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If
you're considering breast reconstruction...
Reconstruction of a breast that has been removed
due to cancer or other disease is one of the most
rewarding surgical procedures available today. New
medical techniques and devices have made it possible
for surgeons to create a breast that can come close
in form and appearance to matching a natural breast.
Frequently, reconstruction is possible immediately
following breast removal (mastectomy), so the patient
wakes up with a breast mound already in place, having
been spared the experience of seeing herself with
no breast at all.
But bear in mind, post-mastectomy breast reconstruction
is not a simple procedure. There are often many
options to consider as you and your doctor explore
what's best for you.
This information will give you a basic understanding
of the procedure — when it's appropriate, how
it's done, and what results you can expect. It can't
answer all of your questions, since a lot depends
on your individual circumstances. Please be sure
to ask your surgeon if there is anything you don't
understand about the procedure.
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The
best candidates for breast reconstruction surgery
Most mastectomy patients are medically appropriate
for reconstruction, many at the same time that the
breast is removed. The best candidates, however,
are women whose cancer, as far as can be determined,
seems to have been eliminated by mastectomy.
Still, there are legitimate reasons to wait. Many
women aren't comfortable weighing all the options
while they're struggling to cope with a diagnosis
of cancer. Others simply don't want to have any
more surgery than is absolutely necessary. Some
patients may be advised by their surgeons to wait,
particularly if the breast is being rebuilt in a
more complicated procedure using flaps of skin and
underlying tissue. Women with other health conditions,
such as obesity, high blood pressure, or smoking,
may also be advised to wait.
In any case, being informed of your reconstruction
options before surgery can help you prepare for
a mastectomy with a more positive outlook for the
future.
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All
breast surgery carries some uncertainty and risk
Virtually any woman who must lose her breast to
cancer can have it rebuilt through reconstructive
surgery. But there are risks associated with any
surgery and specific complications associated with
this procedure.
In general, the usual problems of surgery, such
as bleeding, fluid collection, excessive scar tissue,
or difficulties with anesthesia, can occur although
they're relatively uncommon. And, as with any surgery,
smokers should be advised that nicotine can delay
healing, resulting in conspicuous scars and prolonged
recovery. Occasionally, these complications are
severe enough to require a second operation.
If an implant is used, there is a remote possibility
that an infection will develop, usually within the
first two weeks following surgery. In some of these
cases, the implant may need to be removed for several
months until the infection clears. A new implant
can later be inserted.
The most common problem, capsular contracture,
occurs if the scar or capsule around the implant
begins to tighten. This squeezing of the soft implant
can cause the breast to feel hard. Capsular contracture
can be treated in several ways, and sometimes requires
either removal or "scoring" of the scar tissue,
or perhaps removal or replacement of the implant.
Reconstruction has no known effect on the recurrence
of disease in the breast, nor does it generally
interfere with chemotherapy or radiation treatment,
should cancer recur. Your surgeon may recommend
continuation of periodic mammograms on both the
reconstructed and the remaining normal breast. If
your reconstruction involves an implant, be sure
to go to a radiology center where technicians are
experienced in the special techniques required to
get a reliable x-ray of a breast reconstructed with
an implant.
Women who postpone reconstruction may go through
a period of emotional readjustment. Just as it took
time to get used to the loss of a breast, a woman
may feel anxious and confused as she begins to think
of the reconstructed breast as her own.
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Planning
your breast reconstruction surgery
You can begin talking about reconstruction as soon
as you're diagnosed with cancer. Ideally, you'll
want your breast surgeon and your plastic surgeon
to work together to develop a strategy that will
put you in the best possible condition for reconstruction.
After evaluating your health, your surgeon will
explain which reconstructive options are most appropriate
for your age, health, anatomy, tissues, and goals.
Be sure to discuss your expectations frankly with
your surgeon. He or she should be equally frank
with you, describing your options and the risks
and limitations of each. Post-mastectomy reconstruction
can improve your appearance and renew your self-confidence
— but keep in mind that the desired result
is improvement, not perfection.
Your surgeon should also explain the anesthesia
he or she will use, the facility where the surgery
will be performed, and the costs. In most cases,
health insurance policies will cover most or all
of the cost of post-mastectomy reconstruction. Check
your policy to make sure you're covered and to see
if there are any limitations on what types of reconstruction
are covered.
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Preparing
for your breast reconstruction surgery
Your oncologist and your plastic surgeon will give
you specific instructions on how to prepare for
surgery, including guidelines on eating and drinking,
smoking, and taking or avoiding certain vitamins
and medications.
While making preparations, be sure to arrange for
someone to drive you home after your surgery and
to help you out for a few days, if needed.
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Where
your breast reconstruction surgery will be performed
Breast reconstruction usually involves more than
one operation. The first stage, whether done at
the same time as the mastectomy or later on, is
usually performed in a hospital.
Follow-up procedures may also be done in the hospital.
Or, depending on the extent of surgery required,
your surgeon may prefer an outpatient facility.
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Types
of anesthesia for breast reconstruction surgery
The first stage of reconstruction, creation of
the breast mound, is almost always performed using
general anesthesia, so you'll sleep through the
entire operation.
Follow-up procedures may require only a local anesthesia,
combined with a sedative to make you drowsy. You'll
be awake but relaxed, and may feel some discomfort.
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Types
of breast implants
If your surgeon recommends the use of an implant,
you'll want to discuss what type of implant should
be used. A breast implant is a silicone shell filled
with either silicone gel or a salt-water solution
known as saline.
Because of concerns that there is insufficient
information demonstrating the safety of silicone
gel-filled breast implants, the Food & Drug
Administration (FDA) has determined that new gel-filled
implants should be available only to women participating
in approved studies. This currently includes women
who already have tissue expanders (see below
under Skin Expansion), who choose immediate
reconstruction after mastectomy, or who already
have a gel-filled implant and need it replaced for
medical reasons. Eventually, all patients with appropriate
medical indications may have similar access to silicone
gel-filled implants.
The alternative saline-filled implant, a silicone
shell filled with salt water, continues to be available
on an unrestricted basis, pending further FDA review.
As more information becomes available, these FDA
guidelines may change. Be sure to discuss current
options with your surgeon. (Above guidelines
are current as of July 1992.)
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The
breast reconstruction surgery
While there are many options available in post-mastectomy
reconstruction, you and your surgeon should discuss
the one that's best for you.
Skin expansion. The most common technique
combines skin expansion and subsequent insertion
of an implant.
A tissue expander is inserted following
the mastectomy to prepare for
reconstruction.
Following mastectomy, your surgeon will insert
a balloon expander beneath your skin and chest muscle.
Through a tiny valve mechanism buried beneath the
skin, he or she will periodically inject a salt-water
solution to gradually fill the expander over several
weeks or months. After the skin over the breast
area has stretched enough, the expander may be removed
in a second operation and a more permanent implant
will be inserted. Some expanders are designed to
be left in place as the final implant. The nipple
and the dark skin surrounding it, called the areola,
are reconstructed in a subsequent procedure.
The expander is gradually filled with
saline through an integrated or separate
tube to stretch the skin enough to
accept an implant beneath the chest
muscle.
Some patients do not require preliminary tissue
expansion before receiving an implant. For these
women, the surgeon will proceed with inserting an
implant as the first step.
After surgery, the breast mound is
restored. Scars are permanent, but will
fade with time. The nipple and areola
are reconstructed at a later date.
Flap reconstruction.
An alternative approach to implant reconstruction
involves creation of a skin flap using tissue taken
from other parts of the body, such as the back,
abdomen, or buttocks.
In one type of flap surgery, the tissue remains
attached to its original site, retaining its blood
supply. The flap, consisting of the skin, fat, and
muscle with its blood supply, are tunneled beneath
the skin to the chest, creating a pocket for an
implant or, in some cases, creating the breast mound
itself, without need for an implant.
With flap surgery, tissue is taken from
the back and tunneled to the front of the
chest wall to support the reconstructed
breast.
Another flap technique uses tissue that is surgically
removed from the abdomen, thighs, or buttocks and
then transplanted to the chest by reconnecting the
blood vessels to new ones in that region. This procedure
requires the skills of a plastic surgeon who is
experienced in microvascular surgery as well.
The transported tissue forms a flap for
a breast implant, or it may provide
enough bulk to form the breast mound
without an implant.
Regardless of whether the tissue is tunneled beneath
the skin on a pedicle or transplanted to the chest
as a microvascular flap, this type of surgery is
more complex than skin expansion. Scars will be
left at both the tissue donor site and at the reconstructed
breast, and recovery will take longer than with
an implant. On the other hand, when the breast is
reconstructed entirely with your own tissue, the
results are generally more natural and there are
no concerns about a silicone implant. In some cases,
you may have the added benefit of a improved abdominal
contour.
Tissue may be taken from the abdomen
and tunneled to the breast or surgically
transplanted to form a new breast mound.
Follow-up procedures.
Most breast reconstruction involves a series of
procedures that occur over time. Usually, the initial
reconstructive operation is the most complex. Follow-up
surgery may be required to replace a tissue expander
with an implant or to reconstruct the nipple and
the areola. Many surgeons recommend an additional
operation to enlarge, reduce, or lift the natural
breast to match the reconstructed breast. But keep
in mind, this procedure may leave scars on an otherwise
normal breast and may not be covered by insurance.
After surgery, the breast mound, nipple,
and areola are restored.
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After
your breast reconstruction surgery
You are likely to feel tired and sore for a week
or two after reconstruction. Most of your discomfort
can be controlled by medication prescribed by your
doctor.
Depending on the extent of your surgery, you'll
probably be released from the hospital in two to
five days. Many reconstruction options require a
surgical drain to remove excess fluids from surgical
sites immediately following the operation, but these
are removed within the first week or two after surgery.
Most stitches are removed in a week to 10 days.
Scars at the breast, nipple, and abdomen
will fade substantially with time, but
may never disappear entirely.
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Getting
back to normal after breast reconstruction surgery
It may take you up to six weeks to recover from
a combined mastectomy and reconstruction or from
a flap reconstruction alone. If implants are used
without flaps and reconstruction is done apart from
the mastectomy, your recovery time may be less.
Reconstruction cannot restore normal sensation
to your breast, but in time, some feeling may return.
Most scars will fade substantially over time, though
it may take as long as one to two years, but they'll
never disappear entirely. The better the quality
of your overall reconstruction, the less distracting
you'll find those scars.
Follow your surgeon's advice on when to begin stretching
exercises and normal activities. As a general rule,
you'll want to refrain from any overhead lifting,
strenuous sports, and sexual activity for three
to six weeks following reconstruction
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Your
new look after breast reconstruction surgery
Chances are your reconstructed breast may feel
firmer and look rounder or flatter than your natural
breast. It may not have the same contour as your
breast before mastectomy, nor will it exactly match
your opposite breast. But these differences will
be apparent only to you. For most mastectomy patients,
breast reconstruction dramatically improves their
appearance and quality of life following surgery.
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© Copyright American Society of Plastic Surgeons
If you would like to contact New York plastic surgeon
Dr. Darrick Antell, or if have any further questions
about breast reconstruction or any of our plastic
surgery procedures, please use our contact
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