Breast Reconstruction Surgery

By Denise Mann; reviewed by Walter Erhardt, MD

Many breast cancer survivors — and, increasingly, women 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.

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 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 the woman needs to undergo one less surgery. On the other hand, delayed breast reconstruction may be advisable 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 American Cancer Society. Not every woman with breast cancer chooses or even needs breast reconstruction. For example, many women opt for breast conservation surgery (lumpectomy or segmental mastectomy), which removes less breast tissue than a mastectomy; these women generally do not need breast reconstruction.

However, a number of women who go this route thinking that they won't need reconstruction end up with asymmetrical breasts due to the volume of tissue removed or changes caused by radiation therapy. As a result, these women end up needing breast reconstruction surgery anyway.

Some of the key factors affecting breast reconstruction candidacy 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. The final step in breast reconstruction is nipple and areola reconstruction.

Breast reconstruction with breast implants

The implant most commonly used in conjunction with breast reconstruction is the 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. Recent findings published in the journal Cancer showed that women who underwent implant-based breast reconstruction following breast cancer were more satisfied with the look and feel of their new breasts when they opted for silicone over saline implants.

Current breast reconstruction clinical trials are looking at new types of implants that may be beneficial for breast reconstruction, including highly cohesive silicone gel, aka gummy bear implants.

No matter which implant you and your surgeon decide on, it will be placed between layers of chest muscle, under breast skin that will be saved during the mastectomy.

Some women can have the implant placed immediately, namely those with relaxed muscle tone and stretchy skin, which may allow the cancer surgeons 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, resulting in scars where the tissue was taken and on the reconstructed breast. Tissue flap breast reconstruction procedures usually cannot be offered to women who smoke or have diabetes, connective tissue disease or vascular disease, because blood vessels are involved, and these conditions 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 more closely resemble the original breast. Usually done on an outpatient basis with local anesthesia, nipple and areola reconstruction is generally performed once 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 prior to surgery
  • Smoking cessation
  • 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

During your pre-surgical consultation, you should also ask lots of questions about what to expect before, during and after your breast reconstruction surgery.

Recovery

Your breast reconstruction recovery may leave you feeling tired and sore. These effects will last a week or two if you have implant-based breast reconstruction and longer if you undergo a reconstructive flap procedure. Medications can help control your discomfort. Most women who undergo breast reconstruction go home from the hospital in one to six days (assuming there are no breast reconstruction complications). You may be discharged with a surgical drain to help remove excess fluids from the site while it heals.

There is no substitute for following your plastic surgeon's specific postoperative instructions. In general, you will be advised to refrain from vigorous activities for six to eight weeks after surgery. Your surgeon may suggest that you wear an elastic bandage or support bra to help minimize swelling. You will also likely be given a prescription for an antibiotic to reduce your risk of developing a post-surgical infection. Take all medications as directed for as long as directed, and adhere to all of your scheduled follow-up visits.

There is also an emotional element to surviving breast cancer and undergoing breast reconstruction. It can take time to get used to the look and feel of your new breasts. For many women, reconstruction helps soften some of the feelings associated with a mastectomy.

You may also feel anxious or sad when you look back at what you have been through and ahead to the possibility of breast cancer recurrence. Breast reconstruction rarely, if ever, hides a return of breast cancer. Discuss an appropriate screening strategy with your oncologist, and stick with it.

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, have your mammograms done at an accredited facility with technicians who are trained in manipulating the implant to get the best possible pictures. Talk to your doctor about the best ways to perform breast self-examination following reconstruction.

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 Plastic and Reconstructive Surgery.

Risks of Breast Reconstruction

Potential breast reconstruction risks are numerous, but following your surgeon's pre- and post-surgical instructions carefully can help reduce your chances of developing them.

  • 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

Lymphedema

I'm cancer-free. My breasts look great. How come my arm is so swollen?

Lymphedema is an accumulation of lymphatic fluid, or the clear interstitial fluid that is found between all the cells in the body. It can affect one arm or both arms after breast reconstruction, breast augmentation with implants, mastectomy or prophylactic mastectomy.

These surgeries can cause an obstruction in your lymphatic system and alter the flow of lymph fluid. Think of it as a clogged pipe: the excess fluid remains in your body and causes swelling. Other symptoms may include heaviness or tightness, pain, restricted range of motion, infection and thickening of the skin on your affected limb(s). As many as 70 percent of women who have breast cancer surgery will develop lymphedema.

While there is no cure, appropriate treatment can successfully manage lymphedema. This specialized treatment is called Complete Decongestive Therapy (CDT). CDT reduces the lymphedema, improves skin condition and function.

CDT consists of:

  • Range-of-motion exercises, stretching, and massage to stimulate lymphatic flow
  • Manual lymphatic drainage (MLD). This is a very specialized, non-invasive, gentle hands-on technique that helps to direct lymph flow out of the congested areas and into functional pathways.
  • Wearing a compression sleeve and glove during waking hours
  • Skin care
  • Patient education

CDT should be performed only by an occupational or physical therapist who has completed a minimum of 135 hours of specialized training and has successfully passed the rigorous testing.

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.

Breast Cancer Gene: Understand Your Breast Reconstruction Options

Advances in the screening and early detection of breast cancer mean more options for women at high risk for this cancer. For example, many women who are at increased risk for breast cancer can undergo genetic testing to see if they carry mutations in certain breast cancer genes. Altered copies of the BRCA 1 or 2 gene increase a woman's risk of developing breast and/or ovarian cancer.

The American Cancer Society estimates that there will be 192,370 new cases of invasive breast cancer diagnosed in the United States in 2009. Breast cancer is the second most common cancer among women in the United States, after skin cancer.

Approximately 0.1 to 0.2 percent of the general population carries the BRCA 1 or 2 genetic mutation. For those women with the BRCA1 or BRCA2 mutation, the lifetime risk of developing breast cancer is 40 to 85 percent.

Breast Cancer Testing: Staying Positive about a Positive

The good news is there is something women can do if they do test positive for the breast cancer genes.

A prophylactic mastectomy — surgery to remove one or both breasts — may reduce the risk of developing breast cancer by 90 percent. Some women may also opt for the prophylactic removal of their ovaries to lower their risk of ovarian cancer by up to 90 percent. Removing the ovaries can also reduce a premenopausal woman's risk of getting breast cancer.

Still, electing to undergo a mastectomy when you don't have breast cancer is not an easy decision to make. There are many emotions involved and a lot of soul-searching is often needed.

Breast reconstruction surgery following prophylactic mastectomy can help women restore the look and feel of their breasts after they make this important, potentially life-saving decision. Be sure to have a thorough discussion with your surgeon about what you can expect from breast reconstruction surgery. This should include covering the risks involved, including lymphedema, and what you can do to reduce your risks.

There are other options to reduce breast cancer risk, including anti-estrogen therapies such as tamoxifen. These drugs can be prescribed to women with a family history of breast cancer or other risk factors.

Should You Get Tested for the Breast Cancer Genes?

Currently, there are no standard recommendations about who should get tested for the breast cancer genes. Women who had breast cancer at a very young age — as well as those with a strong family history of breast and/or ovarian cancer — may be referred to genetic counseling to see if they should get tested.

Genetic testing is usually recommended for women with:

  • A male relative with breast cancer
  • A family member who has both breast and ovarian cancer
  • A family member with bilateral breast cancer
  • Family members with ovarian cancer
  • Family members with a positive BRCA1 or BRCA2 genetic test result

A family history of breast or ovarian cancer on the mother or father's side is equally important. Women of Ashkenazi (Eastern European) Jewish ancestry, with or without a family history of breast or ovarian cancer, may also consider genetic counseling.

The Role of Genetic Counseling

It's best to undergo proper genetic counseling prior to genetic testing. Such counseling is an important part of this emotional process.

The counselor will collect a detailed family and medical history, assess your risk of developing cancer and go over the risks and benefits of genetic testing. He or she will also discuss the medical implications of a positive or negative test result, the possibility that a test result might be ambiguous, the psychological risks and benefits of genetic test results and the risk of passing the genes to offspring.

Breast Cancer Gene Testing Cost

The cost of breast cancer gene testing may be another obstacle for some people. BRCA1 and BRCA2 mutation testing costs range from hundreds to thousands of dollars.

Insurance policies vary with regard to whether or not they cover genetic testing for breast cancer genes. If you are considering BRCA1 and BRCA2 mutation testing, inquire as to your insurance company's policies regarding these genetic tests first. Protecting the privacy of your medical information — particularly genetic test results — is important relative to future insurance and employment opportunities.

Breast Reconstruction Options Following Prophylactic Mastectomy

If you test positive and decide to undergo a prophylactic mastectomy, immediate breast reconstruction can usually be performed.

Reconstruction involves several steps, the first of which is to reconstruct the breast mound. Later on, many women also choose to have nipple and areola reconstruction.

Breast reconstruction can be done using a tissue expander, followed by placement of an implant. There are many types and shapes. The most common types of breast implants are saline and silicone breast implants, but there are newer ones made with different materials.

For example, one newer type of breast implant are gummy bear breast implants. These leak-resistant implants are composed of cohesive silicone gel and have the consistency of gummy bears. The gel doesn't migrate, so if the shell should leak, the gel would just stay in one place.

There have been concerns about health problems arising if silicone gel leaks and migrates, but these concerns have largely been allayed. Cohesive gel breast implants are not approved by the Food and Drug Administration (FDA) yet, and are only available through clinical trials.

Another option for breast enhancement surgery following mastectomy is using your own tissue transplanted from your belly, back or buttocks. Sometimes an implant is also needed.

The nipple can be reconstructed with medical tattooing, transplanted tissue or both.

If a woman is not happy with breast reconstruction after mastectomy, a board-certified plastic surgeon can usually improve the result through cosmetic surgery. One option is fat injections for "touch-ups" to improve breast shape and correct implant wrinkling or dimpling. The transfer of tissue may be required to create symmetry and fill in significant indentations. A breast lift to the other breast or adding an implant to the smaller side can sometimes help.

While prophylactic breast removal is very effective, it's not 100 percent effective. Breast cancer can develop in the small amount of tissue that may remain after mastectomy (in the envelope of skin that had surrounded the breast). This means that you and your doctor must develop a customized follow-up plan to monitor and protect your breast and overall health. This may include supervising medications, handling the effects of treatment, careful physical examination, and radiographic and blood testing, every six months.

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.

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.