Nobody expects to receive a diagnosis of breast cancer. With that diagnosis comes grief, questions, uncertainties and confusion. There seem to be so many large decisions to be made in such a short period of time. The information is vast and comes from so many different sources. It is a situation that can leave many women feeling vulnerable. Not only will we give an overview of many of the options available to you, but we also partner with the National Breast Cancer Foundation to help ensure that patients have access to the best resources possible.
It is in this setting that we as plastic surgeons seek to provide hope to women faced with such difficult choices. Our goal is to help each woman along her journey to recovery. We seek to restore what cancer has taken, providing hope that after all of the treatment is done, every woman can feel confidently like herself again.
In this short introduction, we hope to provide you with basic information on breast reconstruction to help you along your journey. Of course, when you are ready, we will stand by you and help you decide which of these procedures will be best suited for you and your personal goals. Regardless of whether or not you choose to undergo breast reconstruction, please know that we support you in your decision and will continue to be there to support you in your breast cancer journey. At the bottom of the page we also provide more information on our proud partnership with the National Breast Cancer Foundation and share with you how you might make a difference to someone else in need.
Dr. Christopher A. Park
Dr. Ryan E. Rebowe
What do we mean by breast reconstruction?
The term “breast reconstruction” typically refers to the process of surgically creating a new breast following a mastectomy, or surgical removal of the breast. This involves creating a replacement for the breast mound and subsequently creating a nipple. There are many ways to perform this procedure, as we will outline shortly. However, the goal of each of the techniques is the same: to create a breast that matches the opposite, natural breast as closely as possible. In cases where both breasts are removed, the objective is to restore the breasts as closely to their preoperative state as possible and hopefully to improve on that. While there is no way to make a breast look exactly the same as it did prior to surgery, in clothes and undergarments a reconstructed breast should provide natural proportions.
Other times, “breast reconstruction” may involve oncoplastic procedures to reshape the breast at the time of a lumpectomy by your oncological breast surgeon. If a patient is in need of a breast reduction, this can sometimes be completed in conjunction with the lumpectomy. Similarly, a breast lift or other type of “reconstructive” procedure may be used to provide the needed lift or fill of the area being removed. We would rather do these reconstructions prior to radiation which is almost universally recommended after lumpectomy for breast cancer than after.
Is breast reconstruction right for me?
It is important to know that breast reconstruction is optional. You do not have to undergo breast reconstruction following mastectomy, and you do not have to make the decision to undergo breast reconstruction at the same time as your mastectomy. The decision on whether or not to undergo breast reconstruction is extremely personal for each woman. Only you can decide whether or not it is the right choice for you.
The benefits of breast reconstruction are many. For many women, it allows for improved body image following a disfiguring operation. Reconstruction allows you to fit better in clothes, undergarments, and bathing suits without the need for a prosthesis. Many studies have shown improvements in quality of life scores and psychosocial well being in women who have breast reconstruction compared to those who have not pursued this option.
However, breast reconstruction does add additional procedures to the process of breast cancer treatment. These procedures are well tolerated by the vast majority of women who choose to undergo breast reconstruction, however this may not be ideal for women who have medical problems at baseline. Significant heart, lung, liver, kidney, or other major organ dysfunction is generally a contraindication for breast reconstruction. Common medical problems such as high blood pressure, diabetes mellitus, and high cholesterol typically will not prevent a patient from undergoing breast reconstruction, but they will need to be managed appropriately around the time of your procedure.
When should I have breast reconstruction?
It is possible to have breast reconstruction “immediately” at the time of your mastectomy, or in a “delayed” fashion many months or even years following your mastectomy. Both time periods are feasible and can provide a good cosmetic outcome.
In general, reconstruction performed immediately, or closer to the time of mastectomy, will have superior aesthetic outcomes as the tissue is more pliable and more easily manipulated. This type of reconstruction can be done at the same time as your mastectomy or shortly after, within 2-6 weeks before scar tissue forms. However, immediate reconstruction is not always possible. Among other things, post-mastectomy radiation therapy, a history of smoking, or need for immediate aggressive chemotherapy are common reasons to delay reconstruction.
Delayed reconstruction can still be very rewarding to women who either choose to pursue this option or if this option is necessary due to medical conditions or other treatment plans. Reconstruction during this period may require some extra steps to ensure that the tissue is of good quality, but the results can be just as good as immediate reconstruction.
Does the type of mastectomy that I have influence the type of reconstruction?
A mastectomy or partial mastectomy (lumpectomy) is meant for only two purposes: to treat a known cancer or to decrease the risk of developing a cancer. It is important to keep this in mind during this process. The type of mastectomy will influence the type of reconstruction that you pursue.
If the mastectomy is “skin sparing,” your cancer surgeon will take the nipple and a small amount of skin around it. This will require the recruitment of additional skin with either an expander or flap during reconstruction (this will be covered later). If the mastectomy is “nipple sparing,” then the nipple will be saved along with the skin. Because there is no skin missing, it may be feasible to place a flap or implant directly underneath the remaining skin. However, there are many instances in which a tissue expander may still be used in order to better control the remaining skin envelope.
Many women will also consider a contralateral prophylactic (or preventative) mastectomy in addition to a mastectomy on the side on which they have cancer. Again, the decision to undergo a contralateral prophylactic mastectomy should be more about cancer reduction than reconstructive potentials. However, having a contralateral mastectomy may improve symmetry between the two breasts. For women interested in flap reconstruction, it is important to note that many women do not have enough abdominal or thigh tissue to make two breasts of adequate size. This should be considered when contemplating a prophylactic mastectomy.
Types of Breast Reconstruction
Implant (Prosthetic) Based Reconstruction
The vast majority of women will be candidates for breast reconstruction utilizing a breast implant. In order to be a candidate for this type of reconstruction, the skin remaining after your mastectomy has to be of good quality. Typically this means that there can be no radiation injury, previous infection, or other issues with the mastectomy skin flaps. In this type of reconstruction, breast implants are utilized to restore volume to the skin once the breast tissue is removed. Because skin is removed during a normal mastectomy, this procedure typically takes 3 stages.
In the first stage, a temporary expandable implant is usually placed, termed a “tissue expander.” When this expander is placed, it is either deflated completely or inflated only a small amount. This allows the skin to shape and form where we want it. It is not always trying to create extra skin by stretching it. Often, we are trying to redrape and reshape loose, stretched skin. Over time, saline (salt water) is then added to the expander in clinic by placing a small needle through the skin and into the expander port. Since the breast skin is typically numb at this point, this procedure normally does not cause a significant amount of discomfort. In general, tissue expanders are harder and less natural-feeling than breast implants as they need to be tough enough to direct the desired shape and resist the compression of the expanding skin.
Once the skin is completely expanded, typically after at least 3 months, the expander may be replaced with a permanent breast implant. Breast implants are made of silicone (plastic) shells filled with either silicone gel or saline (salt water). Each implant has its own set of benefits and risks that your surgeon will review prior to your definitive reconstruction. The breast implant is placed into the pocket created by the tissue expander during the second operation. At this point, the tough and relatively hard expander is replaced by a relatively soft breast implant. This second operation will give a more natural appearing look and feel to the breast. It will take the breast implant approximately 3-6 months to “settle” into the correct place. Nipple reconstruction typically is the focus of the third operation.
Following placement of the permanent implant, there may be some irregularities around the implant or chest wall that are cosmetically unappealing or may cause clothes to fit uncomfortably. At that point, months following implant placement, minor adjustments may be made. These adjustments can be performed by removing fat from the abdomen (utilizing liposuction) and placing the fat into the breast, or by removing excess skin. This is a normal part of breast reconstruction and should be expected. It is also expected that the implant may need some type of operative maintenance during the patient’s lifetime. These short, outpatient surgeries are typically due to natural changes in a woman’s body and not by implant malfunction.
Autologous (Your Own Tissue) Reconstruction
The second option for reconstruction is utilizing your own tissue to rebuild your breast, also termed “autologous” reconstruction or “flap” reconstruction. In this operation, tissue is taken from another part of the body and moved to the breast defect utilizing specialized surgical equipment and technique. Flap procedures are highly specialized and tailored to each woman. In general, women are candidates for this procedure if they have ample donor site tissue and a favorable comorbidity (baseline illness) profile. If you are going to receive or have received radiation to your breast, a flap procedure may be necessary to bring in new, non radiated tissue to the mastectomy site to complete reconstruction after radiation changes have settled.
The tissue typically utilized is the abdominal tissue in the lower part of the abdomen. This is the same skin and fat removed during an abdominoplasty or “tummy tuck” procedure. Therefore, this procedure results in some abdominal contouring in addition to the reconstruction of the breast. Some loss of function of the abdominal musculature may be necessary depending on the patient’s anatomy, but advancements in surgical techniques has made this less likely. Tissue can also be taken from the thigh, buttocks or lower backs, however the non-abdominal donor sites are typically performed only at large tertiary care facilities as they are far less common procedures.
Flap reconstructions can have many benefits. Because the abdominal tissue has many of the same characteristics as breast tissue, it can provide a natural appearing reconstruction similar in shape and natural ptosis (droop) to the native breast. While this type of reconstruction still requires two to three operations to shape the breast, once these operations are complete there is typically no long term need for reoperation. Lastly, the contouring of the abdominal donor site is similar to that achieved with an abdominoplasty (tummy tuck procedure). However, as many patients know, natural is not always the most desired. The flap will be prone to the same gravity, skin stretching, and aging as normal tissues.
These reconstructions also have their drawbacks. The downtime of these procedures is four to six weeks compared to the two to three weeks of an implant based reconstruction. Also, as this procedure requires removing tissue from a distant site, there is a risk of complications at the site from which the tissue was taken. Bleeding, wound problems, abdominal bulge, or other issues can complicate this procedure. Furthermore, when the tissue is moved, there is a risk of flap death and reconstructive failure.
Overall, these procedures are complex operations but can provide for stable, aesthetically pleasing long term reconstructions. While not all women desire this type of surgery or are appropriate candidates, many women will find this reconstruction will provide aesthetically pleasing, stable long term reconstruction.
Which reconstruction is right for me?
There is no one reconstruction that is correct for every woman. The type of mastectomy, the need for radiation, the shape of the native breast, unilateral versus bilateral, desired shape and size, and other factors will all play a part in this decision. This guide is meant to be a general introduction to breast reconstruction. As your surgeons, we will continue to walk you through this journey and recommend a reconstruction that will provide the best option for you. We only hope that in reading this and perusing these photos, each woman will be able to better grasp breast reconstruction and make the best choice for herself along with her surgeon.
Written on November 6, 2019
National Breast Cancer Foundation
Park & Rebowe Clinic for Plastic Surgery in Mobile understands that every woman’s breast cancer journey is unique and comes with its own difficulties and hardships. We are committed to supporting these women through our partnership with the National Breast Cancer Foundation (NBCF) and through the patient education and reconstructive procedures we offer.
The National Breast Cancer Foundation
The National Breast Cancer Foundation is a globally respected breast cancer charity that has been working for decades to help women across the United States during their breast cancer journey. They offer a number of free programs to ensure that support and education is always there for those who need it.
Our donation portal helps raise funding towards providing resources and support for breast cancer patients. Donate today to make a breast cancer victim’s journey easier.
Learn More Today
To find out more about our partnership with the National Breast Cancer Foundation or our breast reconstruction options in Mobile, contact Park & Rebowe Clinic for Plastic Surgery today.
Make A Donation Through Our Partnership
We are a very proud partner of the National Breast Cancer Foundation. Part of our partnership includes annual donations to this wonderful organization! We also offer a portal for anyone who wants to help women locally and across the nation combat breast cancer. To make a donation to someone in need or in honor of a loved one please visit: https://fundraise.nbcf.org/give/308219/#!/donation/checkout
Donations can be one time only or can be made monthly!