It is important to have the option of breast reconstruction available before any treatment of breast cancer begins. Your general surgeon should discuss the option of breast reconstructive surgery with you and offer you a consultation with a plastic surgeon to discus the issue further.
Timing of breast reconstruction is either immediate, at the time of mastectomy, or delayed, at a second procedure. The timing is dependent on many issues, such as whether or not there is a plastic surgeon in your community who can perform the procedure, what other treatments are needed for cancer treatment, or simply patient preference. Immediate reconstruction is an ideal option for a patient who has a nicely shaped breast. In this case, a skin sparing mastectomy may be performed which will preserve the natural breast skin envelope and improve the breast reconstruction outcome. Delayed reconstruction may be better for a patient who knows they will need radiation after mastectomy. The decision for immediate versus delayed reconstruction should be made between the patient and her plastic surgeon.
The goal of breast reconstruction is to rebuild a breast mound which is as symmetrical as possible to the opposite breast. Once the mound is in place, the nipple and areola are reconstructed at a second stage along with any revisions or matching procedures, such as reduction, lift or augmentation, on the opposite breast to improve symmetry. Occasionally the nipple and areola reconstruction is delayed to a third stage to maximize symmetry.
The goal of breast reconstruction is to create a breast mound and a new nipple and areola. However, there are some important limitations to the reconstructed breast mound no matter what type of reconstruction is chosen. Whether the reconstructed breast is made from an implant, or back, abdominal or buttock fat, the mound is flatter than a normal breast. A normal breast has a cone shape, which is primarily from the tissue just beneath the nipple and areolar complex, and is removed during mastectomy.
Although the reconstructed breast often feels quite natural, especially when your own tissue is used, the reconstructed breast will likely not feel like your other breast. A reconstructed breast is often more dense than a normal breast and will not conform into a bra as a normal breast tissue will. Nipple and areola reconstruction give the breast the look of a real nipple and areola but do not reconstruct the cone beneath them. Reconstructed breasts often do not age the same as a normal breast and therefore further symmetry procedures may be desired on the opposite breast in the future. The best outcomes are often when the same procedure is performed on both breasts which is the case with bilateral reconstruction.
Tissue expander/implant reconstruction is a simple procedure where a balloon-like device is inserted under the breast skin and pectoralis muscle and filled with saline over a series of office visits to slowly stretch the skin and muscle to the desired breast size. Once the tissue expansion is complete, a second procedure is performed to remove the expander and place the permanent implant, either a saline or silicone implant. This procedure is the shortest type of reconstruction with the least amount of recovery and downtime.
Reconstruction with your own tissue
Reconstruction by using your own tissue is called flap reconstruction which is identified by where the tissue(fat and skin) comes from. The most common areas where tissue is taken are the back and abdomen. In general, flap reconstruction results in the most natural-appearing breast.
Breast reconstruction options include;
- Tissue explander/implant
- Your own tissue
- Latissimus flap-skin, fat, muscle from your back
- TRAM flap- skin , fat, muscle from your abdomen
- DIEP flap- skin and fat from your abdomen
- GAP flap-skin and fat from your buttocks -skin and fat from your inner thigh
Tissue expansion( picture)
Pros- Simplest, fastest procedure-1 hour
Shortest recovery- 1 night in hospital, 2-4 weeks recovery
Good for bilateral breast reconstruction
Good for reconstruction matching small opposite breast
May be combined with augmentation of opposite breast for better symmetry
Cons- Difficult to match opposite sagging breast
Requires trips to office every 1-2 weeks for expansion procedure
Implants can leak and require replacement in future
Your own tissue
Latissimus flap (Picture)
Shortest procedure using your own tissue -3-4 hours
( 2-3 days in hospital, 3-4 weeks recovery)
Good for small breast reconstruction
May use an implant for more volume
Most reliable reconstruction
Scar on back, back asymmetry
10-15% loss of shoulder strength but minimally effect every day activities
4-5 hour procedure with 3-5 days in hospital and 6 weeks recovery
Abdominal rectus muscle taken with flap increasing chances of decreased abdominal strength, or abdominal hernia
Loss of part of flap
Abdominal scar hidden well