About Breast Reconstruction
Breast reconstruction, also known as reconstructive mammaplasty or postmastectomy surgery.
Breast reconstruction can cover a variety of procedures and is usually performed to restore the shape and form of the breast following either mastectomy or lumpectomy surgery to treat breast cancer. This surgery can be affected by several factors, such as aesthetic goals, anatomy or the need for any post-surgical chemotherapy or radiation therapy, which will determine the options available to you. It is crucial to discuss your cancer surgery with a plastic surgeon before undergoing a mastectomy because this may affect the choices and results of your breast reconstruction surgery.
Breast reconstruction involves the the rebuilding and reconstruction of the breast. It involves using either saline implants or silicone implants or even using the patient’s own skin fat and muscle to construct a natural looking breast. A patient may consider a breast reconstruction surgery to help restore their confidence or the feelings of femininity following a mastectomy or lumpectomy. It will also help to create symmetry if only one breast has been affected such as with a mastectomy.
The cost of breast reconstruction surgery may vary depending on which cosmetic surgeon you decide to go with as well as what geographic location you are in.
How is it performed?
There are three basic options for those considering breast reconstruction: Using breast implants (saline or silicone), reconstructing the breast using your own skin fat and muscle or a combination of those methods. Although most breast reconstruction procedures are considered outpatient surgery some may require you to stay in hospital for the initial procedure (especially if done in conjunction with a mastectomy).
Implant reconstruction procedures
Initially your surgeon will insert a tissue expander beneath your skin and chest muscle, forming an envelope. The tissue expander is a modified saline implant with a valve which allows your surgeon to perform a series of injections through the skin during follow up visits over the next two to six months, slowly filling the implant to the desired size and shape. The next stage, the expander will be removed and replaced with a softer breast implant of either saline or silicone).
With saline implants the expander is sometimes kept for a longer period, which allows the reconstructed breast to be changed without removing the implant. If it is a silicone implant, your breast size cannot be changed without further surgery.
Breast reconstruction with implants using an acellular dermal matrix
An Acellular dermal matrix (ADM) is a sheet of biological tissue, usually a framework of collagen and elastin. It is specifically designed to encourage your own body’s tissues to grow into it, gradually replacing the ADM with your own cells and blood vessels. The acellular dermal matrix acts similar to a hammock, supporting the tissue expander in the skin-muscle envelope, which can improve implant placement.
A procedure using an ADM can be less invasive than other techniques, as it permits a larger breast mound and decreases the number of follow-up visits required to attain the desired implant volume. When an ADM is used, the implant can be inserted much sooner than with other techniques, and in rare cases means an expander is not needed at all, the final implant can be placed into the ADM ‘hammock’ during the mastectomy meaning no further surgery is required. Whether or not you’re a candidate for this technique will depend on the quality of your skin envelope after your mastectomy.
Natural grafts/tissue flap surgery
For certain patients, for instance if you have radiation-damaged tissues, your cosmetic surgeon may recommend the use of a flap of your own skin to replace any damaged tissues. A breast reconstruction using autologous skin and tissue (from your own body) can result in a more natural looking and feeling breast than other implants. Autologous procedures are more far more invasive and complex, prolonging your stay in hospital and leaving large scars where tissue was removed (usually the back, abdomen or buttocks).
Occasionally an entire muscle will need to be moved in order to reconstruct the breast, resulting in weakness in that area of the body. There is also the option of autologous fat grafting or a fat for those with radiation-damaged tissues or small contour irregularities. Fat transfer may require multiple sessions, can cause fatty cysts and is not permanent. Sometimes surgeons will use autologous fat grafts to improve the results from an implant reconstruction or to correct any minor irregularities.
If your surgeon has recommended an immediate breast reconstruction, they may attempt to keep as much breast skin intact as possible by performing a skin-sparing mastectomy. The tumour and clean margins (areas free of cancer cells) will be removed, along with the areola, nipple, fat and other tissues leaving a large amount of skin that can then be used to cover an implant. This is beneficial because it avoids using skin from other parts of the body, which can look different to normal breast skin, and reduces the need for further surgery. Those with droopy or large breasts may find that loose skin continues to sag, affecting the result of the reconstruction.
This is a fairly new technique, similar to a skin-sparing procedure but with the added benefit of leaving the nipple and areola intact and improving the final look of the reconstruction. Unfortunately, this technique is not suitable for everyone and it is still likely that the nipple will lose projection and some sensation. The result is not guaranteed as the tissues may still break down, meaning the nipple and areola have to be removed later. There is also still considered some risk of this increasing the chances of a recurrence of cancer, but this is still debated.
Nipple reconstruction with implant procedures
Nipple reconstruction is completed once the permanent implant has been inserted. It gives the reconstructed breast a more natural look and can help to hide some of your scarring. The procedure usually involves lifting a flap of skin from the breast itself and folding it so as to create a small piece of tissue aesthetically similar to a normal nipple. Colouration is usually achieved by tattooing or grafting. Many surgeons will opt to delay the nipple reconstruction until after your implant has settled, so that the final areola and nipple remain in the correct place. The scar from where the skin is taken can be hidden in the bikini line.
What will my breast reconstruction incisions and scars be like?
How your scars look will depend on a number of factors, namely genetics, age, how your incisions are sutured, the way your body heals and of course, the procedure you undertake.
What result can I expect?
Even though both silicon and saline have lifetime warranties from their manufacturers, the longer you have implants the more likely it is that you will experience some complications or changes. Although research suggests that around 95% of implants are still intact after seven years, it is also true that 50% of women who receive implants during a breast reconstruction require either an exchange or a removal within ten years of their procedure.
Patients who opt to have a single breast reconstruction will naturally notice that breast changes over time differently to the other as the natural breast tissue will lose elasticity at a different rate compared with to an implant-reconstructed breast. A breast reconstruction that uses tissue flaps is still natural tissue and so will be affected by time and gravity accordingly, but may not age at the same rate because the tissue is from another part of the body.
These tissues do not “know” that they have been moved and their growth or shrinkage in response to weight loss may be different from natural breast tissue. The skin and fat from the upper back or buttocks region is much thicker and more fibrous and does not tend to droop or sag as much over time as breast tissue. The skin and fat of the abdomen is very similar to that of breast tissue and tends to droop or sag over time similar to natural breast tissue.
For safety, as well as the most beautiful and healthy outcome, it’s important to return to your plastic surgeon’s office for follow-up evaluation at prescribed times and whenever you notice any changes. Do not hesitate to contact your surgeon when you have any questions or concerns.
- You will not have to cope with wearing external breast forms or pads.
- This is a potential way of helping cope with your mastectomy and cancer experience.
- It can help you feel better about how you look and restore confidence in your sexuality.
- Breast reconstruction involves additional surgery, medical appointments and possibly additional costs.
- Breast reconstruction may interfere with the natural state of your body which has just returned to normal health.
- A reconstructed breast will not have the same sensation and feel as the breast it replaces.
Your surgeon will prepare you for immediately after your breast reconstruction surgery, but here are a few things you should expect: You may be wearing compression sleeves on your legs to help your circulation and even if you are receiving pain medication you may still feel sore.
There may be drains coming out of your underarms and from your stomach, if you had a reconstruction using autologous tissue. You may also have a catheter in your bladder which will be removed post-surgery. The area from which tissue was taken will also be sore and it may be hard for you to get out of bed alone. If you have a breast reconstruction using implants, your armpit region may be sore, but you should still take care to maintain the range of motion in your shoulders by moving your arms.
Your doctor will suggest certain exercises that can help with this and instruct you to get out of bed when possible as this is very important to prevent blood clots forming in the legs. You will be able to use the bathroom by yourself, but may need assistance during the first week.
It is essential you follow all patient care instructions given to you by your physician. This will usually include information about which compression garments to wear, how to take care of your drains, how to take any antibiotics or painkillers, if prescribed and the level of activity that is safe for you to undertake. Your surgeon will also provide detailed instructions about the normal symptoms and how to spot any signs of complications. It is important to realize everyone’s body is different and so the amount of time it takes to recover varies between individuals. Implant-based reconstruction is the simplest and least painful technique and comes with the shortest recovery time.
Most women are able to return to their routine activities within two or three weeks. Flap-based procedures require surgery in two or more areas and are significantly more demanding, depending on how the procedure was performed. A hospital stay is usually required for any muscle-flap surgeries and may involve significant restriction of your activities, for example, after a TRAM flap surgery you will not be allowed to strain or lift anything for at least six weeks.
It is important to keep gently moving your arms and there will be nurses available to help you get in and out of bed. The majority of expandable implant reconstruction surgeries are outpatient procedures and you are encouraged to exercise lightly from the day of the procedure in order to decrease any risk of blood clots forming in your legs. You could spend between one to six nights in the hospital, depending on your body and the exact method of the surgery.
Depending on the type of reconstruction, you may be spending most of your time in bed or sitting during the first few days. The majority of patients can walk without assistance two or three days after a flap reconstruction and your physician will encourage you to walk and move gently several times a day to stimulate circulation in your legs. If your surgeon gives you permission, you can shower, but you may need someone to help you. If you have drains you will need to pin these to a drain belt or you may be given a gauze necklace to support them around your neck. It may also help you to have a way to sit down in the shower.
Your new breasts may be larger at first, due to swelling but as this subsides over the next few weeks, your breasts will assume the shape you desired.
Limits & Risks
Fortunately, significant complications from breast reconstruction are infrequent. Your specific risks for breast reconstruction will be discussed during your consultation. All surgical procedures have some degree of risk.
Some potential complications of all surgeries are:
- Adverse reaction to anaesthesia
- Hematoma or seroma (an accumulation of blood or fluid under the skin that may require removal)
- Infection and bleeding
- Changes in sensation
- Allergic reactions
- Damage to underlying structures
- Unsatisfactory results that may necessitate additional procedures
- Blood clots in your legs or lungs
Other risks specific to breast reconstruction are outlined below:
- Fat necrosis and/or fatty cysts
- Blood clots in the legs or lungs
- Partial or complete loss of the flap
- Loss of sensation at both the donor and reconstruction site
- Donor site complications
- Delayed wound healing with poor scar formation
- Breast hardening (capsular contracture)
- Implant malposition
- Implant rupture
You can minimize the risk to you by carefully following the instructions and advice of your plastic surgeon before and after your cosmetic surgery procedure.