetic, obese or have large breasts). Some women prefer to delay the reconstruction to allow them more time to consider their options.
The decision of when to have breast reconstruction should be made by the woman with advice from the team of medical specialists familiar with her case (family doctor, general surgeon, oncologist and plastic surgeon).
There are several advantages to immediate breast reconstruction. Some women want to avoid the mastectomy scar and find that immediate reconstruction helps reduce distress that often comes with the loss of a breast(s). During immediate reconstruction the general surgeon, who removes the breast, and the plastic surgeon, who reconstructs the breast, work together to save breast skin (skin-sparing technique). This produces the best results. When less skin is removed during mastectomy the scars are often easier to conceal. An additional benefit is that recovery from the mastectomy and breast reconstruction can happen at the same time, without women needing to take additional time off work.
Not all women are candidates for immediate reconstruction. Some women find that making the many decisions necessary for the treatment of breast cancer is enough to deal with at one time. Women who are undecided about reconstruction at the time of mastectomy might prefer to delay the surgery until they get used to living without a breast and have time to explore reconstruction surgery.
Sometimes women who have immediate breast reconstruction compare the appearance and sensation of their natural breast with the reconstructed breast. This can lead them to feel less satisfied with their reconstructed breast than if they had lived without a breast before undergoing delayed reconstruction.
IS BREAST RECONSTRUCTION POSSIBLE IF I NEED RADIOTHERAPY AND/OR CHEMOTHERAPY?
It is still possible for most women to have breast reconstruction before or after radiotherapy and/or chemotherapy. Breast reconstruction should be delayed between 3 to 4 weeks after chemotherapy and usually 4 to 6 weeks after radiotherapy.
With tissue transfer reconstruction (moving muscle from the stomach or back to make a new breast mound) radiation therapy can be started before the surgery or once all wounds have healed in the chest area (usually 3 to 4 weeks). If tissue expansion reconstruction (expander is put under the chest muscle to stretch the muscle so that an implant can be placed to make a breast mound) has been done and radiation is required, it is best the expansion process be done over a longer period of time to minimize risks. If it is known before the mastectomy that radiation treatment is needed, then tissue transfer reconstruction is advised, as complications after tissue expander followed by radiation tend to be high.
WHAT FACTORS SHOULD BE CONSIDERED WHEN DECIDING TO HAVE BREAST RECONSTRUCTION?
Some women with a new diagnosis of breast cancer find it difficult to sift through all the information they receive in the first few days. While it is important for them to be involved in the treatment decisions, they also need to explore all options before making their decisions. Only then can they decide whether to choose immediate breast reconstruction.
Appropriate management of the breast cancer must be the most important factor for them to consider. Women have a right to be informed about all possible choices, including breast reconstruction, as part of the breast cancer management. General
practitioners or family doctors provide women with a referral to a plastic surgeon.
The plastic surgeon with expertise in this type of surgery needs to be involved in the information and decision making process.
Women should ask the plastic surgeons about their experience with breast reconstruction, what options he or she thinks are appropriate for the case, and how comfortable the plastic surgeon feels with the option chosen.
HOW MANY SURGERIES ARE REQUIRED FOR BREAST RECONSTRUCTION?
Breast reconstruction occurs in stages. For immediate flapreconstruction, two surgeries (with general anaethetics) are usually needed. The first stage covers both the mastectomy and tissue expander placement. If the natural breast needs to be enlarged, reduced or uplifted to match the reconstructed breast, that surgery is most commonly done at the same time as the mastectomy and reconstruction.
The second stage to create the nipple and areola is done about 4 to 6 months after the breast reconstruction. Nipple reconstruction and tattooing is optional. However, at this stage there is an opportunity for women to have their breast symmetry and donor site improved if required.
For delayed flapreconstruction three surgeries are needed.
The first stage is the mastectomy. The second stage is the breast mound reconstruction and often includes surgery to balance the size or shape of the opposite breast(s). The third stage, is to create nipple and areola, is optional but highly recommended to give the best outcome.
For immediate tissue expansion and implantsurgery the first stage occurs when tissue expander is placed at the time of mastectomy. The second stage occurs after the expansion process is complete. Second stage surgery involves removing the expander and placing an implant.
For delayed tissue expansion and implant surgery five stages are required. The first stage is the mastectomy surgery, the second stage is the expander placement, the third stage is the tissue expander removal and implant placement, the fourth is nipple/areola reconstruction and fifth tattooing.
With all types of reconstruction, complications may require additional surgery. The need for further surgery beyond the initial reconstructive procedures is usually higher in implant reconstruction cases.
WHAT ARE MY OPTIONS FOR BREAST RECONSTRUCTION IF I HAVE A MASTECTOMY?
The options for reconstruction can be divided into three general categories:
- Implant only
- Using your own body tissue only
- Implant combined with using your own body tissueAll reconstructive options will require multiple surgeries and take time to achieve the final result.
WHICH METHOD MAY BE BEST FOR ME?
The best method for you depends on many factors, including your:
- Body shape
- Past surgeries
- Current health
- Treatment needs
- Personal preferences
During your consultation, the surgeon will discuss your reconstructive options, including the risks, benefits and choices for each procedure. You will also discuss the expected outcomes from reconstruction.
DO I HAVE TO HAVE BREAST RECONSTRUCTION?
No. Some patients decide that they are not ready to have reconstruction for various reasons, or do not want to undergo any further surgeries. Many breast cancer patients may choose to wear a prosthesis (an artificial breast) to allow better fit in clothing and minimize the lopsided feeling that the missing breast tissue or breast may create for some patients after cancer surgery. Living a long cancer-free life is our goal, but retaining your femininity is just as important.
HOW LONG IS THE RECONSTRUCTION PROCESS?
The timeline for completing breast reconstruction varies, depending on how many surgeries are done and the need for other cancer treatments. The reconstruction process takes 6 months to one year, no matter what procedures are chosen, and if no further cancer treatment is necessary. Many patients may choose to not have a nipple reconstructed or may require multiple surgeries to make the reconstructed breast look like the remaining natural breast. Here’s a general reconstruction timeline:
Step 1: First surgery to create breast. Wait about three months for healing. Increase this time if you need chemotherapy or radiation treatment.
Step 2: Surgery to make any changes to refine or balance the reconstructed breast. Wait about 3 to 6 months for healing. This step may be repeated as needed.
Step 3: Surgery to add nipple and areola.
ARE THERE RISKS ASSOCIATED WITH BREAST RECONSTRUCTION?
Yes. As with any surgery, there are risks. The plastic surgeon will review these risks during your clinic visits and answer any questions. Risks of breast reconstruction surgery may include:
- Wound healing problems
- Changes in sensation
- Fluid build up (such as hematomas and seromas)
- Implant failure/rippling/extrusion
- Partial or complete loss of flaps
- Failure or loss of implants
- Asymmetry (lopsidedness)
- Poor cosmetic results
WHAT QUESTIONS SHOULD I ASK MY RECONSTRUCTIVE SURGEON?
- Can breast reconstruction be done in my case?
- When can I have reconstruction done?
- What types of reconstruction are possible for me?
- What type of reconstruction do you think would be best for me? Why?
- How many of these procedures have you done?
- Will the reconstructed breast match my remaining breast and if not, what can be done?
- How will my reconstructed breast feel and will I have any sensation?
- What possible complications should I know about?
- How long will the surgery take and how long will I be in the hospital?
- Will I need blood transfusions? If so, can I donate my own blood?
- How long is the recovery time?
- How much help will I need at home to take care of my drain (tube that lets fluid out) and wound?
- When can I start my exercises and return to normal activity such as driving and working?
- Can I talk with other women who have had the same surgery?
- Will reconstruction interfere with chemotherapy or radiation therapy?
- How long will the implant last?
- What happens if I gain or lose weight?
WHAT IF MY NATURAL BREAST DOESN’T MATCH MY RECONSTRUCTED BREAST?
The ultimate goal of reconstruction is to create a breast that is symmetrical with the remaining natural breast. Sometimes, getting the reconstructed and natural breasts to match is difficult unless surgery is performed on the natural breast, too. For some patients, this may involve placing an implant in the natural breast to make it larger (augmentation); making the natural breast smaller or less droopy by reducing the tissue (reduction), or lifting the breast skin (mastopexy). Your surgeon will discuss these options during your consultation. This balancing procedure is often done 6 to 12 months after your first surgery, to make sure the reconstructed breast has healed and is the desired size and shape.
WHAT IF I MAY NEED CHEMOTHERAPY?
Breast reconstruction should not delay chemotherapy treatments. Usually your medical oncologist will wait until you have healed from your mastectomy and reconstruction before starting chemotherapy. If you have complications such as wound healing problems or infection, chemotherapy may be delayed.
If you are undergoing tissue expansion at the time of chemotherapy, the surgeon may need to take blood. This is to make sure that your body can fight bacteria that may be introduced from your skin during the expansion process. Once chemotherapy is complete, your surgeon will usually wait at least a month before considering further reconstructive surgery.
WHAT IF I MAY NEED RADIATION?
You may want to delay breast reconstruction until you are finished with radiation therapy. Radiation may damage your reconstruction and affect your final cosmetic result. If you require radiation, your surgeons may recommend that you use your own tissue for delayed reconstruction, either alone or with an implant. Implant-only reconstruction is not recommended, since radiation often results in implant complications, including:
- Severe capsular contracture (scar tissue around the implant causes hardening of the breast)
- Fluid buildup
- Poor cosmetic result
If you may need radiation treatment, a tissue expander can be placed during the mastectomy to preserve the skin pocket. It provides a breast mound while you are waiting to hear if you need radiation.
If you do not need radiation, you and your surgeon can plan the final reconstruction. If you do need radiation, the tissue expander can be left in place. However, the tissue expander must be deflated while you are receiving radiation, which usually takes 6 to 8 weeks. The tissue expander is then re-inflated 2 weeks after radiation is complete. A delayed reconstruction is planned with your surgeon. Not all surgeons will recommend this option because there is an increased risk of complications by having a tissue expander in place during radiation treatment.
DOES RECONSTRUCTION CHANGE THE RISK OF MY CANCER RETURNING? DOES IT MAKE CANCER DETECTION HARDER?
The risk of breast cancer recurrence depends on the stage of disease, biologic characteristics of the cancer and additional breast cancer treatments. Reconstructive surgery has not been shown to increase the risk of the cancer returning or make it harder to detect if cancer does return. The methods or tests used to screen for recurrence will be decided by your cancer care team.
WHAT IF I’M CONSIDERING A LUMPECTOMY OR BREAST CONSERVATION INSTEAD OF MASTECTOMY?
If you’re considering breast conservation rather than a mastectomy, reconstructive options may be available to improve the cosmetic result. Breast conservation surgery usually involves removing a portion of breast tissue where the cancer is located, followed by radiation therapy. The removal of breast tissue can often leave an indentation or dimple on the breast. This dimple may not be seen until after radiation treatment.
To prevent this, your plastic surgeon may be able to re-arrange the remaining breast tissue at the time of the cancer removal. This may leave you with a smaller breast or further scarring. These procedures are referred to as oncoplastic surgery. If this isn’t an option at the time of your cancer surgery, delayed reconstructive options may be used, such as the latissimus dorsi flap, local tissue flaps and fat grafting.
WILL THE RECONSTRUCTED BREAST BE MADE SYMMETRICAL TO THE EXISTING BREAST?
Yes, the symmetry procedure is performed approximately 6 to 12 months after the initial flap. The second stage provides refinement of the shape of the reconstructed breast as well as lifting or reduction of the other breast to achieve optimal balance.
WHAT IS DONE TO RESTORE THE NIPPLE AND AREOLA?
The final stage of breast restoration takes place about 2 to 3 months after the second stage procedure. Initially the nipple is reconstructed using the flap tissue, and then medical tattooing or skin grafting is performed to restore the color of the areola. Both of these are performed as an outpatient procedures.
WHAT ARE THE LONG-TERM RESULTS?
The short and long-term results are excellent. Patients are able to leave the hospital after 3 to 4 days. They are able to ambulate on post-operative day number two. Patients return to normal daily activities after about 2 weeks, and are able to resume exercise after 6 weeks.