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Breast Reconstruction
Breast reconstruction is the rebuilding of a breast that has been removed due to cancer or other diseases. Virtually any woman who undergoes surgery for breast cancer can have reconstructive surgery. New medical techniques and devices have made it possible for surgeons to create a breast that looks similar to a natural breast. Although an oncologist is not trained in breast reconstruction surgery, arrangements can be made ahead of time to have a plastic surgeon in the operating room to perform the breast reconstruction after the cancer is removed, so that a patient can wake up with a breast mound already in place, having been spared the experience of seeing herself with no breast at all.
Post-mastectomy and post-lumpectomy breast reconstruction are not simple procedures. It is particularly important to discuss breast-conserving surgery (BCS) as an option instead of a mastectomy as well as the many options to consider as you and your doctor explore what's best for you.
What does it cost?
Breast reconstruction costs approximately $5,000.00 US or $8,000.00 Canadian but, in most cases, health insurance policies will cover most or all of the cost of the 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.
Who performs it?
A plastic surgeon performs the reconstructive surgery, while an oncologist removes the cancer.
What happens during a procedure?
Breast reconstruction is nearly always performed under general anesthesia. You'll be asleep through the entire operation. The procedure is usually performed in an outpatient surgical center, either operated by your surgeon or a hospital facility, and takes several hours depending on the extent of the procedure. If you are having more than one procedure, overnight hospitalization may be required. The most common techniques are as follows:
Skin expansion
The most common technique combines skin expansion and subsequent insertion of an implant.
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.
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.
Flap reconstruction
An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other area, such as the back, abdomen, or buttocks. Because blood vessels are involved, these usually cannot be offered to women with diabetes, connective tissue or vascular disease, or to smokers.
The Latissimus dorsi procedure moves muscle and skin from the patient's back when extra tissue is needed. This extra tissue remains attached to its original site, retaining its blood supply. The flap is made up of skin, fat, and muscle with its blood supply and is tunneled under the skin to the front of the chest. This creates a pocket for an implant to be inserted or, in some cases, creates the breast mound itself.
The Transverse rectus abdominis muscle (TRAM) flap (Tummy Tissue) procedure uses extra tissue and muscle from the lower wall of the abdomen. The tissue from this area alone is often enough to create a breast shape and an implant may not be needed. The skin, fat, blood vessels, and at least one of the abdominal muscles are tunneled under the skin from the abdomen to the chest area. This procedure results in a tightening of the lower abdomen or a "tummy tuck."
The Free flap procedure uses tissue from the buttock, thigh, or tummy. The muscle, fat, and skin from this area is cut off from its blood supply and reattached at the chest. The surgeon doing this surgery must sew together the blood vessels so the blood supply is restored to the tissue. The free flap is the most complicated of the three procedures. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well.
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 and the results are generally more natural.
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.
The decision to have the nipple and areola reconstructed as well after breast reconstruction is up to each woman. Nipple/areola reconstruction is usually done at a later date after reconstruction of the breast is completed and the new breast has had time to settle. Saving and using the nipple from the breast that has been removed because of cancer is not advised as cancer cells may still be hidden in the nipple. Tissue for the nipple/areola is often taken from the patient's body. For the nipple, tissue can be taken from the newly created breast, the opposite nipple, or the ear. Tissue for the areola can be taken from the upper inner thigh. To match the color, tattooing may be done.
Many surgeons recommend an additional operation to enlarge, reduce, or lift the natural breast to match the reconstructed breast. But keep in mind, a procedure performed on a healthy breast may leave scars and may not be covered by insurance.
Are there risks or potential side effects?
As with all surgeries, there is always a possibility of complications, including infection, a reaction to the anesthesia, hematoma, seroma, nerve damage and the occurrence of asymmetries or irregularities. 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. Should infection occur, your surgeon will prescribe a treatment with antibiotics.
The specific complications associated with this procedure are as follows:
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 be inserted later.
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. Click here for more information on the risks associated with breast implants.
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.
What to expect post-procedure?
The extent of the post-operative swelling and bruising is dependent on whether you tend to bruise or swell easily. The amount you can expect varies for each individual but past surgeries or injuries should be a good indication. Applying cold compresses, or ice packs will reduce swelling and relieve discomfort. Many patients use a water-tight plastic sandwich bag filled with frozen berries or peas. Regular icing is the key to relieving the swelling.
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.
How soon does normal life resume?
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.
Are you a good candidate?
Most mastectomy patients are medically appropriate for reconstruction and many for reconstruction 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 or lumpectomy with a more positive outlook for the future. While reconstruction surgery can improve a woman’s body image and self-esteem, it does not remedy pre-existing psychological and personal problems.
How to prepare for surgery?
Always talk to your doctor prior to surgery regarding pre-op instructions. But here are some general hints:
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. Breast reconstruction can improve the way your breast looks 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 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.
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 but here are some general guidelines:- Avoid aspirin, any aspirin containing medication or any other non-steroidal anti-inflammatories (NSAID), such as Motrin® or Advil®, for two weeks prior to treatment. Because aspirin thins the blood, it can interfere with normal blood clotting and increase the risk of bleeding and bruising.
- Smoking inhibits the healing process, so stop smoking before your procedure and if you start again, make sure it is after you are completely healed.
- Avoid drinking alcohol a few days before your surgery.
- Make sure to follow any fasting instructions the night before and morning of your surgery. Your doctor may insist on an empty stomach depending on the type of anesthesia.
- Make sure that you arrange for someone to bring you home and to help you out for 24 hours after surgery.
What is the link between breast reconstruction surgery and breast cancer?
Reconstruction has no known effect on the recurrence of breast cancer. After breast reconstruction, you should keep doing breast self-examination (BSE). Check both the remaining breast and the reconstructed breast at the same time each month. You will need to learn what is normal for you since you had breast reconstruction. The reconstructed breast will feel different and the remaining breast may change as well. To learn how to do BSE, ask your doctor or nurse or call your local American Cancer Society office.
Locate a certified physician with our Doctor Locator.
To view Personal Stories about this procedure contributed by our members, Click Here.
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