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  • Breast Reconstruction Options

    A mastectomy (surgical removal of the entire breast) is sometimes used to treat breast cancer and to help prevent breast cancer in some women at high risk (called prophylactic mastectomy). Many women who have a mastectomy choose to have reconstructive surgery to help restore the look and feel of the breast. The decision to have reconstruction is a personal one and not all women choose this option.  

    If you are going to have a mastectomy, you will likely need to make decisions about breast reconstruction before you have surgery. Knowing more about the different types of breast reconstruction, and some of the issues related to each, may help you discuss your options with your plastic surgeon.   

    Dr. Funda Meric-Bernstam, MD, Professor of Surgical Oncology and Medical Director of the Institute of Personalized Cancer Therapy at the University of Texas M. D. Anderson Cancer Center says, “It is very important that all patients with breast cancer who undergo a mastectomy discuss whether they are a candidate for reconstruction and their breast reconstructive options with their surgeons. Not all women are candidates for reconstruction, and not all women undergoing reconstruction are candidates for all reconstruction types. This decision needs to be personalized. Women who are better informed can ensure that they have access to the most suitable options for themselves.” 

    Breast prostheses

    Some women decide not to have reconstructive surgery and instead may choose to wear a breast prosthesis. This is a breast form made of silicone gel, foam or other materials. When worn in a bra (may be called a surgical bra or a mastectomy bra) under clothes, the prosthesis looks very natural. Breast prostheses and the special bras they fit in are often covered by insurance. Learn more about breast prostheses.   

    Benefits of breast reconstruction

    Breast reconstruction can help you feel more comfortable about how you look and regain confidence in your sexuality.  

    Choosing the type of breast reconstruction that is right for you

    If you choose reconstruction, the type of surgery you have will depend on your:  

    • Body shape 
    • Overall health 
    • Breast cancer treatments after surgery  
    • Lifestyle  
    • Personal preferences 

    Not all women are candidates for all reconstructive procedures. And, for women with larger breasts, breast reduction surgery on the opposite, natural breast may be needed to create a more even look. Your plastic surgeon will help you choose the type of reconstruction that will give you the best results. Although this decision may seem overwhelming, it may be comforting to know that most women who have had breast reconstruction are happy with the method they chose.1  

    The final results of breast reconstruction vary from woman to woman. Your satisfaction with the results may depend on your expectations. Keep in mind a reconstructed breast will not look or feel exactly the same as a natural breast. Most of the scarring will fade over time, but some scars may never go away. And, as you age and the opposite breast changes shape, the reconstructed breast may look or feel less natural. 

    Breast reconstruction can be done using: 

    • Breast implants (filled with saline or silicone) 
    • Natural tissue flaps (use skin, fat and muscle from your own body)  
    • A combination of these methods 

    There is no one best method for reconstruction. There are pros and cons to each method, but fairly few complications with any of the current techniques.1  

     

      

    Breast implants  

    Natural tissue flaps (grafts) 

    Looks and feels like a natural breast 

    Less able to mimic the look and feel of a natural breast. (Silicone implants look and feel more natural than saline implants.) 

    Better able to mimic the look and feel of a natural breast. 

     

    Loss of sensation 

    Will likely lose some sensation in the breast. 

    Some women can lose some sensation in the breast and tissue donation site. 

    Surgery 

    Less extensive. 

    Time in surgery is shorter.  

    More extensive.  

    Time in surgery is longer. 

    DIEP, SIEA, S-GAP and I-GAP procedures require well-trained microvascular surgeons. 

    Is a hospital stay needed? 

    Needed for the first procedure. Follow-up procedures may be done on an outpatient basis. 

    Needed for the procedure (longer stay than with implants).  

    Will the procedure need to be repeated? 

    Implants will likely need to be replaced during lifetime. 

    Tissue flaps will not need to be replaced during lifetime. However, if there are complications, some procedures cannot be repeated. 

    Recovery 

    Two to three weeks. 

     

    Fewer scars. 

    Three to six weeks. 

     

    More scars. 

    Risk of complications 

    Some risk of surgical complications. 

    Some risk of surgical complications (certain procedures have more risks than others). 

    Adapted from selected sources.1-4 

     

    Implants

    Breast Reconstruction with Implants
    Watch the Video 

    There are two basic types of breast implants: saline and silicone. Both types have an outer shell made of a solid form of silicone. Saline implants are filled with saline (a saltwater solution similar to that found in IV fluids). Silicone implants are filled with silicone gel. There are pros and cons to each type of implant (learn more). However, plastic surgeons prefer to use silicone implants because they have a more natural look and feel and tend to last longer than saline implants.  

    Inserting a breast implant (saline or silicone) is a fairly simple process.  

    Step one: A modified saline implant (called a tissue expander) is inserted in the envelope formed by the skin and chest muscle. The expander has a valve that allows more saline to be added after surgery.  

    Step two: Over a period of four to six months (in repeated office visits), the skin-muscle envelope is slowly stretched by injecting more saline into the expander until it reaches the desired size of the final implant.  

    Step three: A surgeon removes the expander and replaces it with the final implant (saline or silicone). This is usually an outpatient surgery. 

    Safety of implants

    Silicone implants are a safe option to saline implants. Research suggests there is no link between silicone implants and lupus, immune system disorders, connective tissue disease or rheumatoid arthritis.5 However, the FDA is looking into a possible link between breast implants (both saline and silicone) and a slight increase in the risk of a rare form of cancer called anaplastic large cell lymphoma (ALCL). (ALCL occurs in breast tissue in about three in 100 million women.6-8) Read our statement on breast implants and the possible link to ALCL.  

    Natural tissue flaps (grafts)

    Breast Reconstruction with Tissue Flap
    Watch the Video 

    The most common flap procedures use tissue from the back, abdomen or buttocks. In some procedures, an entire muscle is removed to reconstruct 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, discuss this with your plastic surgeon. Your body size may also affect which procedures you can have. For example, thinner women may not have enough abdominal fatty tissue for some techniques.   

    Natural tissue flap breast reconstruction methods include:1,12  

    Reconstruction with a combination of an implant plus donated natural tissue

    The acellular dermis procedure is less invasive than some other natural tissue reconstruction methods. Using donated cadaver tissues (called acellular dermal matrix), the plastic surgeon creates a “hammock” under the mastectomy skin envelope to hold the implant in place.9-11 This allows a larger breast mound to be created at the time of the mastectomy. A breast implant is placed in the hammock. Under ideal conditions, a tissue expander is not needed and the final implant can be inserted at the time of the mastectomy and no further surgery is needed.  

    Nipple-areola reconstruction

    Recreating the nipple and areola gives the reconstructed breast a more natural look and can help hide scars.1 The nipple can be recreated with tissue from the reconstructed breast after the skin on the breast has healed. The areola may be recreated with a tattoo or by grafting skin from the groin area (which has a similar tone as the skin on the areola).  

    Timing of breast reconstruction

    Breast reconstruction can be done at the same time as the mastectomy ("immediate") or some time after the surgery ("delayed"). The timing depends on your situation and the treatment you will have after surgery. Not all women are candidates for immediate reconstruction.  

    Factors that can impact reconstruction choices

    Smoking

    Smoking increases the risk of complications (such as wound healing) for all types of breast reconstruction.1,13 For this reason, smokers may not be good candidates for some procedures. All women who smoke are encouraged to stop smoking during the post-surgery healing period.  

    Radiation therapy

    Radiation therapy can cause changes in skin color and tissue shrinkage for all types of breast reconstruction. If you will have radiation therapy after surgery, it may impact both the timing and the type of reconstruction that will give you the best results (learn more).  

    Insurance coverage for reconstructive surgery

    Many states require health insurance providers to pay for reconstructive surgery after a mastectomy. Learn more about insurance coverage for breast reconstruction.   

    Summary

    If you are considering breast reconstruction following mastectomy, you have many options. Although you may not be a candidate for all procedures, your plastic surgeon can help you choose the method that is best for you. While the reconstructed breast will never look exactly like your natural breast, this area of plastic surgery continues to improve. 

    References

    1. Patel SA and Topham NS. Chapter 39: Breast reconstruction, in Harris JR, Lippman ME, Morrow M, Osborne CK. Diseases of the Breast, 4th edition. Lippincott Williams and Wilkins, 2010.  
    2. American Society for Aesthetic Plastic Surgery and American Society of Plastic Surgeons. Breast implants. http://www.surgery.org/consumers/procedures/breast/breast-implants, 2009. 
    3. The University of Texas MD Anderson Cancer Center. Reshaping you: Options for breast reconstruction. http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-topics/cancer-treatment/breast-reconstruction/decision.html, 2009.  
    4. Christensen BO, Overgaard J, Kettner LO, Damsgaard TE. Long-term evaluation of postmastectomy breast reconstruction. Acta Oncol. 50(7):1053-61, 2011. 
    5. Janowsky EC, Kupper LL, Hulka BS. Meta-analyses of the relation between silicone breast implants and the risk of connective-tissue diseases. N Engl J Med. 342(11):781-90, 2000.  
    6. Center for Devices and Radiological Health, U.S. Food and Drug Administration. Anaplastic large cell lymphoma (ALCL) in women with breast implants: Preliminary FDA findings and analyses. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239996.htm, 2011.  
    7. Kim B, Roth C, Chung KC, et al. Anaplastic large cell lymphoma and breast implants: A systematic review. Plast Reconstr Surg..127(6):2141-50, 2011. 
    8. Eaves FF, Haeck P, Rohrich RJ. Breast implants and anaplastic large cell lymphoma (ALCL): Using science to guide our patients and plastic surgeons worldwide. Plast Reconstr Surg. 2011 Mar 25. [Epub ahead of print]. 
    9. Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg. 55(3):232-9, 2005. 
    10. Salzberg CA, Ashikari AY, Koch RM, Chabner-Thompson E. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). Plast Reconstr Surg. 127(2):514-24, 2011.  
    11. Sbitany H, Serletti JM. Acellular dermis-assisted prosthetic breast reconstruction: a systematic and critical review of efficacy and associated morbidity. Plast Reconstr Surg. 128(6):1162-9, 2011. 
    12. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction using perforator flaps. J Surg Oncol. 94(6):441-54, 2006. 
    13. Olsen MA, Lefta M, Dietz JR, et al. Risk factors for surgical site infection after major breast operation. J Am Coll Surg. 207(3):326-35, 2008. 

    Posted May 17, 2012