New medical techniques and devices have made it possible for surgeons to create a breast that closely matches a natural breast in form and appearance. Frequently, reconstruction is possible immediately following breast removal, so the patient wakes up with a breast mound already in place, having been spared the experience of seeing herself with no breast at all.
Most mastectomy patients are medically appropriate for reconstruction, but not all reconstructions are done at the time of the mastectomy. Some women prefer to focus first on their cancer diagnosis and treatment and leave reconstruction for later. Others simply don't want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeons to wait, particularly if the breast is being rebuilt in a more complicated procedure, or if they have other health conditions, such as obesity, high blood pressure, or are smokers. Most insurance will cover post-mastectomy reconstruction.
Planning Your Surgery
You can begin talking about reconstruction as soon as you're diagnosed with cancer. We will want to work with your breast surgeon to develop a strategy that will put you in the best possible condition for reconstruction. You must be clear with us about your expectations. At the same time, you must be willing to accept our recommendations about reconstructive options based on factors such as your age, health, anatomy, tissues and goals. Sometimes the reconstruction will involve the use of an implant – such as a silicone gel implant or a saline filled implant. – and sometimes your own natural tissue can be used to reconstruct a breast. Post-mastectomy reconstruction can improve your appearance and renew your self-confidence.
In most cases, health insurance policies will cover most or all of the cost of post-mastectomy reconstruction. Check your policy to make sure you're covered and to see if there are any limitations on what types of reconstruction are covered.
Reconstructive surgery is nearly always done as an inpatient, often at the time of your mastectomy surgery. The first stage of reconstruction, creation of the breast mound, is almost always performed using general anesthesia, so you'll sleep through the entire operation. Follow-up procedures may require only a local anesthesia, combined with a sedative to make you drowsy. Length of the surgery varies, depending on the type of procedure and whether it is done in tandem with a mastectomy.
During and After
Tissue expansion. The most common technique combines skin and soft tissue expansion followed by insertion of an implant. The process begins by inserting a balloon expander beneath the skin and chest muscle. Over several weeks or months, through a tiny valve mechanism buried beneath the skin, Dr. Chariker will periodically inject a salt-water solution to gradually fill the expander. After the skin over the breast area has stretched enough, he may remove the expander in a second operation and insert a more permanent implant based on the volume used in the expansion process. However, some expanders are designed to be left in place as the final implant. He reconstructs the nipple and areola (the surrounding dark skin) in a subsequent procedure. Some patients do not require preliminary tissue expansion before receiving an implant. For these women, we will proceed with inserting an implant as the first step.
Flap reconstruction. An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the back, abdomen, or buttocks. In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself, without the need of an implant.
Another flap technique uses tissue that is surgically removed from the abdomen, thighs, or buttocks and then transplanted to the chest by reconnecting the blood vessels to new ones in that region. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well. We have extensive training and experience in microsurgery and reconstructive procedures for both children and adults.
Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed breast. Recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about an implant. In some cases, you may have the added benefit of an improved abdominal contour.
Follow-up procedures: Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery may be required to replace a tissue expander with an implant or to reconstruct the nipple and the areola. Some patients also consider an additional operation to enlarge, reduce, or lift the natural breast to match the reconstructed breast.
After reconstruction surgery, you are likely to feel tired and sore for a week or two. Most of your discomfort can be controlled by prescription medication. Depending on the extent of your surgery, you'll probably be released from the hospital in two to five days. Many reconstruction options require a surgical drain to remove excess fluids from surgical sites immediately following the operation, but these are removed within the first week or two after surgery. Most stitches are removed in seven to ten days.
Side Effects and Risks
If an implant is used, there is a remote possibility that an infection will develop, usually within the first two weeks following surgery. In some of these cases, the implant may need to be removed for several months until the infection clears. A new implant would then be inserted post-infection.
The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture sometimes requires either removal or "scoring" of the scar tissue, or removal or replacement of the implant. Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment, should cancer recur. However, for routine mammograms, if you have an implant, be sure to go to a radiology center where technicians are experienced in the special techniques required to get a reliable x-ray of a breast reconstructed with an implant.
It may take you up to six weeks to recover from a combined mastectomy and reconstruction or from a flap reconstruction alone. If implants are used without flaps and reconstruction is done apart from the mastectomy, your recovery time may be less. As a general rule, you'll want to refrain from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following reconstruction.
Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. Most scars will fade substantially over time–it may take as long as one to two years–but they'll never disappear entirely. Chances are your reconstructed breast may feel firmer and look rounder or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. But these differences will be apparent only to you. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.