Breast reconstruction is a surgical procedure performed to restore the normal shape of the breast. If you have had a lumpectomy, the normal shape of the breast may be distorted or unnatural, or there may be a contour irregularity where the surgery was performed. If you have had a mastectomy, the entire breast is removed. Breast reconstruction can restore the normal shape of your breast, and should be an option to all patients with breast cancer. There are essentially 3 main types of breast reconstruction:
1. A prosthesis or implant
2. Your own tissues
3. A combination of your tissues plus an implant
When Breast Reconstruction is performed
Breast Reconstruction can be performed at the same time as your mastectomy (immediate reconstruction), or it can be performed at a later date (delayed reconstruction). Patients often choose to have it done at the same time as their mastectomy because it saves the patient from undergoing another separate procedure and anesthesia. However, there are certain circumstances when having breast reconstruction should be delayed until after a mastectomy is performed. This depends upon the extent of your cancer, and in some situations, whether or not radiation therapy is planned after your mastectomy. A consultation with your doctor and a plastic surgeon prior to any surgical intervention can help you decide.
How Breast Reconstruction is performed
Using prosthesis or Implant
An implant is placed at the time of mastectomy (immediate reconstruction) or at a separate stage (delayed reconstruction) usually underneath the pectoralis major muscle and skin. In some cases, this may be the final and permanent implant. Usually, however, a tissue expander is placed, which is a temporary device that is not yet fully expanded to its maximum size. The expander is initially underfilled with sterile saline solution so that the overlying skin and muscle can heal.
After 2 weeks from surgery, the expander can then be slowly filled with sterile saline in the office so that the overlying tissues are stretched or “expanded.” This involves inserting a small needle through the skin into the expander port and injecting the saline. Only a limited amount of volume is injected each time, and the process is repeated on usually a weekly basis until the tissues are expanded to the appropriate size. In general, this takes about 4-6 sessions/weeks of expansion.
Once you reach the desired size, a second surgery is performed 1-2 months later in which the expander is removed and the permanent implant is placed. This second procedure is usually done as an outpatient, so you can go home the same day. You and your surgeon will determine the type of implant that is placed -either silicone gel-filled, or saline-filled. Breast reconstruction with prosthesis generally involves less operative time compared to the other methods of reconstruction. It also does not require surgery in another part of your body, so there are fewer incisions, and a faster recovery time.
Using your own tissues
Using your own tissues (Autologous Tissue) involves moving tissue from one part of your body up to your chest to shape it into a breast. The most common way to do this is to take excess tissue from your abdomen. The T.R.A.M. (Transverse Rectus Abdominis Myocutaneous) Flap is a method of taking tissue similar to a tummy tuck, and moving it to your chest to make a breast. The advantage of doing this is that generally an implant is not required, assuming that you have enough tissue to use.
If you are considering having both breasts reconstructed, each half of the tissue from the tummy can usually be used for each breast. A major advance in breast reconstruction is the use of “perforator flaps” in which only the blood vessel supplying the overlying skin and fat is used, leaving all of the muscle behind. This has the advantage of preserving muscle function, and should minimize donor site problems.
There are other possible donor sites that can be used for breast reconstruction, such as the buttock region, thighs or hips. In general, these other options are reserved for when your abdomen is not available. Usually no implant is needed, so all of the potential complications of a prosthetic device are eliminated. Using your own skin and fat usually provides for a reconstruction that may look and feel more natural. Also, if you use tissue from your abdomen, it can simultaneously improve the appearance of your tummy region.
Using a Combination of Your Own Tissues Plus an Implant
Occasionally patients may not be a good candidate for either of the above procedures alone. If this is the case, then tissue can be moved from your back to cover an implant. The most common method that is done is a latissimus dorsi (LD) muscle flap plus implant. The advantage of this method is having more tissue to cover an implant, which allows the reconstruction look and feel more natural.
Alternatives to Breast Reconstruction
Some patients who choose not to have breast reconstruction, or are not good candidates for reconstruction because of other health problems, may choose to wear an external prosthesis. The prosthesis is usually made of a type of synthetic foam material that can be placed inside a custom bra to match the opposite breast; or the prosthesis can be made for both breasts. When you wear normal fitting clothes, most people can't tell the difference. However, the prosthesis can sometimes be uncomfortable to wear, particularly when it's hot outside, or when you wear certain types of clothes.
Candidates for Breast Reconstruction
Based on the protections included in The Women's Health and Cancer Rights Act (WHCRA) of 1998, all patients are potential candidates for breast reconstruction of the affected breast as well as symmetry procedures for the opposite breast, if desired. Generally, patients should be in relatively good cardiovascular health, and fit enough to have the surgical procedure(s) required to reconstruct the breast. However, only an office visit, examination, and consultation with a reconstructive plastic surgeon before undergoing any surgical intervention can determine the options that are best for you.