Breast reconstruction is a surgery that involves creating a breast which has been removed in part (lumpectomy) or in its entirety (mastectomy). This is usually secondary to treatment of cancer or prophylactic removal of the breast for patients who are at high risk of developing breast cancer (BRCA gene mutation). Breast reconstruction may be completed at the time of the breast removal (immediate reconstruction) or months to years after the breast removal (delayed reconstruction).
All women who are going to have (or have had) a mastectomy may be considered for breast reconstruction. In the vast majority of cases, if you are in overall good health, there will be good reconstructive options available to you. If you have other significant medical issues that would make additional surgery dangerous or result in a poor outcome, breast reconstruction may not be recommended.
If part of the breast is removed (a lumpectomy), oncoplastic surgery may be offered at the time of lumpectomy, which involves plastic surgical tissue rearrangement to improve the appearance of the breast.
Options for Breast Reconstruction
There are many different options for breast reconstruction. If the entire breast is removed (a mastectomy), then there are two major categories of reconstruction: using a breast implant, or using your own tissue (usually from the abdomen – TRAM or DIEP flap). Sometimes a combination of techniques using both your own tissue (eg. latissimus dorsi flap) combined with an implant may be offered. Each technique has a different length of surgery, recovery, advantages and disadvantages. If your treatment plan has or will have radiation therapy, this may impact your reconstructive options and planning. Individualized options for reconstruction will be make in consultation with Dr. Mahoney, taking into consideration disease-specific and personal factors.
Other additional surgeries that may be considered are as follows:
- a balancing procedure on the opposite breast (lift/reduction/augmentation)
- revision surgery on the reconstructed breast including fat grafting
- nipple/areolar reconstruction or tattooing
Please visit the following websites for more information on breast reconstruction:
Frequently Asked Questions
Breast reconstruction is a personal choice. It can have psychological and physical benefits, and may avoid the use of an external prosthesis. It can be a lengthy process requiring a number of surgeries and recoveries, and it is important that every woman is well informed and confident in her decision regarding breast reconstruction. For women with serious medical problems or advanced cancer, breast reconstruction may not be a reasonable option.
Reconstruction can occur either at the same time as a mastectomy (immediate) or months to years after the mastectomy (delayed). The need for other cancer treatment – including radiotherapy or chemotherapy – may impact the timing of your reconstruction.
If you are a candidate for a nipple-sparing mastectomy, immediate reconstruction may be a good option for you.
Not all women are candidates for immediate reconstruction, particularly if there is planned postoperative radiation therapy. In some cases a woman may choose to postpone the decision and choose breast reconstruction in a delayed fashion.
There are two major categories of breast reconstruction: reconstructing the breast(s) with an implant or using your own tissue (usually from the abdomen). In some cases a combination of techniques using your own tissue (latissimus dorsi flap) combined with an implant may be offered. Each technique has a different length of surgery, recovery time, advantages and disadvantages.
If your treatment has included or will include radiation therapy, implant reconstruction may not be an option for you.
Two stage expander/implant reconstruction
This staged method of reconstruction involves stretching the breast skin and tissue over a period of time prior to insertion of the final implant. Each stage involves a 2-hour surgery under general anesthetic but does not usually require an overnight stay in the hospital. Recovery after the first stage is 2-4 weeks, and after the second stage 1-2 weeks.
The first stage involved insertion of a temporary implant, a tissue expander, that is placed under the skin and muscle to stretch the skin to allow for creation of a breast mound. The expander is inflated every 2 weeks over 2-3 months using saline (salt water).
The second stage is carried out 3-6 months after the final expansion. This involves removal of the temporary expander and insertion of a breast implant.
Silicone implants are recommended for use as the permanent implant in breast reconstruction. Saline implants are heavier and result in a more unnatural look and feel of the breast.
In certain cases, a one-stage implant reconstruction technique may be offered with the additional use of a tissue replacement (acellular dermal matrix). This is a one-stage surgery (2-3 hours) that is done in an immediate setting at the time of mastectomy. It is often done in conjunction with a nipple-sparing mastectomy. It does not usually require an overnight stay in hospital. Recovery time is 2-4 weeks.
It is the reconstruction of the breast using your own tissue (usually taken from the abdomen).
Pedicled TRAM flap
The most common method of using your own tissue to reconstruct your breast mound (autologous reconstruction) involves using excess abdominal tissue. Using your own tissue results in a more natural look and feel to a reconstructed breast. At NYGH, the procedure offered uses the skin and fat of your lower abdomen connected to its blood supply via the transverse rectus abdominus muscle (TRAM), in the form of a pedicled TRAM flap. The muscle is transected at its lowermost point in the pelvis and rotated into the chest area, where the attached skin and fat are used to create a breast mound. This is a 3-5 hour surgery and requires an overnight stay in hospital. Recovery time is 6-8 weeks.
Free Flap (DIEP or other)
Another technique that uses abdominal tissue for breast reconstruction that is not currently available at NYGH, is the Deep Inferior Epigastric Artery Perforator (DIEP) flap. This is one of the ‘free flap’ options for breast reconstruction. It uses the same abdominal tissue as the pedicled TRAM flap, but it is a more involved operation. The DIEP flap involves detaching the blood supply of the abdominal skin and fat and reconnecting it using microsurgical techniques to a new blood supply in the chest area. The rectus abdominus muscle is not detached during this procedure. It is a longer and more complex surgery and requires a hospital stay of about 5 days.
In some cases, such as in the setting of previous radiation therapy, implant reconstruction with a tissue expander or implant may be considered in combination with using your own tissue from the back (latissimus dorsi flap). The first stage of this surgery is 3-5 hours and requires an overnight stay in hospital. Recovery time is 4-6 weeks following the first procedure and 1-2 weeks following the second procedure.
Nipple reconstruction and tattooing are optional procedures usually offered at least 3 months after reconstruction of the breast mound. This may be done in one or two stages under either local or general anesthesia. The most common method of reconstruction involves using skin in the area to create a nipple and tattooing of the areola. There is minimal recovery time.
The opposite breast
Once the reconstruction of the breast mound is complete, your plastic surgeon may discuss touch-up procedures to the reconstructed breast. To obtain symmetry, balancing surgery on the opposite breast, such as a reduction or a lift, may also be offered.
Personal factors including your body shape, cancer diagnosis and cancer treatment plan (including radiotherapy and chemotherapy) will impact the options available to you for breast reconstruction. It is important to understand the advantages and disadvantages of a surgical procedure before proceeding with reconstruction.
The decision to proceed with breast reconstruction is a personal one. It is important to choose what is right for you. Your plastic surgeon will provide additional information about possible surgeries that may be available to you, which will help you make an informed decision.
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