Choices in Breast Reconstructive Procedures

The type of breast reconstruction procedures available to you depends on your medical situation, breast shape and size, general health, lifestyle, and goals. You can have your breast reconstructed with a breast implant, a tissue flap (your own tissues), or a combination of the two. If you have breast reconstruction, with or without breast implants, you will probably undergo several reoperations to improve symmetry and appearance.

For example, after your breast has healed from the original implant surgery, you may want to build a new nipple and darken the areola (skin around the nipple). This procedure can usually be performed on an outpatient basis. Ask your doctor to explain the various ways this can be done, such as using a skin graft from the opposite breast or by tattooing the area. Ask your doctor about the pros and cons of each implant technique. If you decide to have reconstruction for one breast, your doctor may suggest surgery on the other breast to achieve a similar appearance.

The following issues should be considered for women with breast cancer:
• The physical and cosmetic results with breast implants may be affected by chemotherapy, radiation therapy, or any other factor that significantly affects the healing process.
• Skin necrosis may occur because blood circulation to the remaining tissue has been changed by a mastectomy. Radiation treatment may also increase skin necrosis.
• It usually takes more than one operation to achieve the desired cosmetic outcome, especially if the reconstruction procedures include building a new nipple.
• Breast reconstruction is an optional procedure and is not needed to treat the cancer.
•
Breast Reconstruction with Breast Implants

The following information applies to reconstruction following mastectomy. However, similar considerations apply to reconstruction for breast trauma or congenital defects.

Your doctor will decide whether your health and medical condition makes you an appropriate candidate for breast reconstruction with breast implants. Women with larger breasts may require reconstruction with a combination of a tissue flap and an implant.

Your doctor may recommend a breast implant, reduction mammoplasty (breast reduction), or a mastopexy (breast lift), of your opposite, uninvolved breast to improve symmetry with your reconstructed breast. Reduction mammoplasty involves removal of breast tissue and skin. Mastopexy involves removing a strip of skin from under the breast or around the nipple and using it to lift and tighten the skin over the breast. If it is important to you not to alter the unaffected breast, you should discuss this with your doctor because it may affect the breast reconstruction procedures considered for your case.

The breast reconstruction process may begin at the time of your mastectomy (immediate reconstruction) or weeks to years afterwards (delayed reconstruction).

Immediate reconstruction is one-stage or two-stage reconstruction.

• One-stage breast reconstruction may be done at the time of your mastectomy. After the general surgeon removes your breast tissue, the plastic surgeon will insert a breast implant under the skin where breast tissue was removed.
•
• Two-stage reconstruction is more typical. The first stage is a breast tissue expander placed, at the time of your mastectomy, to stretch your skin and create a pocket for a breast implant. Tissue expansion typically lasts four to six months. The tissue expander is then replaced several months later with a breast implant. This is considered immediate reconstruction because the tissue expander is placed at the time of mastectomy.
•
Delayed reconstruction is a two-stage reconstruction starting with a breast tissue expander placed months or years later, which is then replaced several months later with a breast implant. This is considered delayed reconstruction because the tissue expander is placed after the mastectomy site has healed.

It is important to know that the one and two-stage references do not mean the number of surgeries involved. You should expect that any type of breast reconstruction will take several steps to complete. It could take months to years before your reconstruction is complete.

Two potential advantages to immediate reconstruction are that your breast reconstruction starts at the time of your mastectomy and that you may save money when you combine the mastectomy with the first stage of the reconstruction. However, with immediate reconstruction, there may be a higher risk of complications, such as rupture/deflation, as well as longer initial operation and healing times.

A potential advantage to delayed reconstruction is that you can delay your reconstruction decision and surgery until other treatments, such as radiation therapy and chemotherapy, are completed. Delayed reconstruction may be advisable if your surgeon anticipates healing problems with your mastectomy, or if you just need more time to consider your options.

There are medical, financial, and emotional considerations to choosing immediate versus delayed reconstruction. You should discuss the pros and cons with the options available in your individual case with your surgeon, plastic surgeon, and oncologist.

Breast Reconstruction with Tissue Flaps

The breast can be reconstructed by surgically moving a section of skin, fat, muscle, and blood vessels from one area of your body to another. The tissue may be taken from such areas as your lower abdominal area, upper back, or buttocks.
The most common types of tissue flaps are:
• the TRAM (transverse rectus abdominus musculocutaneous) flap that uses tissue from the lower abdominal area
• the Latissimus Dorsi flap that uses tissue from the upper back.
•
Flap surgery has the advantage of using your own tissue to construct a new breast. However, it is important for you to be aware that flap surgery, particularly TRAM flap surgery, is a major operation and more extensive than your mastectomy operation or breast implant surgery. It requires good general health and strong emotional motivation. If you are very overweight, smoke cigarettes, have had previous surgery at the flap site, or have any circulatory problems, you may not be a good candidate for a tissue flap procedure. Also, if you are very thin, you may not have enough tissue at the flap site to construct a breast mound.

Tissue flaps, in general, can be moved to the reconstruction site by one of two methods. The first method is when the flap is left attached to the muscle and blood vessels and tunneled under the skin to the reconstruction site. The second method is when the flap is completely removed and then transferred to the reconstruction site and reattached by microsurgery. More specifically, the TRAM flap can be done by either of these two methods while the Latissimus Dorsi flap procedure involves only the first method. In addition, for TRAM flap surgery, your surgeon may also need to build you a new belly button after the lower abdominal area is reshaped.

Flap surgery requires a hospital stay of several days and generally a longer recovery time than breast implant reconstruction. While you can resume normal daily activity after several weeks, some women report that it takes up to one year to resume a normal lifestyle.

Flap surgery also creates scars at the site where the flap was taken and possibly additional scars on the reconstructed breast. You may also have some temporary or permanent decreased muscle strength at the flap site.

As a special note regarding the TRAM flap procedure, if you are considering pregnancy after your reconstruction, you should discuss with your surgeon how this procedure may affect your abdominal muscle strength. In addition, although abdominal tissue feels like breast tissue to the touch, the nerves are cut during the surgery, so there may be little feeling or sensitivity in your breast. Also, you should know that a surgeon can take tissue from your abdomen only once. If you later need a mastectomy of your second breast and want to have a tissue flap procedure, then the tissue will have to come from another site, such as your back.

Questions to Ask Your Surgeon about Breast Augmentation

The following list of questions may help you to remind you of topics to discuss with your surgeon. You may have additional questions as well.
1. What are the risks and complications associated with having breast implants?
2. How many additional operations of my implanted breast(s) can I expect over my lifetime?
3. How will my breasts look if I choose to have the implants removed without replacement?
4. What shape, size, surface texturing, incision site, and placement site is recommended for me?
5. How will my ability to breast feed be affected?
6. How can I expect my implanted breasts to look over time?
7. How can I expect my implanted breasts to look after pregnancy? After breastfeeding?
8. What are my options if I am dissatisfied with the cosmetic outcome of my implanted breasts?
9. What alternate procedures or products are available if I choose not to have breast implants?
10. Do you have before and after photos I can look at for each procedure and what results are reasonable for me?
11.
Questions to Ask Your Surgeon about Breast Reconstruction

The following list of questions may help to remind you of topics to discuss with your surgeon. You may have additional questions as well.

1. What are all my options for breast reconstruction?
2. What are the risks and complications of each type of breast reconstruction surgery and how common are they?
3. What if my cancer recurs or occurs in the other breast?
4. Will reconstruction interfere with my cancer treatment?
5. How many steps are there in each procedure? What are they? How much experience do you have with each procedure? What is the estimated total cost of each procedure?
6. How long will it take to complete my reconstruction?
7. Do you have before and after photos I can look at for each procedure and what results are reasonable for me?
8. What will my scars look like?
9. What kind of changes in my implanted breast can I expect over time?
10. What kind of changes in my implanted breast can I expect with pregnancy?
11. What are my options if I am dissatisfied with the cosmetic outcome of my implanted breast?
12. How much pain or discomfort will I feel and for how long?
13. How long will I be in the hospital? Will I need blood transfusions, and can I donate my own blood?
14. When will I be able to resume my normal activity (such as athletic activity, sexual activity)?

 

Breast Enlargement : Breast Reduction : Breast Uplift : Brow Lift :  Chin Implant : Ear Surgery :

 Eyelid Surgery : Face Lift : Liposuction  : Male Breast Reduction : Rhinoplasty : Tummy Tuck