Reconstruction of the breast can be a very emotionally and physically rewarding procedure. Not all women desire reconstruction, and it is not a requirement. But many women, perhaps most, find it to be very beneficial in returning to a more normal life after breast cancer.
Before and After
See more samples of before & after photos.
Breast reconstruction, and any procedures necessary to the opposite side, such as a breast lift or breast reduction, is covered by health insurance. This was mandated by Congress in 1998.
Reconstruction may be done immediately – at the same surgery as the mastectomy. It may also be done much later; whenever the patient desires. Nipple reconstruction is done about 3-4 weeks later as an office procedure. If post-mastectomy radiation is known to be necessary, reconstruction is often best deferred until after radiation therapy is complete, in order to achieve the best results. Post-operative chemotherapy requirements may also affect the timing of reconstruction. Reconstruction after mastectomy, in any case, does not affect the chances of breast cancer recurrence. Feel free to discuss any breast cancer care concerns with Dr. Chick or your oncologist if you have any questions or concerns.
Breast reconstruction generally takes one of three forms:
- Implant reconstruction (click here for more info)
- Flap reconstruction (click here for more info)
- A combination of the two (click here for more info)
Breast Reconstruction 1: Implant Reconstruction Method
Breast implants, often using a tissue expander (a temporary breast-implant device), are the simplest way to do breast reconstruction. Implants do a nice job of creating a mound, and in clothes are very satisfactory. Out of clothes, however, they do have limitations to the naturalness of appearance. Recovery generally is the same as if only a mastectomy is done, which is 2 – 3 weeks.
Breast implants may be either silicone or saline filled. Both do a nice job, but the silicone implants are probably somewhat better in terms of softness and shape.
Implants do have some disadvantages, however:
- They all break eventually, and have an average lifetime of 15 years. Replacing them is easy, but it does require surgery.
- There is a risk of capsule contracture. This is a thickening of the breast tissue around the implant, which can make the breast very hard and deformed in appearance. With breast reconstruction, the risk of this is nearly 20%, or one chance in five. If radiation is done, the risk rises dramatically to nearly 100%. I generally do not like to use breast implants in a radiated area, and prefer another method.
Most of the time, implant reconstruction requires multiple stages and begins with the placement of a tissue expander. The tissue expander is a temporary breast-implant device similar to a ballon. It is placed under the muscle and skin after the mastectomy and helps shape and enlarge the implant pocket. At the time of surgery it is empty and then gradually filled up over several weeks until the skin is stretched out and large enough to contain the real implant. Then, during a second outpatient surgery, the expander is removed and the real implant is placed. If work is going to be done on the opposite breast (reduction, lift, or enlargement), it is done during this second procedure.
Breast Reconstruction 2: Flap Reconstruction Method
Breast reconstruction can also be done by shifting body mass from other areas of the body. A common approach is to use fat and skin from the abdomen. This is called the “TRAM flap”, or “tummy tuck reconstruction.” Variations of this procedure are the DIEP flap and the “Free” TRAM flap.
These are more significant procedures than implant reconstruction. The TRAM flap takes about three hours, and requires about three nights in the hospital. However, in the right patient, this procedure is an excellent choice, as it does not use implants, will not suffer hardess from capsule contracture, tolerates radiation fairly well, and is cosmetically superior.
Essentially, what is done is an abdominoplasty, or “tummy tuck.” But instead of discarding the excess skin and fat, it is kept alive by leaving it attached to blood vessels. The fat, skin, and blood vessels are moved onto the chest and tailored into the breast.
The blood vessels from the abdomen are removed from within one of the two rectus muscles (the “six pack” muscles), requiring the muscle to be sacrificed. This may result in some weakness of the abdominal wall, causing a bulge. In rare occasions, a hernia results, which requires repair. Because of this, the best candidates for the TRAM flap procedure are not obese, are in reasonably good physical condition, and are non-smokers. Smoking causes spasming of the blood vessels, and may result in the death of the tummy tuck tissue after surgery.
I like performing TRAM flaps, and have done a large number; more than 500 over the last fifteen years. But keep in mind, although it has great benefits, it also has a higher chance of complications and a longer recovery time (about six weeks).
Free TRAM flaps and the DIEP flaps are variations on this procedure involving microsurgery. These procedures require significantly more operative time (6-10 hours), but do spare the rectus muscles, leading to less abdominal wall weakness afterwards. There are advantages and disadvantages to these, and I would be happy to discuss these with you at the time of consultation.
Breast Reconstruction 3: Combination Method
This reconstructive method uses a combination of an implant and a flap from the latissimus muscle (located in the back). This option works very well for a lot of situations. In very thin women, this procedure helps to provide more tissue over an implant, which helps it look and feel more natural. It is an easier recovery than a TRAM flap reconstruction. In delayed reconstruction, it negates the need for an expander, allowing us to do the reconstruction as one operation. If radiation has been done, it allows us to put non-radiated tissue over the implant with a significantly lower risk of capsule contracture (“hardening of the breast”).
The operation involves taking skin and muscle from the back to supply the skin removed during the mastectomy. It does not have enough bulk to build a breast, so an implant is placed under this flap of tissue.
This operation takes about 2 1/2 hours, and most women spend one or two nights in the hospital afterwards. There is a resulting scar on the back, but it is well hidden in the bra line.
The latissimus muscle is expendable, as there are other muscles that will take over its function. Athletes may notice some reduced strength in some situations, but the majority of women will recover full use of the arm and shoulder.
This flap procedure is a “safer” flap procedure than the TRAM flap procedure in that its blood supply is very good, and few wound healing complications are seen.
This is a good choice for a lot of women who cannot or do not have TRAM flap options.
Schedule a Consultation Today
Dr. Leland Chick and his staff understand that there are many things to consider when undergoing breast reconstruction surgery. They will work with you to help you understand all of your options and help you make a decision that is best for you. To learn more about the breast reconstruction procedures available or about Dr. Chick’s experience as a breast reconstruction surgeon, contact us today at 801-322-1188.