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Breast reconstruction is a surgical procedure to rebuild the contour of the breast, along with the nipple and areola (the pigmented area surrounding the nipple) if desired. Recent advances in reconstructive techniques have given patients more choices when it comes to breast reconstruction, including the option to have breast reconstruction during the same operation in which the breast is removed. Being diagnosed with breast cancer is not usually a medical emergency; most women have a sufficient amount of time to research treatment and reconstructive options before having to make any decisions. Though some women are not interested in breast reconstruction, many breast specialists support reconstructive surgery as an important option for patients to consider. Women are encouraged to weigh both the advantages and disadvantages of breast reconstruction with their plastic surgeons and cancer treatment team and make an informed decision based on their own situation. Breast reconstruction is most often an option for women who have had mastectomy if their entire breast has been removed. Women who undergo lumpectomy (surgical removal of a breast lump and a margin of surrounding tissue) rarely need breast reconstruction. The goal of breast reconstruction is to create breast symmetry when a woman is wearing a bra. When a woman is nude, the reconstructed breast will look different from the unaffected breast, regardless of the type of reconstruction chosen. However, when a woman is wearing a bra, the size and shape of the reconstructed breast should closely resemble the unaffected breast. It is a common misconception that women may have to wait a year or longer to begin the reconstructive progress after breast surgery. Though breast cancer patients who receive chemotherapy after mastectomy may have to delay reconstruction under chemotherapy is finished, the majority of women begin may reconstruction soon after the surgery in which the breast is removed (if not during the same operation). Types of Breast Reconstruction There are two main types of breast reconstruction available to most mastectomy patients:
The insertion of saline (salt-water filled) implants is usually a two-part procedure. The first implant operation involves placing a tissue expander in the intended breast area beneath the skin and chest muscle. The tissue expander is similar to a balloon, and the surgeon will fill the expander with salt-water solution periodically (usually once a week). The procedure to insert the tissue expander into the breast area typically takes about forty-five minutes. After the skin has sufficiently stretched, the surgeon will replace the tissue expander with a permanent saline implant, usually three to four months after the first implant surgery. Occasionally, a woman will not need a tissue expander. If this is the case, then the surgeon will proceed directly to permanent implant surgery. Approximately 50% of saline implants need some type of modification or replacement after five or ten years. The second main type of breast reconstruction, muscle flap reconstruction, involves using a patient’s own tissue to rebuild the contour of the breast. Tissue may be taken from the back, stomach, or buttocks. Muscle flap operations leave scars both from where the tissue was taken and on the reconstructed breast. In a free TRAM (Transverse Rectus Abdominis Muscle) flap procedure, the surgeon transfers some abdominal skin, fat, and a small piece of muscle under the skin to the intended breast area. The tissue from abdomen is usually enough to create a breast shape. If not, a saline implant may also be inserted. In a back tissue (latissimus dorsi) reconstructive flap, a surgeon transfers muscle and skin from the patient's back to the intended breast area. This creates a pocket where an implant is usually inserted. Muscle flap procedures take much longer than implant operations, lasting about four to five hours, and patients typically stay in the hospital three to four days, compared to one day with the implant operation. Though the recovery is slower, the breast usually looks and feels more natural to most women. Because muscle flap reconstruction involves the blood vessels, women who smoke or have diabetes, vascular, or connective tissue diseases cannot typically undergo this type of breast reconstruction.
Because many breast cancers involve the nipple areolar complex, the surgeon usually removes the nipple during mastectomy. After the breast volume has been rebuilt with a tissue expander or muscle flap procedure, the nipple may be recreated. Most nipple recreation takes place two to six months after the initial breast reconstruction to allow the new breast area ample time to heal. A new nipple may be created from a skin graft from a woman’s inner thigh or from the areola (the pigmented region surrounding the nipple) on her natural breast. Occasionally after a skin graft, the skin of the newly created nipple turns white. Some surgeons prefer to tattoo the skin graft of the new nipple to ensure that the color matches the color of the nipple from the natural breast. See the section on peg procedures below for more information. A new type of breast reconstruction developed by Dr. Edward Knowlton, MD, promises to reduce a patient’s mastectomy scar. Results of Dr. Knowlton’s research were published in the September 1992 issue of Contemporary Surgery and also presented in San Diego at the annual meeting of the American Society of Plastic and Reconstructive Surgeons. According to Dr. Knowlton, the peg procedures can recreate both the shape and size of the breast as well as the nipple and areola (darker pigment surrounding the nipple). In one type of peg procedure, the traditional straight-line mastectomy scar is replaced with a circular scar that is hidden within the border of the newly created nipple. The newest peg procedure (called the pectoralis peg) uses only the remaining breast skin after a mastectomy and relies on the body’s own healing processes to create a normal-looking nipple. After the body heals from mastectomy, new blood vessels usually grow into the remaining skin from the pectoralis muscle on the chest wall. The pectoralis peg procedure uses this new blood supply to provide circulation to the newly created nipple and areola. Thus, a skin graft from another portion of the patient's body is not necessary (as it is with most muscle flap reconstructive techniques). The benefits of peg procedures include:
The peg procedures are not suitable for all women considering breast reconstruction. Click here to learn more about the peg procedures. If a woman is contemplating breast reconstruction, she should discuss her options with a plastic surgeon. It is important to make sure that the plastic surgeon is certified by the American Society of Plastic Surgeons and has experience with breast reconstruction. Women may contact the American Society of Plastic Surgeons (ASPS) at 1-800-635-0635 to find out if their plastic surgeon is board certified. The ASPS was formed in 1972 and provides women with a list of ASPS certified members in the caller’s area. The ASPS website also allows women to search for a plastic surgeon by name, city, state, or zip code. Possible Complications With Breast Reconstruction
As with any type of surgery, breast reconstruction has certain risks women should consider before deciding on reconstructive surgery. The most common complication with breast implants is capsular contracture: the scar or capsule around the implant begins to tighten and squeezes down on the soft implant, causing the breast to feel hard. Capsular contracture may be treated with additional surgery to remove the scar tissue. Occasionally, patients with capsular contracture may have to have the breast implant removed and replaced with a new one. Other rare complications from general surgery may also occur during breast reconstruction, including: bleeding, fluid collection, excessive scar tissue, infection, and problems with anesthesia. Women who smoke may experience a slower rate of healing or more noticeable scars since nicotine often interferes with the body’s natural healing process. Rarely, these complications may require additional surgery. Note: It is not possible for women to breast-feed from the reconstructed breast. Even with nipple reconstruction and tattooing of the areola, the breast still lacks the proper glandular tissue and ducts necessary to produce milk. There has been no evidence that breast reconstruction causes a recurrence of breast cancer. The Ban on Silicone Gel Implants In 1992, the U.S. Food and Drug Administration imposed a ban on the general use of silicone gel-filled breast implants. Silicone implants may only be used in closely monitored medical trials until they are determined to be safe for widespread use. Questions concerning the safety of silicone implants arose after manufacturing defects and implant misuse led to silicone leakage and rupturing in many patients. When silicone gel is free in breast tissue, it may move to nearby tissues or to the lymph nodes. Some physicians attribute silicone leakage to immune-related disorders and other sicknesses. Many women who experienced silicone leakage reported:
There is much controversy surrounding silicone breast implants. Many medical experts doubt silicone implants cause any significant medical disease. Radiologists do worry about the difficulty in detecting breast cancer in breast with implants (saline or silicone). See the section below on breast imaging after reconstruction for more information. Advantages and Disadvantages to Breast Reconstruction The majority of women diagnosed with breast cancer will undergo some type of breast surgery as part of their treatment. For many simple or modified radical mastectomy patients, breast reconstruction may be possible during the same surgical procedure. However, there are advantages and disadvantages to immediate breast reconstruction: Advantages to immediate breast reconstruction:
Disadvantages to immediate breast reconstruction:
Some doctors recommend that women who need radiation therapy after breast surgery have delayed breast reconstruction. Though radiation after the insertion saline implants or muscle flap procedures may potentially distort the breasts, this is rare. Radiation therapy can usually be administered to patients after breast reconstruction without any significant consequences. Usually women who have breast reconstruction may choose to have the nipple and areola (the pigmented region surrounding the nipple) reconstructed during additional surgeries. Nipple and areola reconstruction occurs after the breast has had time to settle after the initial reconstructive surgery. Tissue for the nipple can be taken from the newly created breast, the opposite nipple, or even the ear. Tissue for the areola can be taken from the upper inner thigh. To match the other nipple and to create the areola, tattooing may be done. The American Cancer Society suggests breast cancer patients ask their plastic surgeons the following questions before having breast reconstructive surgery:
Health Insurance Coverage for Breast Reconstruction According to the American Society of Plastic and Reconstructive Surgeons, the average surgeon fee for breast reconstruction is:
These fees do not include bills from anesthesiologists, hospitals, or the cost of implants. Most health insurance companies do cover the cost of breast reconstruction after mastectomy. In 1998, the Women's Health and Cancer Rights Act was passed, which requires all health insurance providers who cover mastectomy procedure to also cover the costs of breast cancer reconstruction for mastectomy patients. Under this legislation, insurance companies who cover the cost of mastectomy must also cover the costs of the following:
Breast Imaging After Reconstruction It is important for women who have had breast reconstruction to continue receiving yearly mammography on the normal breast. Women who have had breast reconstruction should also practice monthly breast self-examination (BSE) and have yearly clinical breast exam. Click here to learn more about the guidelines for early detection of breast cancer. Many radiologists do not take screening images of the area where the breast was removed (even if an implant or tissue flap is present) unless there is a clinical concern (for example, a new lump is found). Imaging breasts with implants requires a radiologist to take several special mammography views so he or she may see both the breast tissue and the implant. For this reason, diagnostic mammography is usually performed on women after breast reconstruction. Diagnostic mammography involves pinpointing the exact size and location of breast abnormalities as well as imaging the surrounding breast tissue and lymph nodes. Click here to learn more about mammography with breast implants. Additional Resources and References
Updated: September 12, 2007 |
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