What You Need to Know
The decision of whether to have breast reconstruction is a very
personal one. Some women can't imagine not having breast
reconstruction. Some may choose to wear a prosthesis while others may
choose not to. And still others may go for a few years without breast
reconstruction and then decide reconstruction is what they'd prefer.
Breast reconstruction is the creation, by a plastic surgeon, of a new
and natural-appearing breast. Breast reconstruction has made a big
difference both physically and emotionally for many women who have had
mastectomies. But it's important that you understand the limits of this
surgery before you decide to have it done.
Reconstructive surgery creates a new breast, but it's not a real
breast—it will never have full sensation, as a breast does. If you (or
someone else) touch it, it will feel normal to your hand, but it will
have little sensation itself.
Breast reconstruction is an important alternative to consider. Most
women feel that having the reconstruction is worth it, especially
because it makes it easier to wear certain types of clothing. For many
women, reconstruction also serves another important function: It can
help them put their cancer experiences behind them. On the other hand,
not everyone is pleased with reconstruction. Some women are not happy
with the way their new breast looks. And at least one patient I had
felt that reconstruction was actually a form of denial.
The decision to have reconstructive surgery is highly individual.
Before you make a decision, you should become as informed as possible
about the different procedures and what they entail. You will then need
to decide what you want done and when you want to have it done.
Remember: The only right choices are the ones that are right for you.
Timing of Reconstruction
The first decision you will need to make is when you want the
reconstruction to be done. It can be done immediately after the
mastectomy, or it can be done at a later time. The advantage of having
it done immediately is that you don't have to have another operation
later—your regular surgeon performs the mastectomy and then the plastic
surgeon does the reconstruction. The disadvantages are that doing both
procedures together increases the length of time of the surgery
(usually about six to eight hours). It also may be more difficult to
schedule, since you have to get the surgeon and the plastic surgeon at
the same time.
The second
option is to have the reconstruction done at a later point in time.
This works well for women who haven't yet decided if they want to have
reconstruction or who do not yet feel emotionally prepared to take that
step.
Reconstruction Options
There are two basic kinds of reconstructive surgery: those using
artificial substances and those using your own tissues. Within those
categories there are also variations. The type of reconstruction that
works best for any woman depends on her preferences, the effect she
desires, and the extent of her breast cancer surgery.
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Implants
There are two types of implants: saline and silicone. The saline
implant is a sack of silicone that contains saline inside. Saline is
salt water that closely matches the salt content in our own bodies, so
it is a natural and harmless fluid. The silicone implant is a silicone
sack filled with silicone gel. Although there is much controversy over
silicone and it was banned in 1992 for breast enlargement, it is still
available for breast reconstruction. If you choose a silicone implant,
you should consider enrolling in one of the silicone implant studies.
The procedure for both silicone and saline implants is the same. The
implant is placed behind the pectoralis muscle, the major muscle in the
chest wall. Then the skin is closed over it.
The saline implant feels like water and will therefore have less "heft"
than your natural breast or a silicone implant. If you have the implant
put in at the same time you are having your mastectomy, it will not add
days to your hospital stay.
As with all operations, there is a risk of infection, which can be
especially serious because there is a "foreign body"—the implant—inside
you. If an infection does occur, the implant will have to be removed.
With implants, there is also a possibility that the bag can leak,
flattening the implant. You should note, too, that if silicone is
indeed dangerous (for which there is no conclusive data), having saline
implants does not put you at decreased risk, since the sack itself is
made of silicone.
There are
also a few other things you need to take into account when considering
an implant. For example, the newly reconstructed breast is going to
look like a nice, perfect, young breast—which is probably not how your
other breast looks. Also, it is not as likely to sag as you get older,
and it will not gain or lose weight when you do. For these reasons, you
may need to consider having surgery on the other breast to make it look
more like the reconstructed one. Also, implants don't always last
forever. And if the implant needs to be replaced, you will most likely
need to have a flap reconstruction. (You can read more about flap
reconstruction below.)
Implants are the easiest type of reconstructive surgeries. But it is
important to weigh this factor against the inconvenience and
consequences of possible later surgeries.
The Expander
A variation on the implant is the expander. The expander is a hollow,
empty sack placed behind the pectoralis muscle. The sack contains a
valve and a little tube. For three to six months after the expander is
put in place, the doctor will inject saline into the sack, which
stretches out the skin. Once the sack has become the size you want it
to be, it is removed and replaced with a permanent saline or silicone
sack.
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It
typically takes several months to stretch your skin to the right size,
which is why the expander takes the longest of all reconstructive
procedures. Also, it can be uncomfortable while the skin and muscle are
stretching. Having an expander put in will probably not add more days
to your hospital stay if you have it done at the time of your
mastectomy. But if you have it done at another time, you may have to be
in the hospital for two to three days.
[Enlarge image]
As with all operations, there is a risk of infection, and with an
expander it can be especially serious because there is a "foreign
body"—the sack that is expanding—inside you. This means that if an
infection occurs you may have to have the expander removed. Also, as
with an implant, you may need to consider having surgery on the other
breast to make it look more like the reconstructed one.
Flap Reconstruction
There are several procedures that use your own tissue to make a new
breast. These are called flap reconstructions. This type of
reconstruction involves taking skin, muscle, and fat from another part
of your body and using it to make a new breast.
Flap reconstruction is a better procedure than an implant. Because the
surgeon uses your own tissue, it is easier to make the breast larger,
if that's what is needed. In addition, the breast will have a more
natural droop than one made with an implant. And since it's made from
real tissue, skin, and fat, a breast made from a flap reconstruction
may feel more normal to you when you touch it. However, it will still
have little sensation.
If
you choose to have a flap procedure you will have two scars, one where
your breast was removed and one where the tissue was removed to make
the flap. There are two different surgical techniques for making the
flap: the pedicle, or attached flap, and the free flap.
The Pedicle, or Attached Flap
For the pedicle, or attached flap, a flap of skin and muscle are cut
out, but the artery and vein that feed the flap remain attached, almost
like a leash. The flap of skin and muscle is tunneled under the skin to
where the breast was removed. Then the site from which the flap was
taken is sewn closed. Since the blood vessels aren't cut, the blood
supply remains. This procedure usually involves about five to eight
hours of surgery, and a hospital stay of four to seven days.
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The
advantage of the pedicle, or attached flap, is that it is easier to do
than other types of flap procedures. A disadvantage is that the tissue
that is used for the flap can only come from the two locations that can
stretch to the breast: the abdomen (rectus flap, also known as the
TRAM—transverse rectus abdominus myocutaneous—flap) and the back
(latissimus dorsi flap). The other disadvantage is that tunneling the
tissue through the body to the breast area affects a lot of tissue and
can cause some long-term problems, such as a weakening of the muscles
in the abdomen (if the flap is from the abdomen) or the back (if the
flap is from the back).
Because the TRAM flap requires stomach muscle to be removed, it may
result in an abdominal hernia. It also may result in an abdominal
bulge, since the abdomen no longer has its supporting muscle tissue.
The Free Flap and the Perforator Flap
In the free flap procedure, the tissue is removed and the artery and
vein are cut. Then the flap is moved to where the breast was removed,
and the artery and vein are sewn to an artery or vein in the armpit.
Because the artery and vein are cut, the free flap, unlike the attached
flap, can be taken from areas other than the abdomen or back. The most
common free flaps come from the buttock area (gluteal flap), the hip
area (deep circumflex iliac flap), the lateral thigh (the tensor fascia
lateral flap), the inner thigh (the gracilis flap), and the opposite
back (latissimus free flap).
The free flap surgery is harder to do, and it requires a surgeon
skilled at sewing blood vessels together under a microscope. This means
that if you want to have a free flap, you will need to find a surgeon
who has specific expertise doing these types of procedures.
The free flap tends to have fewer complications because the tissue
isn't tunneled through the body to the breast area, and because less
tissue is removed. The procedure usually involves about five to eight
hours of surgery, and a hospital stay of four to seven days.
Dr. Robert Allen, of New Orleans, introduced a new variation of the
free flap called the perforator flap. Instead of taking some muscle
with the free flap, Dr. Allen dissected the arteries that perforate
through the muscle to the skin. After Dr. Allen introduced this
technique, surgeons began to rethink how much muscle they needed to
move, which has led to what's now called the "muscle sparing" free
flap. The most common abdominal perforator flap is the DIEP (deep
inferior epigastric perforator). When the tissue is taken from the
upper buttocks/hip region, it is called a GAP (gluteal artery
perforator).
If a woman is
overweight, the DIEP flap is typically better than the TRAM flap.
(Overweight women are at higher risk of developing a hernia from muscle
loss after a TRAM flap.)
The Latissimus Flap with Implant
Another alternative is to do a combination operation, using the
latissimus flap and a silicone implant behind it. This is an easier
surgery than the free flap, so more surgeons can do it, and it can be
especially useful if there is a problem in the abdominal area. It's
also a good option for a woman who has had previous abdominal surgery
or who is very thin and does not have enough tissue in her abdomen to
make a new breast. This procedure typically requires a woman to be in
the hospital for four or five days. The stitches are out in two to
three weeks, and by five or six weeks normal levels of activity can be
resumed.
Important Points About Flap Reconstruction
The flap procedures require highly trained plastic surgeons, and it
might be virtually impossible for you find a surgeon in your area
trained to perform them. Many more plastic surgeons are trained to do
the implant and expander, which are simpler procedures.
Also, you should prepare yourself for being in a lot of pain, both in
your breast area and in the area where the flap was removed from, and
to need a lot of pain medication. Typically you will be on full
bed-rest for one or two days, with a catheter. By day three or four,
you will start to feel a bit better and be able to walk around a
little. And by day five or six, you'll be able to go home. You'll have
drains placed in your chest and in the area the tissue was removed
from. At this point, your chest will probably feel numb, but the area
where the tissue was removed from will continue to hurt a lot, and you
will need to take pain medication after you go home.
Lastly, you need to be prepared that you'll most likely end up having a
second operation to do some touch-ups if there is too much tissue in
one place or another and to make a nipple, if you want one.
Partial Reconstruction After Lumpectomy
When a patient has a poor result after a wide-excision lumpectomy, a
reasonable result often can still be achieved by one of two methods. If
the breast is large enough in overall volume, the surgeon can
"rearrange" the breast tissue to reshape the breast. This usually
involves lifting the nipple up and moving the breast tissue around to
fill in the indented areas. Usually, a similar procedure with a slight
reduction is needed in the opposite breast to achieve symmetry.
A second option is to increase the volume in the indented area. This is
usually done by taking a flap of tissue from under the arm and
transporting it into the indented area or by taking part of the
latissimus muscle, and the skin and fat over it, and moving it into the
indented area. This allows the reconstructed breast to be made entirely
from the patient's own tissue, which makes it easy to examine by
palpation or mammogram.
The
one thing you shouldn't do is to get a small silicone or saline implant
put in the remaining breast tissue. Women who have had lumpectomies
need to have mammograms to look for a recurrence, and we can't
mammogram through an implant. When women have an implant for
augmentation, there are techniques we can use to push the implant back
and take a mammogram. But when an implant is used to fill out the
breast after a lumpectomy, it is in the middle of the breast tissue so
it is always in the way. A flap, however, uses the body's own tissue,
which is mostly fat, so it won't block the mammogram.
Nipple Considerations
You don't have to have a nipple made. But if you want your breast to
look as real as possible, you'll probably want the procedure done.
Your new nipple will not be made right away because the surgeon needs
to be sure it's in the right place, and the swelling that naturally
occurs after reconstructive surgery can make that hard to determine.
The new nipple will look real, and will match the color or your
original nipple. Sometimes the skin from your inner thigh is used,
since it's darker than breast skin. In other instances, the surgeon
will make the nipple from the tissue in the flap and then tattoo an
areola.
Radiation After Reconstruction
In most instances radiation is not necessary after a mastectomy; the
surgery is believed to have removed the entire tumor. However,
radiation may be required if a woman is at high risk for a local
recurrence and there is concern that there are cancer cells that may be
lingering in the remaining chest wall or regional lymph nodes.
A woman is at high risk for a local recurrence if she has four or more
positive axillary nodes, a tumor over 5cm, close margins (cancer cells
at the edge of the mastectomy), and significant amounts of
lympho-vascular invasion in the breast tissue. In this instance,
post-mastectomy radiation can reduce the chance of local recurrence and
improve disease-free survival.
Initially, some studies found that women who had radiation after
undergoing breast reconstruction were more likely to develop
complications. The most recent research, however, indicates that this
does not appear to be the case.
Undergoing radiation can affect when you have your reconstructive
surgery. The problem is that radiation causes scarring of the muscle
and skin of the chest wall, which makes the tissue tight and difficult
to move. This means that if you choose to have an implant or an
expander, you will need to have your reconstruction before you have
your radiation. If you choose to have a flap procedure, you can have it
done before or after the radiation.
How to Decide What's Right for You
You will need to talk to both your surgeon and a plastic surgeon to
determine which procedure is right for you. Make sure you ask the
surgeons which procedures they are most familiar with and do regularly.
If you really want a flap procedure, but your plastic surgeon doesn't
do it, you may want to call your local breast cancer support group to
see if they can recommend a plastic surgeon who knows how to do the
flap procedure. If there's no one in your area, and you still want that
type of reconstruction, you can always have the mastectomy first and
then find the right plastic surgeon to do the reconstruction when your
treatment is done. If you prefer to have an immediate reconstruction,
but the plastic surgeon won't do it that way, then you'll need to find
a plastic surgeon who is comfortable doing that type of procedure.
When you speak with the plastic surgeon, make sure you ask to see
pictures of both their best and worst results. This will give you a
more realistic idea of what your breast will look like after surgery.
Lastly, be prepared to consider surgery on the breast that does not
have cancer. To make both breasts look the same may require reducing
the breast if it's too droopy, enlarging the breast if it's too small,
or lifting the nipple and reshaping the breast.
What Happens If the Reconstruction Isn't What You Expected
Sometimes reconstruction isn't entirely successful. It may not give you
the look you want or it may be a source of pain or medical problems. If
this occurs, there is no need to live with the consequences for the
rest of your life, as they are often reversible. You may find that the
reconstruction is a source of unpleasant sensations ranging from pins
and needles, to burning, to sharp pain.
You may just find it is hard to adapt to the feel of an implant. Or you
may find that the implant seems solid, even rock-like to the touch.
When this occurs it's not because of the implant itself, but because
scar tissue has formed around it, encasing it in a tough capsule.
With implants, the new breast is often heavier, because the implant and
scar tissue weigh more than breast tissue. This can result in a breast
that looks too big, or feels too big. In other instances, the
reconstructed breast can end up being too small. Other times women find
that the new nipple that was made is higher or lower that the nipple on
the other breast.
One thing
you don't have to do is accept your problem. A plastic surgeon can cut
away hard scar tissue and replace implants, exchange an implant for a
flap, reduce or enlarge a breast, or lift and reorient nipples.
Technology is improving and so are surgical techniques as experience
with the procedure—and the demand for it—grows. Get a referral to a
plastic surgeon from a friend or your breast surgeon, explain your
problem, and have the plastic surgeon outline a plan for correcting it.
If possible, get a second opinion. Again, ask for pictures of the
plastic surgeon's best and worst outcomes. Occasionally, if the skin
has been altered by radiation, or is not elastic enough to make
additional reconstructive surgery advisable, the best course may be to
remove the implant and get a prosthesis instead.
Insurance Coverage
Insurance companies are required to pay all or part of the cost of
breast reconstruction, whether you have the surgery done at the time of
your mastectomy or at a later date. They are also required to pay all
or part of any surgery needed on the other breast to make both breasts
symmetrical. Be sure to check with your insurance company about which
procedures they cover, as this may affect your decision.
If You Smoke
A cancer diagnosis is often an incentive for some women to quit
smoking. Quitting smoking may also be necessary for you to receive
certain types of breast reconstruction. Studies have found that it
takes longer for the abdomen of a woman who smokes to heal and that her
fat tissue may be more likely to develop into scar tissue. Women who
smoke are also more likely to develop an abdominal hernia following
their surgery. To reduce these complications, women who wish to have
any type of flap reconstruction will be asked to stop smoking three to
four weeks prior to their surgery.
What Will My Breast Look Like?
In the Show Me section of our website, you can find photographs of some of the women included in the book Show
Me: A Photo Collection of Breast Cancer Survivors' Lumpectomies,
Mastectomies, Breast Reconstructions and Thoughts on Body Image. To go to the Show Me section.
The two websites listed below also provide information on how
reconstructive surgery is performed and what the results look like. Our
links to these sites should not be perceived as an endorsement of these
centers. They are for informational purposes only.
www.diepflap.com
www.centerforrestoration.com
Additional Information:
www.nlm.nih.gov
www.cancer.org
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