Breast Reconstruction Surgery

By Denise Mann; reviewed by Walter Erhardt, MD

Actress Christina Applegate, the 36-year-old star of ABC's hit sitcom "Samantha Who?," announced recently that she had undergone a double mastectomy to remove a tumor in one breast and to prevent future breast tumors from developing in the other.

Now the actress, who first came into American homes as airhead teen Kelly Bundy on FOX's "Married with Children," plans to have breast reconstruction surgery. As a result, "I'm going to have the best boobs in the nursing home," she joked recently on "Good Morning America."

Like Applegate, many breast cancer survivors — and, increasingly, those who undergo preventive mastectomies because they are at high risk for breast cancer due to genetic predispositions — are seeking reconstructive breast surgery to rebuild their breasts.

Here is what you need to know about breast reconstruction.

What Is Breast Reconstruction?

Breast reconstruction surgery restores breast appearance for women who have had their breast(s) removed to treat breast cancer. A plastic surgeon rebuilds the breast so it is about the same size and shape as it was before the mastectomy. The nipple and the darker area surrounding the nipple (the areola) can also be surgically reconstructed.

Some women will have breast reconstruction done at the same time as the mastectomy, while others, like Applegate, may wait a requisite period of time.

With immediate breast reconstruction, the chest tissue is undamaged by radiation therapy or scarring. Also, immediate reconstruction means one less surgery.

Delayed breast reconstruction may be advised if radiation to the chest area is needed after the mastectomy. Radiation therapy that follows breast reconstruction can increase complications after surgery.

The reconstruction process may require one or more operations. The final surgery is typically the nipple and areola reconstruction.

Am I a Candidate for Breast Reconstruction?

Each year, more than 240,000 American women are diagnosed with breast cancer, according to the Atlanta-based American Cancer Society. According to the American Society of Plastic Surgeons, more than 57,000 breast reconstructions were performed in 2007, up 2 percent since 2006.

Not every woman with breast cancer chooses or even needs breast reconstruction. For example, many women may opt for breast conservation surgery (lumpectomy or segmental mastectomy), which removes less breast tissue than a mastectomy. These women may not need breast reconstruction.

On the other hand, a number of women go this route thinking that they won't need reconstruction, but end up with a significant asymmetry due to the volume of tissue removed or changes as a result of radiation therapy. So they end up needing surgery anyway.

The key factors that affect your eligibility for breast reconstruction include:

• Your overall health
• The stage of your breast cancer
• The size of your natural breast
• The amount of tissue available for a flap procedure
• Your desire to match the appearance of the opposite breast
• Your desire for bilateral reconstructive surgery
• Insurance coverage for the unaffected breast and related costs
• The type of cancer treatment as well as choice of reconstructive procedure
• The size of the implant or reconstructed breast

Types of Breast Reconstruction

Plastic surgeons can perform several types of breast reconstruction surgery. Options include a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. A tissue flap is a section of your own skin, fat and muscle that is moved from your stomach, back or other area of your body to the chest area.

Breast reconstruction with breast implants The most common implant is a saline-filled implant. These implants have an external silicone shell and are filled with salt water. Silicone gel-filled implants are another option for breast reconstruction. Due to the more natural feel and texture of silicone implants, many breast cancer survivors who undergo breast reconstruction choose these over saline implants. [Please read our article on saline implants vs. silicone implants.]

Current breast reconstruction clinical trials are looking at new types of implants that may be beneficial for breast reconstruction.

Whatever implant you and your surgeon decide on, it is placed between layers of chest muscle, under breast skin that will be saved during the mastectomy.

Some women can have the implant placed immediately if they have relaxed muscle tone and stretchy skin and your cancer surgeon is able to do a skin- and tissue-sparing mastectomy. Women with tight chest skin and muscles, however, may need an expandable implant or a tissue expander, which is followed by a permanent implant in a two-stage operation.

Breast reconstruction with tissue flap. Tissue flap procedures use tissue from your stomach, back, thighs or buttocks to reconstruct the breast. The two most common types of tissue flap surgeries are the TRAM flap (transverse rectus abdominis muscle flap), which uses tissue from the stomach, and the latissimus dorsi flap, which uses tissue from the upper back.

The TRAM flap procedure can be done in one of two ways. The pedicle flap involves leaving the flap attached to its original blood supply and tunneling it under the skin to the breast area. In contrast, a free flap means that the surgeon cuts the flap of skin, fat, blood vessels and muscle free from its original location and then attaches the flap to blood vessels in the chest area.

The latissimus dorsi muscle flap procedure removes a large muscle in the back, along with skin and underlying fatty tissue. The surgeon uses these tissues to reconstruct the breast. Including fatty tissue helps create a more natural-looking breast, but the flap itself is usually only about one inch thick, so an implant is also required.

These tissue flap operations require two surgical sites and thus scars where the tissue was taken and on the reconstructed breast. Tissue flap breast reconstruction procedures usually cannot be offered to women with diabetes, connective tissue disease or vascular disease, or to smokers, because blood vessels are involved, and these can all damage blood vessels.

A newer type of flap procedure, the deep inferior epigastric artery perforator (DIEP) flap, uses fat and skin from the same area as the TRAM flap, but does not use the muscle to form the breast mound. This procedure results in a tightening of the lower abdomen, essentially a "tummy tuck." The procedure is done as a "free" flap, which means the donor tissue is completely removed and then reattached.

Another newer type of tissue flap surgery is called the gluteal free flap. This surgery uses tissue from the buttocks to create the breast shape. It is an option for women who cannot use the stomach sites because they are too thin.

Nipple and Areola Reconstruction

Nipple and areola reconstructions are the final phase of breast reconstruction. This separate surgery is done to make the reconstructed breast resemble the original breast more closely. It can be done on an outpatient basis with local anesthesia. It is usually done after the new breast has had time to heal, which may be three or four months after surgery. Occasionally, however, nipple reconstruction can be done at the time of the flap surgery.

The tissue used to rebuild the nipple and areola is taken from your own body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh or buttocks. Tattooing may be done to match the color of the nipple of the other breast and to create the areola.

Preparing for Breast Reconstruction Surgery

Once you have decided to undergo breast reconstruction surgery, your breast surgeon and your plastic surgeon will give you specific instructions on how to prepare, including:

• Guidelines on eating and drinking
• Stopping smoking
• Instructions to take or avoid certain vitamins and medicines. For example, it is often prudent to avoid aspirin, anti-inflammatory drugs and herbal supplements, as they can increase bleeding risk.
• Undergoing lab testing
• Having a complete medical evaluation

What to Expect Following Breast Reconstruction Surgery

You may feel tired and sore for a week or two after implant reconstruction and longer after flap procedures. Medications can control most of your discomfort. Most people can go home from the hospital in one to six days. You may be discharged with a surgical drain to help remove excess fluids from the site while it heals.

You should be up and around in six to eight weeks. If implants are used without flaps, recovery time may be shorter. Your plastic surgeon will give you more specific details about your recovery from breast reconstruction.

Breast Health After Breast Reconstruction

Breast reconstruction has no known effect on the recurrence of breast cancer. It should not cause problems with chemotherapy or radiation treatment if cancer does recur.

Make sure to talk to your doctors about mammograms. If you need a mammogram and your reconstruction involves an implant, be sure to get your mammograms done at an accredited facility with technologists trained in manipulating the implant to get the best possible images.

After breast reconstruction, you may choose to keep doing breast self-examination. Check both the remaining breast and the reconstructed breast at the same time.

Benefits of Breast Reconstruction

• Improved body image
• Improved self-esteem
• No need for prosthesis
• A whopping 98 percent of elective mastectomy patients would have breast reconstruction again, according to an article in the July 2008 issue of the medical journal Plastic and Reconstructive Surgery.

Risks of Breast Reconstruction

• Dissatisfaction with the cosmetic results
• Bleeding
• Scars
• Complications at the donor sites for flap procedures, including abdominal hernias and muscle damage or weakness
• Differences in the size and shape of the two breasts
• Delayed or incomplete healing due to previous surgery, chemotherapy, radiation, smoking, alcohol, diabetes, various medicines and other factors
• Lack of 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.
• Swelling in the arm (lymphedema)
• Infection
• Tissue death (necrosis) of all or part of the flap
• Problems at the donor site
• Fatigue
• The need for additional surgeries to correct problems
• Problems with anesthesia

Important: If you are considering breast reconstruction, with either an implant or a flap, you need to know that reconstruction rarely, if ever, hides a return of breast cancer. You should not consider this a significant risk when deciding to have breast reconstruction after mastectomy.

Will Insurance Cover My Breast Reconstruction Surgery?

Health insurance policies typically cover most or all of the cost of reconstruction after a mastectomy. Check your policy to make sure you are covered. Also, see if there are any limits on what types of reconstruction are covered.

Choosing a Plastic Surgeon for Your Breast Reconstruction

Once you decide to have breast reconstruction, you will need to find a board-certified plastic surgeon experienced in breast reconstruction. A doctor's board certification is the best indicator of his or her training in a specialty. It also helps ensure that he or she is up to date on the latest techniques and technologies. Your breast surgeon may be able to suggest appropriate doctors for you.

Sources:
American Cancer Society website. Breast reconstruction after mastectomy.
American Society of Plastic Surgeons website. Breast reconstruction.
Spear S.L., Schwarz K.A., Venturi M.L., et al. Prophylactic mastectomy and reconstruction: clinical outcomes and patient satisfaction. Plastic Reconstructive Surgery, 2008;122:1-8.

[page updated September 2008]