What is breast reconstruction?
The goal of breast reconstruction is to restore one or both breasts to near normal shape, appearance, symmetry and size following mastectomy, lumpectomy or congenital deformities.
Breast reconstruction often involves multiple procedures performed in stages and can either begin at the time of mastectomy or be delayed until a later date.
Breast reconstruction generally falls into two categories: implant-based reconstruction or flap reconstruction. Implant reconstruction relies on breast implants to help form a new breast mound. Flap (or autologous) reconstruction uses the patient’s own tissue from another part of the body to form a new breast.
There are a number of factors that should be taken into consideration when choosing which option is best:
- Type of mastectomy
- Cancer treatments
- Patient’s body type
A note about symmetry
If only one breast is affected, it alone may be reconstructed. In addition, a breast lift, breast reduction or breast augmentation may be recommended for the opposite breast to improve symmetry of the size, shape and position of both breasts.
When choosing a board certified plastic surgeon for breast reconstruction, remember that the surgeon’s experience and your comfort with him or her are just as important as the final cost of the surgery.
Breast reconstruction and health insurance
Breast reconstruction surgery after breast cancer is considered a reconstructive procedure and should be covered by health insurance. However, your coverage may only provide a portion of the total fee.
Breast reconstruction candidates
Breast reconstruction is a highly individualized procedure. You should do it for yourself, not to fulfill someone else’s desires or to try to fit any sort of ideal image.
You may be a candidate for breast reconstruction if:
- You are able to cope well with your diagnosis and treatment
- You do not have additional medical conditions or other illnesses that may impair healing
- You have a positive outlook and realistic goals for restoring your breast and body image
Although breast reconstruction can rebuild your breast, the results are highly variable:
- A reconstructed breast will not have the same sensation or feel as the breast it replaces
- Visible incision lines will always be present on the breast, whether from reconstruction or mastectomy
- Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the back, abdomen or buttocks
Breast reconstruction results
The final results of breast reconstruction following mastectomy can help lessen the physical and emotional impact of mastectomy.
Over time, some breast skin sensation may return, and scar lines will improve, although they will never disappear completely.
There are trade-offs, but most women feel these are small compared to the large improvement in their quality of life and the ability to look and feel whole.
Careful monitoring of breast health through self-exam and other diagnostic techniques is essential to your long-term health.
Breast reconstruction procedure steps
A breast reconstruction procedure includes the following steps:
Step 1 – Anesthesia
Step 2 – Flap techniques reposition a woman’s own tissue to create or cover the breast mound
A TRAM flap uses donor muscle, fat and skin from a woman’s lower abdomen to reconstruct the breast. The flap may either remain attached to the original blood supply and be tunneled up through the chest wall, or be completely detached, and formed into a breast mound.
Alternatively, your surgeon may choose the DIEP flap or SIEA flap techniques, which do not use abdominal muscle but transfer only skin and fat to the chest from the abdomen. If there is insufficient tissue on the lower abdomen, other donor sites such as the buttocks or thighs may be selected (SGAP flap, TUG flap, PAP flap).
A latissimus dorsi flap uses muscle, fat and skin from the back tunneled to the mastectomy site and remains attached to its donor site, leaving blood supply intact.
Occasionally, the flap can reconstruct a complete breast mound, but often the latissimus flap provides the muscle and tissue necessary to cover and support a breast implant.
Step 3 – Tissue expansion stretches healthy skin to provide coverage for a breast implant
For women who do not require breast radiation and would like to avoid a separate donor site, implant-based reconstruction is an option. Reconstruction with tissue expansion allows an easier recovery than flap procedures, but it can be more lengthy reconstruction process.
It usually requires several office visits over 1-2 months after placement of the expander to gradually fill the device with saline through an internal valve to expand the skin. Newer air-filled devices may allow patient-controlled expansion at home using a remote dosage controller.
A second surgical procedure will be needed to replace the expander if it is not designed to serve as a permanent implant.
Step 4 – Surgical placement of a breast implant creates a breast mound
A breast implant can be an addition or alternative to flap techniques. Surgeons may also use an implant as a temporary placeholder during other breast cancer treatments until you are ready for more involved flap reconstruction techniques. Saline and silicone implants are available for reconstruction.
Your surgeon will help you decide what is best for you. Reconstruction with an implant alone usually requires tissue expansion. Direct-to-implant breast reconstruction may be an option for some women undergoing mastectomy with certain tumor characteristics and breast shapes.
Step 5 – Reconstructing a nipple and areola, breast revision techniques
For women who are not candidates for nipple-sparing mastectomy, breast reconstruction is completed through a variety of techniques that reconstruct the nipple and areola. Techniques usually involve folding skin to create the shape of a nipple followed by tattooing. Three-dimensional nipple-areola tattooing may be used alone to create the appearance of a realistic nipple with the illusion of projection. Breast reconstruction outcomes can often be enhanced with staged revision procedures that improve symmetry, use liposuction with fat grafting, and improve the appearance of the donor site.