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Rebuilding After Breast Cancer

What You Should Know about Breast Reconstruction after Mastectomy

by James H. Boehmler IV, MD

Breast cancer will affect nearly one out of every six women during their lifetime. Although some women can undergo breast-conserving therapy, many women may require or request a mastectomy – surgery that removes all the breast tissue and the nipple. Most women who have had a mastectomy can have breast reconstruction. The Women’s Health and Cancer Rights Act of 1998 mandates that insurance companies provide coverage for all breast reconstruction surgeries, including symmetry procedures for the other “non-cancer” breast.

Who is a Candidate?
In general, all women are eventual candidates for breast reconstruction. The type of reconstruction used may depend on the woman’s body shape, her body-image goals, the need for surgery to her other breast, and her medical history and need for other treatment, including radiation therapy.

Goals of Breast Reconstruction
The main goal of breast reconstruction is for a woman to look normal in clothing without obvious signs of surgery. This allows a woman to be out in public without feeling self-conscious or having to fill a bra with an external prosthesis. Absolute symmetry with the other breast is frequently difficult, particularly when naked, but the majority of reconstructions can provide a level of symmetry that the woman and her surgeon are satisfied with. Frequently, both breasts can be lifted and shaped to give women breasts that have a more youthful appearance.

Timing of Breast Reconstruction
Breast reconstruction can be performed in the “immediate” or “delayed” setting. Immediate breast reconstruction occurs at the time of the mastectomy, so the woman wakes up from surgery with a newly reconstructed breast. Delayed reconstruction occurs after the woman has recovered from her mastectomy and has finished all other cancer treatments.

The main goal of breast reconstruction is for a woman to look normal in clothing without obvious signs of surgery.

In general, a satisfactory breast reconstruction can be performed in either setting, although immediate breast reconstruction can allow for a “skin-sparing mastectomy,” which may have an improved cosmetic appearance, particularly if combined with a tissue-based reconstruction (see below). Regardless of the timing of reconstruction or the method used, it usually takes several procedures to have a finished breast reconstruction. Nipple reconstruction and areola tattooing complete the reconstruction process, though some women opt to forgo these procedures.

Types of Breast Reconstruction
Implant-based breast reconstruction utilizes artificial prostheses that are placed under the mastectomy skin and chest muscles. This is usually done in two stages. In the first stage, a tissue expander (a temporary implant) is placed. It has a valve that allows the tissue expander to be gradually inflated at outpatient office visits in order to stretch the skin. Once enough volume is placed, the woman is taken back to the operating room for removal of the tissue expander and placement of a breast implant, which can be filled with either saline or silicone.

Benefits of implant-based reconstruction include shorter surgery time and hospital stay and less initial post-operative pain. Downsides include the possibility of infection, scarring, tightness, and rupture of the implant. It also requires women to come into the clinic for weekly expansions. The best candidates for implant-based reconstruction are thin women who are undergoing two-sided mastectomies.

Tissue-based breast reconstruction uses extra fat and skin, most commonly from the lower abdomen, to reconstruct the breast. The fat is the “filler” of the breast, and the skin can be used to replace the nipple, areola, and skin removed from the mastectomy. Abdominaltissue breast reconstruction (also called a TRAM or DIEP flap, depending on the technique used) gives the added benefit of a “tummy tuck.”

Benefits of tissue reconstruction of the breast include immediate full-size breast reconstruction (no need for office visits for expansion), improved abdominal contour, longevity of the reconstruction, and improved appearance compared to implant-based reconstructions. Downsides include longer surgery and hospital times, longer recovery from surgery, and additional risks to the abdomen, including hernia and bulge. The best candidates for tissue-based reconstruction are women who have extra tissue to “donate” to their breasts, wish to avoid implant materials, desire the best cosmetic reconstruction, and are willing to undergo the longer recovery time. For women who have undergone radiation therapy, tissue-based reconstructions tend to provide a better long-term reconstruction option than implants.

The breast is an important physical and psychological component of a woman’s body and self-image. These can be permanently altered with a diagnosis of breast cancer. Successfully reconstructing the breast can be an important first step in a woman’s recovery from breast cancer treatment.

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