Breast Reconstruction

Breast Reconstruction and Prosthesis
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Breast reconstruction can help restore the look and feel of the breast after a mastectomy. Performed by a plastic surgeon, breast reconstruction can be done at the same time as the mastectomy ("immediate") or some time after the surgery ("delayed"). Many women now get immediate breast reconstruction. However, the timing of reconstruction depends not only on your wishes but also on your situation and the follow-up care you might need after surgery. Not all women are candidates for immediate reconstruction. It is important to discuss your options with your breast surgeon, oncologist and plastic surgeon.

Although a reconstructed breast may never look or feel the same as your original breast, this area of plastic surgery continues to improve. Having a breast reconstructed can help you feel less self-conscious about how you look and restore confidence in your sexuality.

Breast reconstruction can be done using artificial implants (filled with saline or silicone), skin, fat and muscle from your own body or a combination of these methods. There are pros and cons to each method. Artificial implants need less extensive surgery than procedures using your own body tissues, but the results can look and feel less natural [98]. There is no one best method. Your body shape and anatomy may affect the types of reconstruction likely to give you the best results. You should discuss your options with your plastic surgeon. It may be comforting to know that most women are happy with the method they chose. And, there are relatively few complications with any of the current techniques [98].

Most breast reconstruction methods involve several steps. Both immediate and delayed reconstruction require a hospital stay for the first procedure. However, follow-up procedures may be done on an outpatient basis [99].

Smoking increases the risk of complications for all types of breast reconstructive surgery [90]. If you smoke, talk to your plastic surgeon about any problems with wound healing or with flap procedures that may occur [63].

Implants

Inserting an artificial implant is a fairly simple procedure that may not require extra hospital time if it can be done at the time of the mastectomy. The shape of the reconstructed breast with an implant may not look or feel quite like the natural, opposite breast, especially as you age and your natural breast changes shape. For this reason, this procedure is better suited for women with small or medium-sized breasts with little or no sagging [98]. It is also possible to have surgery to enlarge or reduce the size of the opposite breast to help make both breasts look the same.

There are two basic types of breast implants: saline and silicone. Although there was concern in the past over the safety of silicone implants, to date, there is no proven evidence that they are linked to lupus, immune system disorders, connective tissue disease or rheumatoid arthritis [98]. Therefore, women should consider silicone implants as an option to saline implants. For both saline and silicone implants, the outer cover of the implant (also called the implant sac) is made of a solid form of silicone. The two types of implants differ in the substance used to fill the implant sac. Saline implants are filled with saline, a saltwater solution similar to that found in IV fluids. Silicone implants are filled with silicone gel, a semi-solid substance made from silicone.

In general, inserting a saline implant is a two- or three-step procedure. The process often begins with the insertion of a tissue expander between the skin and chest muscle. This forms a skin-muscle envelope. The tissue expander is a modified saline implant with a valve that lets more saline be added after the first surgery. A simple injection of saline through the skin into the valve fills the implant. During repeated office visits over a period of four to six months, the skin-muscle envelope is slowly stretched until the desired size of the final implant is reached. The next step of the process is an outpatient procedure in an operating room where the expander is removed and replaced with a permanent implant (saline or silicone). In some cases, the expander is kept in place for an extended period of time. This allows the size of the reconstructed breast to be changed (by increasing or decreasing the amount of saline in the implant) at a later time without having to remove the implant.

The procedure for inserting a silicone implant is similar to that for a saline implant. However, it usually involves fewer steps because the implant sac is pre-filled with a specific amount of silicone gel. Thus, the size of the reconstructed breasts cannot be changed without surgical replacement of the implant.

Some women do not need tissue expansion and can have an implant (saline or silicone) directly inserted. This depends on whether the size of the available skin-muscle envelope at the time of the mastectomy is large enough to cover the desired final implant. These cases are exceptions rather than the rule.

Breast reconstruction with implants using acellular dermal matrix

A newer reconstructive technique takes advantage of the entire skin envelope available at the time of the mastectomy [100,101]. This technique creates a hammock underneath the mastectomy skin envelope to hold the expander or implant in place. The hammock is made from donated tissues (called "acellular dermal matrix"), either in combination with or without your chest muscle. Similar procedures have been used in the past for other reconstructive procedures in the body. The procedure is less invasive and the length of the surgery is shorter than some other techniques. It also allows a larger breast mound to be created at the time of the mastectomy. This decreases the number of office visits needed to reach the desired implant volume. And, the expander can be replaced with the final implant sooner than other tissue expanding techniques. Under ideal conditions, an expander is not needed and the final implant can be placed into the created hammock at the time of the mastectomy and no further surgery is needed.

Not all women are candidates for this procedure. It is dependent on the quality of the mastectomy skin envelope. You should talk with your reconstructive surgeon to find out whether or not you are a good candidate for this procedure.

Reconstruction of the nipple is either done when the permanent implant is inserted in the operating room or as a third step in the office.

Comparison of Saline and Silicone Implants

There are pros and cons to each type of implant. These are summarized in the table below. However, you should discuss your options with a plastic surgeon in order to choose the type that is best for you. 
 

Breast Implants and Radiation Therapy

Radiation therapy can cause problems with both implant and natural tissue reconstruction. If implants are the preferred method of reconstruction and radiation therapy will be used after mastectomy, immediate rather than delayed breast reconstruction is recommended [63]. Skin that has received radiation and is later stretched to fit an implant is at high risk for complications and a poor cosmetic result [63]. Results are better when the procedures to expand the skin are done before radiation therapy begins.

Breast Implants and Mammography

It is important for women who have breast implants to notify their health care provider before getting a mammogram (standard X-ray film or digital) so that special adjustments to the mammography machine can be made.

Natural Grafts/Tissue Flap Surgery

Reconstruction using skin and tissue flaps (grafts) from your own body tends to look and feel more like a natural breast. However, these procedures are more complicated and invasive than those with artificial implants and usually prolong the hospital stay. They also leave scars in the area of the body where the tissue was taken. In some flap procedures an entire muscle needs to be removed for the reconstruction of the breast. This can cause weakness in that area of the body and might have a negative impact on certain physical or athletic activities. If you are active, you should discuss this with your plastic surgeon. Today, the most common natural graft procedures use tissue from the back, tummy or buttocks.

Latissimus dorsi muscle flap breast reconstruction

The latissimus dorsi muscle flap procedure removes a large muscle in the back along with skin and underlying fatty tissue and uses these tissues to reconstruct the breast. The inclusion of fatty tissue helps create a more natural looking breast. However, the flap itself is only about one inch thick. Therefore, even with the added fatty tissue, this procedure usually requires an artificial implant together with the natural tissue to make the reconstructed breast match the size of the unaffected breast. Even so, because much of the reconstructed breast is formed with natural tissue, the look and feel of the breast will be more natural than with an implant alone.

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction

The transverse rectus abdominis myocutaneous (TRAM) flap is a common type of breast reconstruction that uses natural tissues. This procedure uses skin, muscle tissue and fat tissue from the lower abdomen (tummy) to reconstruct the breast. A TRAM flap creates a very natural looking breast. It usually does not require an implant as long as there is enough excess skin and fatty tissue in the lower abdomen. However, it does have some drawbacks. Once the procedure has been done, it cannot be repeated. And, women who do not have excess tissue in the abdominal area may not be candidates for the procedure. Moreover, the surgery is complicated and invasive and leaves a large scar across the lower abdomen. Since the lower abdominal muscle is used to form the reconstructed breast, its loss will cause some weakness in this area of the body. Women who are athletic or physically active should consider this aspect of the procedure.

Deep inferior epigastric perforator (DIEP) flap breast reconstruction

An increasingly popular procedure is the deep inferior epigastric perforator (DIEP) flap. The DIEP flap procedure, like the TRAM flap procedure, uses skin and fat tissue from the lower abdomen to form the reconstructed breast. Unlike the TRAM flap, the DIEP flap procedure keeps the abdominal (tummy) muscle intact. This speeds recovery and preserves abdominal strength after the procedure. However, as with the TRAM flap, a DIEP flap reconstruction cannot be repeated. It is also more complicated than the latissimus dorsi muscle flap and TRAM flap procedures. It usually requires two surgeons well trained in microvascular techniques. It also tends to take longer to perform than other natural graft procedures, which can increase the risk of complications during surgery. And, it's still unclear whether the benefits of the DIEP flap procedure outweigh the risks when compared to other techniques [98]. Therefore, the DIEF flap procedure should only be done by surgeons who are well-trained and experienced with this technique.

Superior gluteal artery perforator (S-GAP) flap breast reconstruction

The superior gluteal artery perforator (S-GAP) flap procedure uses skin and fatty tissue from the upper part of a buttock to reconstruct the breast. Because no buttock muscle tissue is used, athletic ability after surgery is not usually affected [104]. S-GAP flap reconstruction may be a good option for women with more fat tissue in their buttocks area than in their abdomen [104]. If the procedure leaves a woman's buttocks noticeably dissimilar in size, liposuction can be used at a later time to remove fat from the opposite buttock to create a more even look. Like the DIEP flap, the S-GAP flap procedure is more complex than the other types of natural tissue graft procedures and requires a surgeon well-trained in microvascular techniques [105]. It takes longer to perform than other types of tissue flap surgeries, even longer than the DIEP flap procedure [104]. The longer time in surgery may increase the risk of complications. Unlike the DIEP flap procedure, if an S-GAP flap procedure is not successful, it can be repeated using the tissues of the opposite buttocks (either immediately or at a later time) [104].

Skin-Sparing Mastectomy

If a woman is having immediate breast reconstruction, the surgeon may try to keep as much of the skin of the breast as possible intact. This is called a skin-sparing mastectomy. The tumor and margins are removed, as are the nipple, areola, fat and other tissue that make up the breast. What remains is much of the skin that surrounded the breast. This skin can then be used to cover a tissue flap or artificial implant.

The major benefit of a skin-sparing mastectomy is that it avoids using skin from other parts of the body for reconstruction. That skin can have a different color, texture and thickness compared to the natural breast skin. Thus, because natural breast skin is used, the reconstructed breast will look more like the opposite, unaffected breast. Although it's been suggested that skin-sparing mastectomy may increase the risk of cancer recurrence, most studies to date have not found increased risk [106,107].

Natural Tissue Reconstruction and Radiation Therapy

Radiation therapy can cause problems (such as changes in skin color and tissue shrinkage) with both implant and natural tissue reconstruction. For women undergoing a natural tissue reconstruction and who will have radiation therapy following mastectomy, it might be better to delay reconstruction until after radiation therapy is completed [63]. This lowers the chances that the look, feel and size of the reconstructed breast will be adversely affected by the radiation therapy [63].

Nipple-Areola Reconstruction

The nipple and areola are usually the last stage of breast reconstruction. Recreating the nipple and areola gives the reconstructed breast a more natural look and can help hide scars. These procedures do not usually require an overnight stay in the hospital. The nipple can be recreated with tissue from the reconstructed breast itself after the skin on the breast has healed and had a chance to expand over the new tissue or implant. The areola may also be created by tattooing the area or by grafting skin from the groin area. Skin in the groin area has a similar tone to the skin on the areola and the graft scar can be concealed in the bikini line [98].

Nipple-sparing mastectomy

Nipple-sparing mastectomy is a newer procedure that removes the tumor and margins as well as the fat and other tissue in the breast, but leaves the nipple and areola intact. This improves the overall cosmetic look of the breast. Radiation therapy to the nipple may be given during or after the surgery to reduce the chances of recurrence [108,109]. Not all women are candidates for this procedure. Along with the risks of any surgery, there are other complications with nipple-sparing mastectomy. The nipple will lose sensation and some projection. In some cases, the tissues may break down and some or all of the nipple and areola may need to be removed later [108-110].

After Breast Reconstruction

Most women feel tired and sore for two to three weeks after reconstruction. Overhead lifting, strenuous sports and sexual activity should be avoided for four to six weeks following reconstructive surgery. Most women can resume normal activity levels within eight weeks [111]. You should talk to your health care provider about specific recommendations following your surgery.

It is important to remember that while breast reconstruction can improve appearance and boost self-confidence, the reconstructed breast will not have the same feeling or the exact look and feel of a natural breast. Most of the scarring will fade over time, but some scars may never completely go away [111].

Most women who undergo breast reconstruction live through a period of emotional adjustment. Feeling anxious or depressed is common. It may be useful to talk with a counselor or to other women who have undergone breast reconstruction.

Insurance Coverage for Reconstructive Surgery

Many states require health insurance providers to pay for reconstructive surgery following mastectomy. At this time, however, no federal laws mandate this coverage. The Women's Health and Cancer Rights Act of 1998 requires that all health insurance providers and health maintenance organizations (HMOs) that pay for mastectomy also pay for reconstruction. Many states have laws that go further and require all health insurers to cover reconstructive surgery as well as prostheses and lymphedema therapy. As coverage varies from state to state, it is important to check with your state insurance commissioner's office or your health insurance provider to find out which services are covered by your state's laws and your health plan.

For more information on the Women's Health and Cancer Rights Act, visit the Department of Labor website or call toll-free at 866-275-7922.

For more information on coverage of breast cancer-related services by state, visit the National Cancer Institute's State Cancer Legislative Database's website. 
 

Questions for Your Plastic Surgeon

• What are the types of reconstruction surgery?
• Which type is best for me and why?
• How many of these procedures have you performed? Can you show me photos of both your best, and your more typical, results?
• What are the chances of infection and/or rejection of an implant device? Are there any other risks or side effects to consider?
• What are the short- and long-term consequences with muscle flap reconstruction versus implant reconstruction?
• When is the best time for me to have reconstruction — at the time of the mastectomy or later? Is there a time limit for having reconstruction done?
• How many hospital stays are needed? How long will each hospital stay be?
• Will my insurance cover breast reconstruction?
• How can I expect the reconstructed breast to look and feel? How will it compare in appearance with my healthy breast?
• Will I be able to detect a possible return of cancer after reconstructive surgery? Is a mammogram still recommended for me?
• Is there much pain after surgery? What body changes may I have after surgery, and for how long?
• If I do not choose reconstruction, where can I find a prosthesis? How do I get reimbursed from my insurance company?

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