Breast reconstruction is a surgical procedure to rebuild the contour of the breast, along with the nipple and areola (the pigmented area surrounding the nipple) if desired. Recent advances in reconstructive techniques have given patients more choices when it comes to breast reconstruction, including the option to have breast reconstruction during the same operation in which the breast is removed. Being diagnosed with breast cancer is not usually a medical emergency; most women have a sufficient amount of time to research treatment and reconstructive options before having to make any decisions.
Although many breast cancers can now be treated by "lumpectomy" there are still a number of women who will be advised by their cancer surgeon to undergo mastectomy. The reasons for this usually are related to the size of the tumor when first discovered, and to the risk of multiple tumors in a breast due to the type of tumor present. There are several different types of breast cancer and individual factors such as age and general health may affect the type of treatment recommended by the cancer surgeon. When the recommendation is for removal of all of the breast tissue the patient may ask the cancer surgeon about the possibility of reconstruction if the surgeon does not mention the possibility. Most patients who undergo mastectomy are candidates for some type of reconstruction if they so desire. Patients who fail to develop a normal breast due to childhood injury or congenital defects are candidates for reconstruction, often during mid to late puberty.
Some would argue that the only real function of the breast is to provide milk for the newborn. Since there is no reconstructive technique capable of meeting this criteria there are those who would argue that breast reconstruction is cosmetic. A second and very important function of the breast is to provide a normal appearance of symmetry. Although none of our paired features are perfectly symmetrical we expect to see in others and to feel and see in ourselves an overall sense of visual balance. When this is lacking the eye is immediately alerted. Patients who seek breast reconstruction after experiencing loss of the breast often cite a feeling of asymmetry or a lack of "wholeness". Each patient's motivation may be different but there goal is to restore a symmetrical appearance and feel which for some women cannot be obtained with an external prosthesis.
The goal of breast reconstruction once was to improve the clothed appearance of a patient. Today, the criteria for a successful reconstruction are much more demanding. Now the emphasis is on reconstructing natural breast contours and symmetry rather than a simple breast mound. Results have improved dramatically over the past two decades due largely to refining a variety of options available for reconstruction. Breast reconstruction is an important final step on the difficult road of breast cancer treatment, bringing completion to the whole process.
Reconstruction is now performed either with prosthetic devices (expanders and implants) or with the patient's own tissue (TRAM and latissimus flaps). Which option to pursue depends on the individual patient's body shape, lifestyle, and preferences, as well as cancer therapy. Surgery on the opposite breast, including reduction and lifting procedures, may also be performed to obtain symmetry at the time of mastectomy or on a delayed basis.
Tissue expansion with implants: Implant reconstruction often requires more than one procedure in order to make enough space for the implant. Implant reconstruction is usually combined with a procedure called tissue expansion, during which saline (salt water) is slowly added over a period of time to a type of implant called an expander implant. When the space is large enough to fit an implant that will match the natural breast, a permanent implant then replaces the expander one. The procedures for placing expanders and implants are usually short and do not require overnight stays in the hospital. Most implants used today are made of saline (salt water), which is harmless. If a saline implant leaks, the fluid is absorbed by the patient’s body with no harm. Silicone is also used to fill an implant. A silicone implant feels more like a natural breast. Most recent studies show that silicone is not associated with autoimmune disorders such as lupus. If you are considering a silicone implant, your doctor will discuss it with you in detail.
Flap reconstruction: Flap reconstruction uses a piece of body tissue - usually skin, fat, and muscle - that is transferred to the breast area to recreate a soft, natural-looking breast. This type of breast reconstruction is more complicated than an implant procedure, in terms of its scale and longer recovery time. The advantage for the woman is a more natural look and feel. The tissue for the reconstructed breast will need to be taken from another site in the body. Flaps of muscle and skin are taken from the back, abdomen or buttocks. Because muscle flap reconstruction requires healthy blood vessels, women with diabetes, connective tissue disease, vascular disease, previous major abdominal surgery and women who smoke may need to consider other options. Flap reconstructions take three to six hours of surgery. Although flap surgery takes longer than implant surgery, the procedure can be finished during one surgery and the risk of complications is minimal. Most patients will spend no more than four to five days in the hospital. You will be walking and eating within a day or two. Blood transfusions are rarely required, although your surgeon may ask that you donate a unit of your own blood several weeks prior to the procedure. The most common type of flap used in breast reconstruction is a TRAM (transposition of the rectus abdominus muscle) flap. A TRAM flap is taken from the abdomen.
Nipple reconstruction: Most patients undergo nipple reconstruction after breast reconstruction. This is usually a separate outpatient procedure that can be performed with minimal anesthesia. Recovery is not difficult, although the final outcome may require a tattoo for a better match in color. The surgeon measures and marks a nipple location that's symmetrical to your other breast. The surgeon reconstructs your nipple using tissue from the breast itself or from skin taken from another part of your body, such as your inner thigh. Tattooing the skin makes it more closely match your natural nipple and areola.
Reconstruction may be carried out after all of a breast is removed (mastectomy) or part of it (segmental mastectomy, quadrantectomy or wide local excision). The new breast uses as much of a woman's remaining chest tissue as possible. It can be created around an artificial implant and/or a piece of muscle and/or fat and skin transferred from another part of the body, usually the back or abdomen. Surgeons can also create a new nipple.
The aim of reconstruction is to make a breast that matches the remaining breast in size, shape and position and feels as soft and natural as possible. In some cases, surgery may be required to the other breast to achieve symmetry. Where both breasts are being reconstructed the aim is to recreate breasts that match and are in proportion to the woman's shape. The overall aim is to make a woman feel happy and confident with her restored shape.