Breast Reconstruction

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Breast reconstruction following mastectomy or congenital absence of the breast can take several forms. The goal of reconstruction is to replace both the skin and volume (mound) removed at the time of the mastectomy. This will hopefully allow you to resume any pre-surgical activities and not be limited in the clothing you can comfortably wear. This can be achieved in several ways which will be addressed later, however it is important to realize that this process will only create a new mound in place of the removed, diseased tissue. It will not create a new, normal breast. There are several different procedures for breast reconstruction (and nipple/areolar reconstruction) and each of these results in a different appearance of the breast and each involves a different operative technique with its associated differences in operative time, risks and recovery period. The goals of reconstruction may range from the simple desire to eliminate an external prosthesis to an elegant reconstruction of the breast with near natural shape including nipple and areola reconstruction. The goals are very individual and the degree to which the breast will be reconstructed depends on your personal objectives.

The timing of reconstruction depends on the surgical procedure used. Whether done immediately at the time of the mastectomy or at a later date (delayed reconstruction) the final results will be comparable. Factors such as lymph node involvement, need for chemotherapy or radiation or personal desires to wait may delay certain types of reconstruction.

Although the ideal outcome of breast reconstruction is a breast mound and nipple which is identical to the other side, this may be an unobtainable goal. Factors such as the existing scar location and quality, the location of the tumor, whether radiation is planned, the type of surgical procedure and the appearance of the opposite breast all must be taken into account and will have an influence on the final result. The goal is symmetry in size and shape. Times exist when the other breast may be of insufficient size or may be too large to achieve symmetry with the techniques available. The breast also may have too much “droop” or ptosis. These conditions may necessitate adding volume, removing or reducing volume or lifting the breast to help achieve a more even match in size and shape. These factors can be addressed at the time of the initial consultation.

The specific type of tumor, your family history of breast cancer and your age are factors which may increase your risks of developing cancer in the opposite or contralateral breast. Although not a common occurrence, this risk should also be considered when planning reconstruction of the involved breast. There exist situations where bilateral or two sided mastectomies and reconstruction may be performed to treat or prevent cancer on the “uninvolved” side. Bilateral reconstruction can often result in good symmetry in size and shape. Concerns regarding bilateral breast disease should be discussed with your general surgeon.

If the uninvolved breast is not treated at the time of the mastectomy, it will need careful and frequent examination by your physician as well as by mammography. This will allow early detection of any abnormalities in this breast. In addition, although the breast tissue will have been removed from the diseased breast, you are still at risk to develop a recurrence of the cancer on that side. This area should not be neglected and will also require frequent examination by you and your surgeon. The reconstructed side will not require mammography as the residual tissue is superficial and easily examined by physical examination alone.

There are several different surgical procedures that can be used to reconstruct a breast mound. These operations address the replacement of the missing tissue, both skin and volume, by different methods. Each of these will have benefits and risks unique to that operation. In addition, every surgery has inherent risks. These will be the same for each of the procedures and include:

  • Bleeding and the potential need for additional surgery or a blood transfusion (and the possibility of blood borne infections such as hepatitis, HIV and transfusion reactions)
  • Infection, which may require removal of the implant if one is used for the reconstruction.
  • Scars, which may take up to 12 months to fade and flatten. Sometimes these scars may widen, become discolored or raised and ugly.
  • Numbness, which may be permanent and irreversible.
  • Pain, which is usually temporary in nature, may be chronic and untreatable.
  • Weakness, resulting from muscle utilization for reconstruction may limit your ability to resume vigorous activity.
  • Blood clots (pulmonary emboli), which may travel to the lungs resulting in illness or rarely, death.
  • Delayed healing, which may require additional surgery, prolonged local wound care and which may result in wider scars. SMOKING WILL INCREASE YOUR RISK OF THIS AND MOST OTHER COMPLICATIONS!
  • Persistent fluid accumulation, which may require aspiration and the need for drain placement/replacement.
  • Hernias, which may require additional surgery.
  • Asymmetry, which may require additional surgery or may be unable, even with surgery, to be corrected.
  • Implant problems, which will be discussed later under implant concerns. Three of the four operations require a breast implant to replace volume.
  • Death. Surgery of any type may result in anesthetic or surgical complications which may result in death.

These potential problems may occur but every possible factor will be taken into consideration and all attempts will be made to reduce or eliminate these risks for your surgery.

The following discussions will be directed towards each reconstructive procedure. The operation you chose will be one of these and the others are presented for your information and comparison. You should remember that there is no one perfect operation for all patients requiring reconstruction. The method of reconstruction chosen will take into consideration your desires, the size and shape of the other breast, your work and recreational activity level, the type of tumor you have and your overall health. Please feel free to ask many questions and be sure to write them down so that we may address them at the time of your consultation.

Click below for specific information on procedures and techniques:

Other Techniques:
There is also a technique in which the upper portion of the gluteal muscle and upper buttock fat and skin are utilized to replace the breast. This is a lengthy operation requiring 6-7 hours and has a more tenuous blood supply. This requires microscopic re-connection of blood vessels which increases the chance for partial or total flap death. This technique is usually reserved for an end stage procedure when all other techniques are not applicable. Removal and utilization of skin, muscle and fat from the upper, inner thigh has been used in a similar fashion.

Nipple Reconstruction:
Reconstruction of the nipple and areola is done following mound reconstruction. The color is added by application of tattoo dye and the nipple is formed by a local flap of skin that adds projection to the nipple. It is an office procedure with local anesthesia and has a rapid recovery.

The goal with any of these techniques is the greatest degree of symmetry possible. If bilateral mastectomies are performed the degree of symmetry that can be obtained is usually very good. Symmetry available with other techniques in unilateral or one-sided reconstruction is dependent upon your non-involved breast. Although each of these procedures can be performed with hopes of achieving the greatest degree of symmetry there are factors at the time of surgery and in settling of the breasts which may make additional skin excision or breast mound alteration necessary to achieve the degree of symmetry you desire. Often times this additional surgery can be performed at the time of nipple reconstruction which occurs 1 to 3 months following major breast mound reconstruction. Procedures to alter the other breast can be done at the same time if desired.

Breast reconstruction will require surgery to create a new breast mound. It should be the goal to achieve this outcome in the safest and most time efficient manner so that you can re­sume normal activities and get on with your life. It is not an overnight process and will re­quire time and effort to achieve the goals you set. The results are variable, but should allow you to wear any type of clothing with confidence and to return to an active lifestyle.