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
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CHOOSING A PLASTIC
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
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
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
During the several weeks required to fully inflate the expander,
you will probably have a feeling of fullness in your breast, but no
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RECONSTRUCTION WITH YOUR OWN TISSUES
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
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
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
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
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
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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IS RIGHT FOR ME?
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
• They are not lifetime devices, and may rupture or need
• 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.
• 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
• You don't have to wake up from mastectomy surgery without
• One surgery rather than two means lower cost, fewer problems
from anesthetic and surgery, and less recovery time.
• 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
External Breast Forms
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
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
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
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
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