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A Guide For Your Partner


Breast Reconstruction


Breast Reconstruction
After a mastectomy, the shape of the breast can be reconstructed using implants, or the patient's own tissues. It is important that you realize that reconstructive surgery cannot give you a new, normally functioning breast. It can only create a breast form which, under the best conditions, will have the shape and texture of your other breast.

For many women, a breast reconstruction after a mastectomy is a milestone that symbolizes that they have completed the treatment, and are ready to get on with their lives. It is also an opportunity to regain their feminine silhouette and restore their self-image.

Years ago, reconstructions were less common, partially because many cancers were discovered at an advanced stage, when long-term survival was not a certainty, and partially because reconstruction techniques left a lot to be desired.

Today, almost any woman who has had a mastectomy can have her breast reconstructed. The new techniques yield excellent cosmetic results.

Myths about the disadvantages of reconstruction—such as presumed difficulty in detecting future recurrence—have been disproved. In addition, cost issues are also less of a factor, because coverage by insurance companies is now mandated by law.


There are a number of techniques available to build a new breast mound, create a new nipple and areola, and make changes in the other breast to achieve better symmetry.

If you are considering reconstruction, even if it's to be done at a later date, arrange a meeting with a plastic surgeon well before your mastectomy, to discuss the details of the procedure. If your primary surgeon works closely with the plastic surgeon, the process will be smoother, and the results will be better.

Very commonly, you may need a minor plastic procedure on the other breast, such as a breast lift, to achieve the best similarity possible to the reconstructed breast.

Reconstruction may be easier if you have a skin-sparing mastectomy, where much of the skin of the breast is left in place. However, this procedure may carry an increased risk of local breast cancer recurrence. Discuss the safety of this option with both the breast surgeon and the plastic surgeon.

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Reconstruction can be done at any time: at the time of mastectomy—which is called immediate reconstruction—or at a later date—which is called delayed reconstruction.

There are two main methods for reconstruction. One uses synthetic implants to create the shape of a breast. The other, the patient's own tissues, transplanted from another area of the body. Both methods are undergoing constant improvements and refinements.

Once the breast is rebuilt, you can go on to have a reconstruction of the nipple and the areola, to achieve an even more natural look. You may also benefit from cosmetic surgery on the other breast for better symmetry.

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For your reconstruction, it is crucial that you select a surgeon who has extensive experience in reconstructive breast surgery, and is a board-certified specialist, because the cosmetic results will depend significantly on the surgeon's skill. Your primary surgeon can refer you to one, or you can get a list of names in your area by contacting the American Society of Plastic Surgeons, listed in the Resources section.

One more key point: it is important that your expectations be realistic. The new breast can look natural, and feel normal to someone touching it, but you will not have sensation in the nipple, and will have decreased or no sensation in the skin of the breast. Your satisfaction with the final result will depend as much on the surgeon's skill and technique used, as on your healing pattern and your expectations.

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Reconstruction with Implants

The Implant Procedure
The most common method of breast reconstruction is with implants. Synthetic implants are teardrop-shaped pouches that are inserted under the skin to create the form of a breast. The pouch is made of silicone, and is filled with saline (salt water solution) or with silicone gel.

In the early 1990's silicone was a source of concern because of a possible link to certain connective tissue diseases. Recent studies have shown that these suspicions were unfounded, and silicone implants continue to be available for breast reconstruction. You'll meet with a plastic surgeon before your mastectomy to choose an implant that will match your other breast and provide a pleasing, symmetrical appearance.

If you're having immediate reconstruction, the plastic surgeon will take over right after the mastectomy, while you're still under anesthesia. This part of the surgery will take about an hour.

In order to achieve the most pleasant shape and feel for the reconstructed breast, the implant is usually placed under the muscle, rather than directly under the skin.

If the implant is small, and sufficient skin from the breast remains in place, the surgeon may be able to insert the implant without undue stretch to the skin and muscles of your chest wall. Your reconstruction will be complete. However, if the implant is too large, the surgeon will need to use a temporary expander.

The expander is an elastic bag equipped with a fill tube and a valve. After the expander is inserted in place, it is filled with a small amount of saline. You'll return to the surgeon's office every week or two to have more saline injected into the expander. Gradually, over three to six months, the skin and muscle will stretch, just like they do over the abdomen during pregnancy. Then the expander will be removed and the permanent implant inserted in its place. A nipple and areola can be created during a future procedure.

A new type of implant, the Becker implant, has been recently re-introduced. It is a pouch that can first be used as an expander. Then, when the skin is sufficiently stretched, the fill tube is removed in a minor office procedure, and the pouch is left behind as a permanent implant. This is called a one-stage reconstruction, and can eliminate an extra surgical procedure.

After Surgery
The first 24 to 72 hours after your initial implant surgery is when you experience the most discomfort. Your breast will be swollen and tender. Although every woman's recovery time is different, you should be able to resume many of your regular activities after about one week. You will need to wait at least one month before doing anything strenuous.

During the several weeks required to fully inflate the expander, you will probably have a feeling of fullness in your breast, but no major discomfort.

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Breast reconstruction can be done using skin, muscle, and fat taken from another part of your body. This tissue transfer is called a myocutaneous flap, musculocutaneous flap, or simply, a flap.

There are different types of myocutaneous flaps. Some, (like TRAM flaps and latissimus dorsi flaps), move tissues from an area of the body to the breast area, while preserving the original blood supply. Others, (like the DIEP, SIEP, or IGAP) are free flaps—the original blood supply to the transplanted tissue is cut then reconstructed.

TRAM (Transverse Rectus Abdominis) Flap
The TRAM flap has been one of the most common flaps for years. It uses one of the rectus abdominis muscles—the "abs," as weight lifters call them. The muscle, fat, and skin are separated from their natural attachments, and pulled up, under the skin, to the breast area. The flap is then shaped into the form of a breast. Some of the original blood supply is preserved.

The TRAM flap is the most versatile of the tissue flaps, and can usually create a good match to the other breast for all but the largest-breasted women. No implant is required as is often the case with the latissimus dorsi flap.

The procedure takes three to five hours, and usually requires a four to seven day hospital stay. It also entails an abdominal incision, and does result in significant discomfort for some time after the surgery.

Rarely, a hernia may develop in the area from where the muscle was taken. But an additional cosmetic benefit of a TRAM flap is that it also gives the woman a "tummy tuck" as part of the procedure.

Latissimus Dorsi Flap
The latissimus dorsi flap is sometimes referred to as Lat flap. For this procedure, an incision is made under the shoulder blade, and a temporary tunnel is created under the skin, just like for the TRAM flap. A portion of the latissimus dorsi muscle from the upper back, and the fat and skin covering it, are pulled through this tunnel and relocated to the breast area.

For most women, the latissimus muscle does not provide enough bulk to match the opposite breast, so a synthetic implant is added to make the reconstructed breast larger.

The procedure takes five to six hours and is done under general anesthesia.

Free Flap
To create a free flap, a portion of muscle, fat, and skin is removed from the abdomen or buttocks, and transplanted to the breast site. The original blood supply to the flap is cut, and then reconnected to a new artery and vein in the breast area. This procedure requires a plastic surgeon who is skilled in micro-surgery, because it involves sewing together blood vessels so thin, that the work must be done under a microscope.

Several more advanced forms of free flaps are gaining popularity. They use the so-called perforator vessels—blood vessels that branch off a deep artery and pass through the muscle, on the way to the fat and skin. The plastic surgeon isolates these vessels from the bigger artery, and dissects them out through the muscle, rather than taking them with the muscle. This technique offers the benefit of a longer blood vessel that is easier to re-attach in the breast area. By preserving the muscle, the patient's recovery is shorter, there is much less discomfort after surgery.

One example of a perforator flap is the DIEP (deep inferior epigastric perforator) flap. This flap uses fat and skin from the same area as the TRAM flap, but does not disturb the muscle. Recovery time is shorter, post-operative discomfort is less. In addition, the muscle in the donor area is not damaged, and retains its shape and function, unlike for the traditional TRAM flap, in which most, if not all the muscle is removed. A welcome by-product of the DIEP flap procedure is a tummy tuck.

Another option in free flaps is the IGAP flap that uses the inferior gluteal artery and a portion of the buttock tissue. The location of the donor site can be effectively concealed, and the outline of the buttock preserved.

Recovery After Reconstruction
Your post-operative course will depend on the procedure you had, and on your body's ability to heal.

For some of the more complex free flap procedures, you will spend 24 hours in the intensive care unit, where you will have frequent checks to ensure that the blood supply to the flap is adequate. Then you will be transferred to a regular floor to continue your convalescence.

At home the care of the wound will be almost the same as if you only had a mastectomy. Generally, you will have additional drains in place, that will need to be drained by you or your care giver several times a day for the first few days. Most women can resume their activities of daily living within the week.

All flap reconstructions are complicated procedures and involve certain risks. Large portions of tissues are moved, and their blood supply is disrupted. There is a possibility that the flap will necrose, or die. This would require removal of the flap, causing significant discomfort and possible deformity.

Flaps cause pain both at the donor site and in the breast area. Removal of muscles from their original position can cause pain and weakness, or rarely, a hernia in the donor area.

On the other hand, the use of flaps avoids placing foreign materials into your body, and can result in the most natural-looking reconstructions. Many women—and their partners‹appreciate the fact that the breast feels more natural than after an implant reconstruction.

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Reconstruction is not for everyone, and it may not be right for you. Many women choose to do nothing, or to wear an artificial breast form.

If you decide to have breast reconstruction, your options will be many. Be sure to ask your plastic surgeon to show you photos, and perhaps arrange for you to interview some of the patients who had the same procedure. Here are some factors to keep in mind when making your decisions:

Synthetic Implants:

• They are not lifetime devices, and may rupture or need replacement.
• Implants may lead to capsular contracture, and misplacement.
• Some women report feeling the implant as a foreign object.
• Implants can be easily placed by most plastic surgeons.
• There is less surgery, less pain, shorter recovery, no additional scar, and less expense than with tissue flaps.

Tissue Flaps:

• They are typically soft and normal-appearing.
• There is no artificial implant in the body.
• With some flaps, a "tummy tuck" is an added bonus.
• There is lengthy, extensive, and expensive surgery, with blood transfusions and considerable post-operative discomfort.
• There is an additional scar at the donor site.
• There is a small but significant risk of the flap "not taking."

Immediate Reconstruction:

• You don't have to wake up from mastectomy surgery without a breast.
• One surgery rather than two means lower cost, fewer problems from anesthetic and surgery, and less recovery time.

Delayed Reconstruction:

• Provides additional time to make reconstructive choices.
• For the woman undergoing chemotherapy, possibly decreases the chance of infection in the reconstruction area.
• Avoids difficulties coordinating operative schedules, which may delay surgery.

Nipple and Areola Reconstruction
Women who want their reconstructed breast to look as natural as possible may choose to have a nipple and areola reconstruction. This procedure is usually done a few months after the breast reconstruction, so that the breast has had time to "settle" in place.

Small flaps of skin on the reconstructed breast are raised and brought together into the shape of a nipple. The areola is created either from a skin graft, or by tattooing. The procedures can be done under local anesthesia.


External Breast Forms

Many women choose to have no reconstruction of any type after the mastectomy. Some make this decision because they want to avoid extra surgery. Others because they're comfortable with their appearance and body image. A few view their scars as battle scars from a war they waged. And yet others do want reconstruction to erase the visual reminder of cancer, or to enhance their self-image. There is no right or wrong answer, and your decision must be respected by those who are close to you, and by your healthcare team.

If you choose to have no reconstruction, you may want to use a breast form instead. Breast forms, or prostheses as they are also called, are available in a variety of sizes, shapes, and colors. Some are designed to fit into a special bra. Others can be attached securely to your chest using a special adhesive. Prostheses range from inexpensive foam inserts to custom-molded replacements with realistic color and texture, designed to duplicate your natural breast as exactly as possible.

Breast forms are used not just to maintain appearance and sense of balance. They play an important functional role by relieving the uneven strain on your posture that may occur after a mastectomy, particularly if your breasts are large.

The decision to have reconstruction or to wear an external prosthesis is a very personal one, and is based on your feelings about your body, your sexuality, and your tolerance for additional surgery. Your decision is legitimate, and must be respected by your healthcare providers and your loved ones.



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