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Reconstruction after mastectomy

Breast reconstruction after a mastectomy

Breast reconstruction is a type of surgery for women who either decide to or require breast removal (mastectomy) to treat their breast cancer. The surgery attempts to reconstruct the breast so that it is the same size and shape as it was before. Most women who have a mastectomy can have reconstruction either at the same time as the mastectomy or at a later date.

Today, the majority of women with breast cancer choose surgery that removes only part of the breast tissue. This is called breast conservation surgery, lumpectomy or partial mastectomy. Some women will have a mastectomy, which means the entire breast is removed. Many women who have a mastectomy choose reconstructive surgery to rebuild the shape and natural look of the breast. Women choose breast reconstruction for many reasons: to make their breasts look balanced when they are wearing a bra; to permanently regain their breast shape; and so they don’t have to use a form that fits inside the bra (an external prosthesis). Your body image and self-esteem may improve after reconstruction, but keep in mind that the reconstructed breast will not be a perfect match or substitute for your natural breast. The reconstruction process often means one or more operations and is never a simple process.

Immediate breast reconstruction

The reconstruction is done at the same time the breast is removed (mastectomy). The advantage in doing reconstruction immediately is that the chest tissues are less damaged by scarring and more skin can be preserved. After the initial surgery, there will be a number of steps that are needed to complete the reconstruction.

Delayed breast reconstruction

The mastectomy was completed and reconstruction surgery is done at a later date. This is usually the patient’s choice, but sometimes her doctors may recommend delaying reconstruction because of the risks involved. Some women do not want to think about reconstruction while coping with a diagnosis of cancer.

Types of breast reconstruction

Implant procedures

This typically requires a two-stage reconstruction. First, an implanted tissue expander (like a deflated balloon) is put under the skin and chest muscle. Through a tiny valve under the skin, the surgeon injects saline solution at regular intervals to fill the expander over time (up to several months). After the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in an implant. The most common implants are saline-filled implants (silicone shell filled with salt water) and silicone gel-filled implants. Most recent studies show that silicone implants do not increase the risk of developing immune system problems.

Implants may not last a lifetime and may need to be replaced later. There can be problems with implants including rupture, infection or pain. Scar tissue may form around the implant (capsular contracture).

Tissue flap procedures

These procedures use tissue from your tummy or back to rebuild the breast. The two most common types of tissue flap surgeries are the transverse rectus abdominis muscle flap (TRAM flap) which uses the tissue from your tummy area and the latissimus dorsi flap, which uses tissue from the upper back. These procedures require two surgical sites and leave two scars — one where the tissue was taken and one on the reconstructed breast. There can be problems at the donor sites, such as abdominal hernias and muscle damage or weakness. Flap procedures depend on the tissue’s blood supply and may not be offered to patients with diabetes, connective tissue disease, vascular disease or to smokers since these conditions may compromise the patient’s blood supply.

Deep inferior epigastric perforator (DIEP) 

The skin, fat and blood vessels are moved from the patient’s belly to her chest. The tissue’s removal gives the patient results similar to a tummy tuck. The scar left behind is usually below the bikini line.The physician then uses a surgical microscope to attach the blood vessels from the new tissue to the vessels in the chest area to give the new breast a blood supply.

TRAM flap

Uses tissue and muscle from the lower abdominal wall. It is often enough to shape the breast and an implant may not be needed. The skin, fat, blood vessels and at least one abdominal muscle are moved from the belly to the chest to create the breast. The procedure also results in tightening of the lower belly or a “tummy tuck.”

Latissimus dorsi flap

Moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant which can be used for added fullness to the reconstructed breast.

Nipple and areola reconstruction

These reconstructions are optional and usually the final phase of breast reconstruction. They are typically performed in the office under local anesthesia after the breast has healed (three to four months). Tissue used to rebuild the nipple is often taken from other areas of your body, such as from the skin of the new breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks. A tattoo may be used to match the color of the nipple of the other breast and to create an areola.

Nipple-sparing procedures

The nipple and areola are left in place while the breast tissue under them is removed. Women who have a small early stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple, may be candidates for this procedure. Since the nipple does contain breast tissue there is some risk and some doctors will recommend a dose of radiation to reduce the risk of the cancer coming back.

This is a fairly new procedure and some problems may occur. The nipple may not have enough blood supply and may die or become deformed. There is little feeling left in the nipple since the nerves that supply it are removed with the mastectomy.

Risks of smoking

Using tobacco causes the blood vessels to tighten (constrict) and reduces the supply of nutrients and oxygen to tissues. Smoking can delay healing. This can cause more noticeable scars and a longer recovery time. Sometimes these problems are bad enough that a second operation is needed to fix them. You may be asked to quit smoking a few weeks or months before surgery to reduce these risks.

Risks of reconstruction

  • Bleeding
  • Fluid build-up with swelling and pain (seroma)
  • Growth of scar tissue
  • Infection
  • Tissue death (necrosis) of all or part of the flap, skin or fat
  • Exposure or loss of the tissue expander or implant
  • Problems with the donor site of the flap
  • Loss of, or changes in nipple and breast sensation
  • Extreme tiredness (fatigue)
  • The need for more surgery to fix problems that occur later
  • Changes in the affected area
  • Problems with anesthesia