Introduction: What is Breast Reconstruction?
Breast reconstruction is a surgery performed to restore the shape of the breasts after the tissue is removed during a mastectomy (conducted to treat or prevent breast cancer).
Breast reconstruction is performed by three methods:
- Using a tissue expander/implant
- Tissue flap reconstruction: using your own tissue from your abdomen or from your back to create a new breast mound (autologous reconstruction)
- Combination of both
Nipple and Areola Reconstruction
The nipple and areola can be reconstructed at a later stage. A small elevation is made keeping the other nipple as reference. The normal pigmentation of an areola can be tattooed using a dye, which is carried out as an office procedure.
Symmetry in breast shape and size
A small difference may exist in the size and shape of the two breasts following reconstruction, but may not be noticeable under a bra. However, for the more noticeable ones, women may surgically reduce, enlarge or lift the remaining breast to maintain symmetry.
Who is an Ideal Candidate for a Breast Reconstruction?
Ideal candidates for breast reconstruction include:
- Healthy individuals without significant medical comorbidities
- At least 9 months post radiation therapy
- At least 4-6 weeks post chemotherapy
- Realistic about expectations of surgical outcomes - Although breast reconstruction can rebuild your breast, the results are highly variable as listed below:
- A reconstructed breast will not have the same sensation or feel as the breast it replaces
- Visible incision lines will always be present on the breast, whether from reconstruction or mastectomy
- Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the back, abdomen or buttocks
Before your procedure, a detailed medical history is obtained, and a thorough physical examination is performed. During your consultation, your doctor will advise you to stop smoking, if you smoke, to avoid post-surgical complications and delayed healing. You should eat a healthy diet and avoid any restrictive dieting during this time. You should inform your doctor of all medications that you are taking and about significant medical conditions, allergies and previous surgeries if any.
Depending on your age, exam, family history and breast health history you may require breast imaging prior to your procedure.
Photographs will also be taken during pre-operative consultation to submit for insurance, to be used in surgical planning and for before and after comparison. Your goals will be discussed, and realistic expectations will be set. After discussing surgical options, we will make an individualized surgical plan together that best suits your goals.
This is the best time to ask all your questions so that you can feel comfortable and confident going into surgery.
Procedure: Breast Reconstruction
Breast reconstruction can potentially be performed at the time of mastectomy or it can be performed in a delayed fashion a few months after mastectomy based on what is best for the patient.
No matter what type of breast reconstruction you will likely have multiple procedures to complete the reconstruction and to get everything looking as good as possible. These procedures include everything from the main reconstruction to build the breast mound, to liposuction and fat grafting to improve contour to nipple reconstruction to complete the picture.
Breast reconstruction is performed under general anesthesia either in an outpatient or hospital setting based on the type of surgery that you will be having
- In the pre-operative area a surgical marker will be used to draw anatomic guidelines on the breasts to help carry out the incisions and to outline the area for your new breasts. If you are having autologous reconstruction then your donor site will also be marked to harvest your flap
- A TRAM flap uses donor muscle, fat and skin from your lower abdomen to help reconstruct the breast. This flap may either remain attached to its own blood supply through the muscle or be attached to its new blood supply on the chest. Varying degrees of muscle can be used from the abdomen – if no abdominal muscle is used then this flap is referred to as a DIEP flap. After harvesting the flap from the abdomen you will essentially be getting a tummy tuck and your incision will be hidden below the belt line and around your belly button.
- A latissimus dorsi flap uses donor muscle, fat and skin from your back and the incision is usually made across your back to be hidden in your bra strap line.
- Tissue expander based reconstruction involves placement of the expander device either above or below the muscle to be inflated in clinic over time until the desired breast volume is reached and then is subsequently exchanged for a permanent breast implant in the operating room.
- Implant based reconstruction involves placement of a breast implant above or below the muscle which can be done with or without initial tissue expansion in select cases.
- Nipple reconstruction is performed using your own skin locally on your new breast to create a projected nipple and sometimes also using a skin graft from another area on the body to create the areola (alternatively some patients may have a nipple tattooed with 3D tattooing which can also have amazing results)
- Acellular dermal matrix or mesh may be used in implant or tissue expander based reconstruction for extra support of the breast
- Liposuction and fat grafting may be used in second or third stage operations to help improve the contour of your new breasts and make them appear more natural. We suction out fat from another area of the body usually the abdomen/ flanks/ thighs and use that fat to inject back into your breast area.
- In each of these procedures your incisions will be closed with dissolvable sutures that will be under the skin and you will have either surgical glue or surgical tape over your incisions which take about 1-2 weeks to fall off.
- You will potentially have drains in place after surgery based on the amount of tissue that needs to be removed that will be removed in 1-2 weeks.
Risks and Complications of a Breast Reduction
Breast reduction is a relatively safe procedure; however, as with any surgery, the following risks and complications are possible:
- Anesthetic risks
- Blood clots in the lungs or legs, cardiac and pulmonary complications
- Breast scarring
- Pain in the breasts
- Changes in sensation in the breasts or nipples
- Bleeding (hematoma)
- Fat necrosis
- Asymmetric appearance of nipples or breasts or suboptimal aesthetic results
- Incomplete healing in the nipple area
- Delayed healing
- Accumulation of fluid in breast tissue (seroma)
- Possibility of revision surgery
- Flap surgery includes the risk of partial or complete loss of the flap and a loss of sensation at both the donor and reconstruction site .
- Breast implants carry the risk of breast firmness (capsular contracture) and implant rupture.
- Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is linked to textured implants which I do not use or other very rare cancers in the capsule around the breast implant, such as breast implant-associated squamous cell carcinoma (BIA-SCC) can occur
- Breast implants may be associated with systemic symptoms commonly referred to as breast implant illness (BII), which can include fatigue, "brain fog," muscle or joint pain and rash.
- Acellular dermal matrix products may have a higher chance for complications or problems.
Recovery after Breast Reduction Procedure
Most people stay in the hospital at least overnight especially if having reconstruction on the same day as the mastectomy. If having flap surgery you may stay multiple days in the hospital.
In general, postoperative care instructions and recovery involve the following:
After breast reconstruction surgery there will be some temporary pain, discomfort, bruising and swelling. Medications will be prescribed to relieve pain. You will wear a contoured elastic garment for extra support around the chest/breasts. Upon discharge, patients will be instructed about proper wound care and how to manage their drains at home if they have them. For women having breast reconstruction, you should avoid underwire bras for at least 6 weeks while healing. Stitches are usually dissolvable and internal. Specific post-operative care regimen to minimize scarring will be discussed with each patient. Strenuous physical activity and heavy lifting over five pounds is discouraged for six weeks post-operatively – details of this limitation will be discussed with you specific to the surgery that you will be having. You will likely be able to resume work in 2 to 4 weeks depending on what kind of surgery you have done and what kind of job you have and how you are feeling. Full recovery may take up to one year and you need to have follow-up appointments to ensure a positive surgical outcome.
The goal of breast reconstruction is normal appearance in clothing. The results of breast reconstruction after mastectomy can help to lessen the impact of the mastectomy. Remember every patient is different and goes through their own journey. You, along with your surgical team, can find the path that is right for you to make you feel comfortable in your skin.