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Breast Reconstruction

Women who have surgery to treat their breast cancer may choose breast reconstruction surgery to rebuild the shape and look of the breast.
Types of breast reconstruction procedures

There are several types of reconstructive surgery available, and the reconstruction process sometimes means more than one operation. One should make their decision about breast reconstruction only after they are fully informed.

Two main types of operations can be done to reconstruct the shape of your breast or breasts:

  • Implant reconstruction, which uses a saline or silicone implant to create a breast shape
  • Autologous or flap reconstruction, which takes tissue from another area of the body to create a breast form

Sometimes a combination of an implant and flap procedure is used to get the best result

Deciding factors

Here are some things one might want to consider while making a decision about breast reconstruction:

  • Is it important to you to have a permanent breast shape? Some women prefer to use a prosthesis (a wearable artificial breast shape) instead of having reconstruction. Other women feel that a reconstructed breast is more convenient than wearing, removing, and taking care of a prosthetic breast
  • If you’re having a mastectomy on one breast, is it important to you that your breasts look balanced when wearing a bra or bathing suit? After mastectomy, many women want their breasts to have a natural, balanced appearance in bras, bathing suits, and other garments with low necklines. Though you’ll be able to see some difference between the rebuilt breast and your other breast when you're naked, reconstruction usually looks very natural when you're wearing a bra or bathing suit
  • How important is it that you be able to resume your normal activities as soon as possible? In most cases, women who choose no reconstruction are able to resume their daily activities more quickly than women who choose reconstruction
  • Are you an athlete, or do you have a physically demanding job? If so, full range of motion after reconstruction naturally will be very important to you. Some women find that implants, which are placed under or over the chest muscle, can limit comfort and range of motion, especially if the area hardens over time (a complication called capsular contracture). On the other hand, certain flap procedures actually cut through muscle in the back or lower abdomen, which can cause weakness or loss of function. Newer“perforator flap” techniques, such as the DIEP and SIEA flaps, lower this risk by preserving the muscle structure at the donor site; surgeons only remove the tissue that is needed to rebuild the breast. These are important things to consider as you weigh your options
  • Do you have any other medical conditions that might affect your ability to heal after surgery? If you have diabetes, circulatory problems, or a bleeding disorder, it may take your body longer to heal from reconstruction surgery than it will for someone who doesn't have these conditions. Heavy smoking and drinking also can affect your ability to heal. All surgery leaves some scars, but the skin cells along your incision may die (a condition called necrosis) if your ability to heal is reduced. If you smoke, you may be required to quit smoking for a period of time before reconstruction surgery so your body
Breast reconstruction can be done at different times, depending on what works best for your situation:

At the same time as mastectomy surgery. This is called immediate reconstruction. As soon as the breast is removed by the breast cancer surgeon, the plastic surgeon reconstructs the breast either with tissue from another location on your body or with an implant (and sometimes both). Nearly all of the work is done during one operation, and you wake up with a rebuilt breast (or breasts). This approach requires co-ordination of both the breast cancer surgery and plastic surgery teams. Immediate reconstruction may not always be possible if you need additional treatments such as chemotherapy or radiation therapy. In some cases, a surgeon will recommend waiting until after these treatments are finished before starting reconstruction. Or, depending on your situation, a surgeon may recommend doing part of the reconstruction immediately and then finishing the reconstruction after chemotherapy and/or radiation therapy are done. You and your surgeon can discuss your particular situation and needs. If you’re having prophylactic mastectomy — mastectomy to reduce a high risk of breast cancer — then reconstruction is always done immediately.

After mastectomy or lumpectomy surgery, as well as after radiation therapy, chemotherapy, or targeted therapies that are given. This is called delayed reconstruction. Treatments such as radiation therapy and sometimes chemotherapy given after surgery can cause the reconstructed breast to lose volume and change color, texture, and appearance. Radiation therapy in particular is known to cause undesirable changes to an implant reconstruction. Cancers that are larger than 5 centimeters and that have spread to the lymph nodes are more likely to need radiation therapy after surgery.

Reconstruction also can be done years later if desired. Some women aren’t ready to have the surgery sooner, or they change their minds about their initial decision to “go flat” or wear a prosthesis.

As a staged approach, involving some reconstructive surgery during mastectomy or lumpectomy and more reconstructive surgery after any additional treatments. This is also called delayed-immediate reconstruction.

In delayed-immediate reconstruction, a tissue expander or ordinary breast implant is inserted under the chest muscle and preserved breast skin after the breast is removed. Temporarily placing an expander or implant will preserve the shape of the breast and breast skin during the upcoming radiation treatments and allow for the final benefit of a skin-sparing mastectomy technique.

The timing of breast reconstruction is one of the most discussed topics in reconstruction research. It's important that the entire team of doctors — breast surgeon, plastic surgeon, radiation oncologist, medical oncologist, and other caregivers — meet as a group and discuss the situation. Ideally, this group should meet before you make your decision about mastectomy or lumpectomy because the type of breast surgery you have can affect the reconstruction outcome. For example, some women may opt to have mastectomy instead of lumpectomy because the plastic surgeon advises that reconstruction after mastectomy offers better cosmetic results. Because each breast cancer is unique, each reconstruction surgery and its timing are unique. Together, you and your team can decide on an approach that is best for you.

A number of factors influence the timing of your reconstruction:

Cancer stage: In general, women diagnosed with stage I or some stage II breast cancers who choose mastectomy based on a biopsy are less likely to need radiation or other treatments after mastectomy and are often good candidates for immediate reconstruction. This is their best option because it combines the mastectomy and reconstruction into one surgical procedure. However, if there’s a good chance that radiation will be needed, the staged approach may be used instead. Your surgeon will help you choose the timing that is right for you.

Women diagnosed with stage III or stage IV cancers almost always need radiation therapy or other treatments after mastectomy because of the size of the cancer or the number of lymph nodes involved. In this case, some doctors recommend delaying reconstruction until all other breast cancer treatments are completed. Reconstruction may require extra healing time that could delay radiation and chemotherapy.

In some cases, though, immediate reconstruction may be appropriate. For example, if you have chemotherapy as your first treatment to shrink the breast cancer, this may allow for a downstaging of your tumor. You may then be eligible for skin-sparing mastectomy, which preserves as much of the breast skin as possible. While radiation may still be necessary, your doctor may be comfortable with its potential effects on an immediate flap reconstruction. Or, your doctor may suggest the staged reconstruction with a tissue expander or saline implant to maintain a breast pocket throughout your treatments. You and your doctor can discuss what makes the most sense for you.

Benefits of breast reconstruction

Women might choose breast reconstruction for many reasons:

  • To make their chest look balanced when they are wearing a bra or swimsuit
  • To permanently regain their breast shape
  • So they don’t have to use a breast form that fits inside the bra (an external prosthesis)
  • To be happier with their bodies and how they feel about themselves

Breast reconstruction often leaves scars that can be seen when you’re naked, but they often fade over time. Newer techniques have also reduced the amount of scarring. When you’re wearing a bra, the breasts should be alike enough in size and shape to let you feel comfortable about how you look in most types of clothes.

Some important things to think about
  • You might have a choice between having breast reconstruction at the same time as the mastectomy (immediate reconstruction) or at a later time (delayed reconstruction)
  • Some women don’t want to have to make decisions about reconstruction while being treated for their breast cancer. If this is the case, you might choose to wait until after your breast cancer surgery to decide about reconstruction
  • You might not want to have any more surgery than is absolutely required
  • Not all reconstructive surgery is a total success, and the result might not look like you’d hoped
  • The cancer surgery and reconstruction surgery will leave scars on the breast and any areas where tissue was moved to create the new breast mound
  • A rebuilt breast will not have the same sensation and feeling as the natural breast, and any flap donor sites might also lose some sensation. With time, the skin can become more sensitive, but it won’t feel the same as it did before the surgery
  • You may have extra concerns if you tend to bleed or scar more than most people
  • Breast skin or flaps might not survive after reconstructive surgery. This tissue death is called necrosis. If it happens, healing is delayed and more surgery is often needed to fix the problem.
  • Healing could be affected by previous surgery, chemotherapy, or radiation therapy. It can also be affected by smoking, diabetes, some medicines, and other factors
  • Surgeons may suggest you wait to have reconstruction, especially if you smoke or have other health problems. It’s best to quit smoking at least 2 months before reconstructive surgery to allow for better healing. You might not be able to have reconstruction at all if you are obese, too thin, or have blood circulation problems
  • The surgeon may suggest surgery to reshape the other breast to match the reconstructed breast. This could include reducing or enlarging its size, or even surgically lifting the breast
  • Many doctors recommend that women not have immediate reconstruction if they will need radiation treatments after surgery. It can cause problems after surgery and lower the chances of success. Flap surgeries (moving tissue around) are often delayed until after radiation

Knowing your reconstruction options before surgery can help you prepare with a more realistic outlook expectations for the outcomes.

Reconstruction does not make breast cancer come back. If the cancer does come back, reconstructed breasts should not cause problems with chemotherapy or radiation treatment.

If you are thinking about breast reconstruction, either with an implant or flap, you need to know that reconstruction rarely, if ever, hides a return of breast cancer. You should not consider this a big risk when deciding to have breast reconstruction.

Many women decide that breast reconstruction is not right for them. Or they might not be able to have more surgery. If you do not have breast reconstruction, you can use breast forms or prosthetics that simulate the look and feel of a natural breast. But you can also decide not to use a breast form.

If you’ve decided to have breast reconstruction, you’ll still have many things to think about as you and your doctors talk about what type of reconstruction might be best for you. Some of the factors you and your doctors will need to take into account when considering your options include:
  • Your overall health (including issues that might affect your healing, such as smoking or certain health conditions)
  • The size and location of your breast cancer
  • Your breast size
  • The extent of your breast cancer surgery
  • Whether you will need treatments other than surgery for your cancer
  • The amount of tissue available (for example, very thin women may not have enough extra tummy tissue to use this area for breast reconstruction)
  • Whether you want reconstructive surgery on one or both breasts
  • Your desire to match the look of the other breast
  • Your insurance coverage and related costs for the unaffected breast
  • How quickly you want to be able to recover from surgery
  • Your willingness to have potentially more than one surgery as part of the reconstruction
  • The effects that different types of reconstructive surgery might have on other parts of your body

Your surgeon will review your medical history and overall health, and will explain which reconstructive options might be best for you based on your age, health, body type, lifestyle, goals, and other factors. Talk with your surgeon openly about your preferences. Be sure to voice any concerns and priorities you have for the reconstruction, and find a surgeon that you feel comfortable with. Your surgeon should explain the limits, risks, and benefits of each option.

Immediate versus delayed breast reconstruction

You may have a choice between having breast reconstruction at the same time as the surgery to treat the cancer (immediate reconstruction) or at a later time (delayed reconstruction).

Immediate breast reconstruction is done, or at least started, at the same time as the surgery to treat the cancer. The benefit of this is that breast skin is often preserved, which can produce better-looking results. Women also do not have to go without the shape of a breast.

While the first step in reconstruction is often the major one, many steps are often needed to get the final shape. If you’re planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take.

Delayed breast reconstruction means that the rebuilding is started later. This may be a better choice for some women. You might choose to delay breast reconstruction if:

  • You don’t want to think about reconstruction while coping with treating the cancer. If this is the case, you might choose to wait until after your breast cancer surgery to decide about reconstruction
  • You have other health problems. Your surgeon may suggest you wait for one reason or another, especially if you smoke or have other health problems. It’s best to quit smoking at least 2 months before reconstructive surgery to allow for better healing
  • You need radiation therapy. Many doctors recommend that women not have immediate reconstruction if they will need radiation treatments after surgery. Radiation can cause problems after surgery such as delayed healing and scarring, and can lower the chances of success. Flap reconstruction surgeries (using other body tissues to create the new breast) are often delayed until after radiation
Knowing what to expect

As you prepare for breast reconstruction surgery, your surgeon will help you answer questions about what to expect. Breast reconstruction can make you feel better about how you look and renew your self-confidence, but keep in mind that the reconstructed breast will not be a perfect match or substitute for your natural breast. If tissue from your tummy, shoulder, or buttocks will be used, those areas will also look different after surgery. Talk with your surgeon about surgical scars and changes in shape or contour. Ask where they will be, and how they will look and feel after they heal.

Your surgeon (or other doctors involved) would explain the details of your surgery, including:

  • The drugs (anesthesia) that will be used to make you sleep and not feel pain during the surgery
  • Where the surgery will be done
  • What to expect after surgery
  • The plan for follow-up
  • Costs
What to Expect After Breast Reconstruction Surgery

It’s important to have an idea of what to expect after breast reconstruction surgery, including the possible risks and side effects. The time it takes you to recover from surgery will vary depending on the type of reconstruction you have. Most women begin to feel better in a couple of weeks and can return to normal activities in a couple of months. Be sure you understand how to take care of your surgery sites and how to follow up with your breast care, including regular mammograms.

Possible risks during and after reconstruction surgery

There are certain risks from any type of surgery, and breast reconstruction may pose certain unique problems for some women. Even though many of these are not common, it’s important to have an idea of the possible risks and side effects.

Risks of infection

Infection can happen with any surgery, most often in the first couple of weeks after surgery. If an implant has been placed, it might have to be removed until the infection clears. A new implant can be put in later. If you have a tissue flap, surgery may be needed to clean the wound.

Risks of capsular contracture

The most common problem with breast implants is capsular contracture. A scar (or capsule) can form around the soft implant. As it tightens, it can start to squeeze the implant, making the breast feel hard. Capsular contracture can be treated. Sometimes surgery can remove the scar tissue, or the implant can be removed or replaced.

Additional risks for smokers

Using tobacco narrows blood vessels and reduces the supply of nutrients and oxygen to tissues. As with any surgery, smoking can delay healing. This can cause more noticeable scars and a longer recovery time. Sometimes these problems are bad enough that a second operation is needed to fix them. You may be asked to quit smoking a few weeks or months before surgery to reduce these risks. This can be hard to do, so ask your doctor for help.

Recovering after reconstruction surgery

You’re likely to feel tired and sore for a week or 2 after implant surgery, or longer after a flap procedure (which will leave you with 2 surgical wounds). Your doctor will give you medicines to help control pain and other discomfort.

Depending on the type of surgery you have, you will most likely be able to go home from the hospital within a few days. You may be discharged with one or more drains in place. A drain is a small tube that’s put in the wound to remove extra fluid from the surgery site while it heals. In most cases, fluid drains into a little hollow ball that you’ll learn how to empty before you leave the hospital. Follow your doctor’s instructions on wound and drain care and also seek advice on the kind of support garments you should wear.

Getting back to normal

Most women can start to get back to normal activities within about 6 to 8 weeks. If implants are used without flaps, your recovery time may be shorter. Some things to keep in mind:

  • Reconstruction does not restore normal feeling to your breast, but some feeling may return over a period of years
  • It may take up to about 8 weeks for bruising and swelling to go away. Try to be patient as you wait to see the final result
  • It may take as long as 1 to 2 years for tissues to heal fully and scars to fade, but the scars never go away completely
  • Ask when you can go back to wearing regular bras. Talk with your surgeon about the type of bra to wear – sometimes it will depend on the type of surgery you had. After you heal, underwires and lace might feel uncomfortable if they press on scars or rub your skin
  • Follow your surgeon’s advice on when to begin stretching exercises and normal activities, because it’s different with different types of reconstruction. As a basic rule, you’ll want to avoid overhead lifting, strenuous sports, and some sexual activities for 4 to 6 weeks after reconstruction. Check with your surgeon for specific guidance
  • Women who have reconstruction months or years after a mastectomy may go through a period of emotional adjustment once they’ve had their breast reconstructed. Just as it takes time to get used to the loss of a breast, it takes time to start thinking of the reconstructed breast as your own. Talking with other women who have had breast reconstruction might be helpful. Talking with a mental health professional might also help you sort out anxiety and other distressing feelings
  • Silicone gel implants may open up or leak inside the breast without causing symptoms. Surgeons usually recommend getting regular magnetic resonance imaging (MRI) of implants to make sure they aren’t leaking. (This isn’t needed with saline implants.) You’ll likely have your first MRI 1 to 3 years after your implant surgery and every 2 years from then on, although it may vary by implant. Your insurance might not cover this. Be sure to talk to your doctor about long-term follow-up
  • Call your doctor right away if you notice any new skin changes, swelling, lumps, pain, or fluid from the breast, armpit, or flap donor site, or if you have other symptoms that concern you