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. Reconstruction is often 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.
Most mastectomy patients are medically appropriate for reconstruction. Many reconstructions may begin at the same time that the breast is removed. The best candidates are women whose cancer seems to have been eliminated by mastectomy.
However, there are legitimate reasons to delay reconstruction. 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 a tissue flap. Women with other health conditions, such as obesity, high blood pressure, or smoking, may also be advised to wait. Smokers should be advised that nicotine can delay healing, resulting in skin breakdown and prolonged recovery.
Reconstruction has no known effect on the recurrence of breast cancer, nor does it interfere with chemotherapy or radiation treatment, should cancer recur.
Patients can begin discussing reconstruction as soon as the diagnosis of breast cancer is made. 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 openly 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.
The most common breast reconstruction technique combines tissue expansion and the subsequent insertion of a permanent breast implant. This procedure is performed under a general anesthetic. Tissue expansion reconstruction is a staged procedure.
The first stage places an expandable “balloon” under the pectoralis muscle and skin. Over the course of 3-4 months, the expander will slowly be filled with sterile saline via a fill port, buried beneath the skin. Expansion is performed every 1-2 weeks in our office, gradually allowing the skin and tissue over the chest wall to stretch to accommodate a permanent breast implant. Patients usually recover for 1-2 weeks after the procedure.
The second stage involves removal of the inflated tissue expander, placement of a permanent saline filled breast implant, and creation of an inframammary crease. A 1-2 night hospital stay is usually required, and recovery time is 1-2 weeks. Any symmetry procedure required for the opposite breast may be performed at this time.
The third stage is reconstruction of the nipple with a local skin flap raised from the reconstructed breast. This is done under local anesthesia in an outpatient setting, and requires little or no recovery time.
The final stage is medical tattooing of the nipple and areola. This colors and defines the nipple/areolar complex, and is done under local anesthesia in our office. No recovery time is required.
An alternative approach to implant reconstruction involves creation of a tissue flap (skin, fat and muscle) taken from areas on the back, abdomen, or buttocks.
Approximately 3-4 months after all flap reconstructions, nipple reconstruction and any necessary revision of the reconstructed breast mound can be performed, as can any symmetry procedure for the opposite breast. Whether such procedures are done as Day Surgery or with an overnight hospital stay will depend on each individual’s needs. Recovery time will also vary for each patient. Eight weeks after nipple reconstruction, medical tattooing of the nipple and aerolar complex can be performed as described above.
Pedicled Tram Flap
In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The most common area used in pedicled flap reconstruction is the abdomen. The flap is referred to as TRAM Flap (Transverse Rectus Abdominis Myocutaneous Flap).
The lower portion of the rectus abdominis muscle with its blood supply, subcutaneous tissue and skin are detached inferiorly. This tissue, pedicled on the upper portion of the muscle, is tunneled up to the chest wall where the breast mound is shaped and reconstructed. This procedure gives a natural appearing reconstruction. This type of reconstruction takes several hours under general anesthesia, and requires a hospital stay of 3-5 days. Recovery time is approximately 4-6 weeks.
Free Tram Flap
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, called a free flap, requires the skills of a plastic surgeon who is experienced in microvascular surgery as well. Free flap breast reconstruction can be safely performed in smokers or some obese patients, and does not require the use of breast implants. Again, the abdomen is the most common site used for free flap creation; this flap is referred to as a free TRAM flap.
In this procedure, the rectus abdominis muscle, subcutaneous tissue and skin are detached from the abdomen, shaped into a breast mound and microscopically reattached to the chest wall. This procedure gives a durable, natural appearing reconstruction and can provide a high-volume breast mound. This type of reconstruction does take approximately 8 hours under general anesthesia and requires a hospital stay of 5-7 days. Recovery time is approximately 4-6 weeks.
Latissimus Dorsi Flap
The latissimus dorsi muscle (located below the shoulder blade) is carefully mobilized, tunneled under the arm, and laid in the breast area. This creates a low-volume breast reconstruction, which may be augmented with a saline breast implant. A hospital stay of 2-3 days is required, and recovery time is approximately 3-4 weeks.
Additional Information for Breast Reconstruction
- Flap reconstruction surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and on the reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with tissue, the results are generally more natural. In some cases, patients have the added benefit of an improved abdominal contour.
- The initial reconstructive operation is the most complex. Additional surgery may be required to replace a tissue expander with an implant or to reconstruct the nipple and the areola. Your surgeon may recommend an operation to enlarge, reduce, or lift the natural breast to match the reconstructed breast.
- Depending on the extent of your surgery, you’ll probably be released from the hospital in 2 to 5 days.
- Many reconstructive options require a surgical drain to remove excess fluids from surgical sites; these are removed within 1-2 weeks after surgery.
- Most stitches are removed in a week to 10 days.