Breast Reconstruction--Part I

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

The decision to have breast reconstruction is a matter of personal choice. Whether the reconstruction should be "immediate" or "delayed" is one that is not always easily answered. Nor is the answer the same for everyone. Learn as much as you can about the process before making a decision. No single source of information can provide every fact or give you all the answers. You and those close to you should discuss any questions and concerns about reconstructive surgery with your health care team.

Women choose breast reconstruction for different reasons. It is important for you to understand what your own reasons are. The surgical goals of reconstruction are:

• To make your breasts look balanced when you are wearing a bra, not necessarily "the same" when you are not wearing a bra. The breasts should be close enough to one another in size and shape that you will feel comfortable about how you look in most types of clothing.
• To permanently regain your breast contour. Breast reconstruction cannot restore your normal breast sensation. With time, the skin on the reconstructed breast can become more sensitive, but it will not give you the same kind of pleasure as before a mastectomy.
• To give the convenience of not needing an external prosthesis

Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery. Also, you may be disappointed with how your breast looks after surgery. You and those close to you must be realistic about what to expect from reconstruction. Reconstruction will not give you back the pre-cancer breast.

There are three main types of breast reconstruction:

• Reconstruction using an implant of some kind.

• Tissue flap reconstruction, in which skin, muscle and fat from your back or abdomen (tummy) is tunneled through to the chest to create a new breast. The skin, muscle and fat stays connected to the area of the body from which it was taken.

• Free flap reconstruction, in which skin and fat from your lower abdomen, or occasionally buttock, is grafted to the breast area. The skin and fat is completely removed from the original area and a new blood supply is created for the new breast tissue, using microsurgery.

Or you can think of the types of reconstruction as implant based or tissue based or a combination of implant and tissue.

Implant-based reconstruction does not require removal of tissue from some other part of the patient’s body, so the procedure does not result in additional scars at a donor site. Breast reconstruction is easier and simpler with implants than with autologous (your own) tissue, and almost all plastic surgeons know how to do implant-based reconstruction. For these reasons, implant-based reconstruction is the most commonly used type of breast reconstruction in all parts of the world. The results are not always as natural as are those of autologous tissue-based reconstruction, and the quality of the outcome may be lower, but the risk of being hurt by the reconstruction is also lower. To make up the missing breast volume, the breast implant is placed beneath the muscle and skin of the chest wall. This can be done at the time of the mastectomy or as a delayed procedure, even years later.

During a mastectomy, both breast gland tissue and some of the overlying skin are removed. If the original breast was a very large one, the skin remaining after the mastectomy may be enough to adequately cover an implant. In those cases, using the remaining skin results in a breast that is smaller than the original one but may still be adequate. In many cases, however, missing breast skin will need to be replaced in some way. This is most commonly done by one of two methods: tissue expansion or a Latissimus Dorsi flap. A tissue expander is a balloon-like device that, as it is gradually filled with saline, stretches the breast skin remaining after a mastectomy until there is enough skin to cover an implant without tension. This skin expansion is performed gradually over a period of about two months. It may be inconvenient (will require weekly or bi-weekly visits to your surgeon's office), but usually is not painful.

Most plastic surgeons over-expand the breast being reconstructed to a volume 5% to 10% larger than the opposite breast. When the breast skin has been expanded to the desired size, it is then necessary to wait four to six months to let the expanded skin lose its elasticity so that the stretch becomes permanent before removing the tissue expander and inserting the permanent breast implant. The expanded skin will have redundancy and droop down on the chest wall as a normal breast would. This effect of drooping (ptosis) is important in achieving a shape like that of an original breast. Ptosis is difficult to achieve with tissue expansion and an implant. To achieve symmetry, the opposite breast may need to be enlarged with an implant, reduced, or lifted.

The main advantage of implant-based techniques, compared with autologous tissue-based approaches, is that most or all of the material used to make up the breast volume comes from a box on a shelf. Therefore, the initial operation for implant-based reconstruction is relatively minor. In general, the risks of the surgery (apart from failure to achieve a successful reconstruction) are also less serious than those of autologous tissue-based reconstruction. Special equipment and subspecialized surgical training are not required, so the breast reconstruction can be done in almost any hospital.

Complications of implant based surgery include hematoma, infection, capsular contracture, rippling, and asymmetry.

References

• Breast Reconstruction--American Society of Plastic Surgeons
• Back to the Latissimus Dorsi by Dana Khuthaila, MD, and Dennis Hammond, MD, PSP August 2005 (very nice article)
• Breast Reconstruction--CancerBackUp.org
• Breast Reconstruction--Medline Plus
• Breast Reconstruction After Mastectomy--American Cancer Society
• Breast Reconstruction after Mastectomy--Mayo Clinic
• Breast Reconstruction Guide for Patients by Stephen S. Kroll, M.D.
• Reoperative Plastic Surgery of the Breast by Kenneth C. Shestak, MD; Lippincott Williams & Wilkins, December 2005