Breast Reconstruction (Reconstructive mammaplasty)

Breast reconstruction includes a variety of procedures performed to restore the form and shape of the breast, following mastectomy or lumpectomy surgery. Factors such as individual anatomy, aesthetic goals and the need for any postsurgical chemotherapy or radiation will determine your options. Discussing your cancer surgery with a plastic surgeon before undergoing mastectomy is crucial, because the proposed cancer removal surgery may significantly affect the choices and the results of any type of breast reconstruction.

When to Consider Breast Reconstruction

– If you think reconstruction will give you a sense of psychological well being or a feeling of “wholeness”
– To help restore your feelings of femininity and confidence in your appearance
– To improve symmetry if only one of your breasts is affected
– To allow you to wear low-cut necklines and normal swimwear

Considerations

Pros
– You will not have to cope with wearing external breast forms or pads.
– This is a way of removing any reminders of your mastectomy and cancer experience.
– It can help you feel better about how you look and restore confidence in your sexuality.

Cons
– Breast reconstruction involves additional surgery, medical appointments and possibly additional costs.
– Breast reconstruction may interfere with the natural state of your body, which has just returned to normal health.
– A reconstructed breast will not have the same sensation and feel as the breast it replaces.

Am I good candidate for a breast reconstruction?

– Results are best if you are not overweight (body mass index is under 30).
– You should not have blood-flow (circulation) problems or other serious health problems, such as high blood pressure and heart disease. Diabetes and autoimmune diseases, such as rheumatoid arthritis and scleroderma, increase the risk of wound healing problems and infections. Clotting disorders may increase the risks of breast reconstruction using flaps, and bleeding disorders and agents used to prevent blood clots increase the rate of postoperative bleeding.
– Smoking interferes with blood flow and can cause problems after surgery, delay healing and lead to larger scars.
– Radiation therapy significantly affects the timing and even the type of breast reconstruction you will undergo. It delays wound healing and can cause the skin to darken and tighten. Reconstruction, which may be delayed for months after radiation, may include the use of your own tissue to help replace some affected skin.
– Chemotherapy following mastectomy can also affect the timing of your reconstruction.
– Previous surgical history, past medical history and coexisting illnesses are factors in determining whether this surgery is suitable for you.

How is a breast reconstruction procedure performed?

The three basic options for breast reconstruction:
– Using breast implants (saline or silicone).
– Reconstructing the breast using your own skin, fat and muscle.
– A combination of these methods.

Implant reconstruction procedures

This is usually a two-or three-step process.
– In the initial procedure, your surgeon inserts a tissue expander beneath the skin and chest muscle, forming a skin-muscle envelope. The tissue expander is a modified saline implant with a valve, allowing more saline to be added after the first surgery. Serial injections of saline through the skin into the valve slowly fill the implant and will subsequently expand your breast mound. During office visits over two to six months, the skin-muscle envelope is slowly stretched until it reaches the size you want for the final implant.
– In the next stage, you will undergo outpatient surgery during which the expander is removed and replaced with a softer breast implant (saline or silicone).
– Sometimes, with saline implants, the expander is kept in place for a longer period, allowing the size of the reconstructed breast to be changed (by increasing or decreasing the amount of saline) without implant removal. With a silicone implant, your breast size cannot be changed without another surgery.
– It is rare for a woman to have an implant (saline or silicone) inserted directly without first having tissue expansion. In this situation, the size of the skin-muscle envelope at the time of mastectomy is large enough to cover the desired final implant.

Natural grafts/tissue flap surgery

In certain circumstances, especially if you have radiation-damaged tissues, your surgeon may recommend the use of a flap of your own tissue, which can provide coverage or replacement of the damaged tissues with healthy, nonirradiated tissue.
– Reconstruction using skin and tissue flaps from your own body (autologous tissue) can look and feel more like a natural breast than reconstruction with implants. However, these procedures are more complex and invasive, usually prolong the hospital stay and leave scars in the areas from which the tissue was taken.
– The most common natural flap procedures use tissue from the back, abdomen or buttocks. In some procedures an entire muscle needs to be moved to reconstruct the breast, causing weakness in that area of the body.
– Autologous fat grafting or fat transfer is another option for treating radiation-damaged tissues or small areas of contour irregularities. Fat transfer has pros and cons, including graft loss and fatty cysts and may require multiple surgical sessions. Your surgeon can discuss the advantages and limitations of this surgery with you after he or she has evaluated you. Surgeons sometimes use autologous fat grafts to improve the results from implant reconstruction or to correct contour irregularities.
Skin-sparing mastectomy
– If you are having immediate breast reconstruction, your surgeon may perform a skin-sparing mastectomy to keep as much of your breast skin intact as possible. The tumor and clean margins (areas free of cancer cells) are removed along with the nipple, areola (pigmented skin surrounding the nipple), fat and other tissue that make up the breast. What remains is much of the skin that surrounded the breast. This skin can then be used to cover a tissue flap or an implant.
– The major benefit of a skin-sparing mastectomy is that it avoids using skin from other body parts for reconstruction, which can have a different color, texture and thickness compared with natural breast skin.
– A patient who has large or droopy breasts may be at a potential disadvantage of a skin-sparing mastectomy; the loose skin may continue to sag and compromise the reconstructive result. It is best to discuss this with your plastic surgeon before your mastectomy surgery if you are considering breast reconstruction.

Preparing for Your Procedure

How do I prepare for a breast reconstruction procedure?
– Follow the instructions given to at your preoperative appointment. These will likely include having blood tests, a chest x-ray and an electrocardiogram (ECG).
– Stop smoking at least six weeks before undergoing surgery to promote better healing.
– Avoid taking aspirin, certain anti-inflammatory drugs and some herbal medications that can cause increased bleeding.
– Regardless of the type of surgery to be performed, hydration is very important before and after surgery for safe recovery and good outcomes.

Aftercare and Recovery

Immediately after your breast reconstruction surgery
Your surgeon will prepare you for the experience, but here are a few things you can expect:
– You may wake up from surgery feeling groggy and/or very tired.
– You may have compression sleeves on your legs to help with circulation.
– Although you may be receiving pain medication, you may still feel sore.
– You may have drains coming out of your underarms to assist in healing (and from your stomach if you had an autologous reconstruction using tissue from your abdominal area).
If you have an autologous flap breast reconstruction:
– You may have a catheter in your bladder, which will be removed after surgery.
– The area from which tissue was taken to form your new breast(s) may also be sore.
– It may be difficult for you to get out of bed alone.
If you have a breast implant reconstruction:
– Your armpit region may be a little sore following surgery, but it is important to move your arms and maintain the range of motion in your shoulders. Certain exercises can help with this, and your doctor will discuss this with you.
– Your surgeon will encourage you to get out of bed with assistance; early ambulation is very important to prevent the formation of clots in your legs.
– You will be able to use the bathroom by yourself but may need assistance during the first week following certain types of reconstructive procedures.
Recovery time frame after breast reconstruction In the hospital Surgeries involving muscle flaps usually require a hospital stay and may involve restriction of your activities. After a TRAM flap surgery, you are not allowed to strain or lift for six weeks.
– Soon after surgery you will be asked to move your arms, but not forcefully. Nurses will help you in and out of bed. Most expander/implant reconstruction surgeries are performed as outpatient procedures and you are encouraged to walk the day of your surgery, which aids circulation and decreases the risk of clots forming in your legs.
– The length of your hospital stay will depend on your general health, the type of operation you have and how your recovery progresses. You may spend anywhere from one to six nights in the hospital. Flap procedures require a stay of two to six days, depending on the type of flap procedures performed and the blood supply to that flap.
– Your incisions will most likely be covered with bandages following flap reconstruction surgery but may simply have been closed with skin glue or tape following implant reconstruction.
– Your surgeon may recommend an elastic bandage or a soft bra to minimize swelling and support the reconstructed breast(s).
– Make sure you are clear about what is expected of you before you are discharged from the hospital or surgical center. Having a loved one or patient advocate with you is a good way to help make sure you take it all in.
At home
– Depending on what type of reconstruction you have, you may be spending significant time in bed or a chair during the first few days. Most patients can walk without assistance by the second or third day after a flap reconstruction and your surgeon will encourage you to walk at least three or four times a day to stimulate the circulation in your legs.
– You may be too tired to shower during the first week, but if your surgeon gives you permission and you feel up to it, you can shower. You may need someone to help you. You will need to pin all of your drains to a Velcro drain belt or you may be given something in the hospital such as a gauze necklace to support the drains around your neck. It may help if you have a shower stool, so you can sit down in the shower. When the drain is removed, it will be much easier to shower.
– Make sure you ask for pain-relieving medicines if you need them. In general, if your pain is well controlled, you’ll recover more quickly.
– Early in your recovery, you will most likely see your surgeon weekly until the last drain has been removed. You cannot rush removal of the drains; as bothersome as they may be, they are essential to proper wound healing. Generally, once a drain produces less than twenty to thirty milliliters in a twenty-four–hour period, your surgeon will remove it. In most patients, drain removal does not hurt.
– At first your new breasts may be larger due to swelling, which can happen after surgery. As the swelling subsides, your breasts will assume the shape you desired over a few weeks or months.
– You will be given exercises to perform at home to help your recovery. At first you may have some discomfort when you move your arms, but it is important to continue to use your arms and do the exercises suggested.
– How soon you can return to work depends on the type of work you do and your surgery. If your job doesn’t involve heavy manual work, you may be able to go back to work sooner, but remember that you’re likely to feel more tired than usual for a while.
– In general, you can resume driving once you are no longer taking any pain medications and are able to use the gearshift and parking brake. You must be able to do an emergency stop or move the steering wheel suddenly if necessary, and driving while taking pain medications is not only a bad idea, it is illegal in most states.
– Your wounds may feel itchy as they heal, but you must not scratch them. The itching will lessen as the wounds heal. It usually takes about six weeks for the wounds to heal enough that the itching subsides. Remember that wounds go through phases, and the inflammatory phase of healing may last months (in this phase the incisions appear pink, flushed, and are usually slightly raised or firm). Your scars will take a year to fully mature, so be patient and follow the advice of your surgeon in regard to treatments to help minimize your scar.

How Long Will the Results Last?

For implant-based reconstruction, you can feel secure that both saline and silicone implants are safe and effective when used according to their labeling. Saline and silicone implants have lifetime warranties from their manufacturers; however, the longer you have implants, the more likely you are to experience complications.
For patients who are having reconstruction of a single breast, changes in that breast will, over time, be different from that in the other breast. The patient’s own natural breast tissue is more likely to sag and lose elasticity compared with an implant-reconstructed breast, which tends to stay youthful, with less drooping over time.
– For patients who undergo a bilateral mastectomy and bilateral reconstruction with implants, it is quite common for them to have well-projected, young-appearing breasts with no sagging even in their eighth decade of life.
– Breast reconstruction using tissue flaps are subjected to the same forces of gravity as natural breast tissue. The tissues may not age the same because the tissues are from other parts of the body.
– The skin and fat from the upper back or buttocks region is much thicker and more fibrous and does not tend to droop or sag as much over time as breast tissue.
– The skin and fat of the abdomen is very similar to that of breast tissue and tends to droop or sag over time, similar to natural breast tissue. These tissues do not “know” that they have been moved from another part of the body, and may their growth or shrinkage in response to weight loss may be different from your natural breast tissue.

Limitations and Risks

– Adverse reaction to anesthesia
– Hematoma or seroma (an accumulation of blood or fluid under the skin that may require removal)
– Infection and bleeding
– Changes in skin sensation
– Scarring
– Allergic reactions
– Damage to underlying structures
– Unsatisfactory results that may necessitate additional procedures
– Fat necrosis and/or fatty cysts
– Blood clots in the legs or lungs
– Partial or complete loss of the flap
– Loss of sensation at both the donor and reconstruction site.
– Hernia
– Delayed wound healing with poor scar formation.
– Breast hardening (capsular contracture)
– Implant malposition
– Implant rupture