Breast reconstruction is a series of surgical procedures performed to recreate a breast. Reconstructions are commonly begun after portions of one or both breasts are removed as a treatment for breast cancer. A breast may need to be refashioned for other reasons such as trauma or to correct abnormalities that occur during breast development.
Many experts consider reconstruction to be an integral component of the therapy for breast cancer. A naturally appearing breast offers a sense of wholeness and normalcy, which can aid in the psychological recovery from breast cancer. It eliminates the need for an external prosthesis (false breast), which many women find to be physically uncomfortable as well as inconvenient.
Breast reconstruction is performed in two stages, with the ultimate goal of creating a breast that looks and feels as natural as possible. It is important to remember that while a good result may closely mimic a normal breast, there will inevitably be scars and some loss of sensation. The reconstructed breast cannot exactly match the original.
The first step is to create a structure called a breast mound. This can be accomplished using artificial materials called breast implants, or by using tissues from other parts of the woman's body. The second step involves creating a balance between the newly constructed breast and the breast on the opposite side. The nipple and areolar complex (darker area around the nipple) are recreated. This is usually done several months after the mound is created, to allow swelling to subside. Other procedures may be necessary, such as lifting the opposite breast (mastopexy) or making it larger or smaller to match the reconstructed breast.
Immediate or delayed reconstruction
While immediate reconstruction (IR) is not recommended for women with breast cancer who need to undergo other, more important treatments, breast reconstruction can be done almost anytime. It can be delayed, or it can be completed during the same procedure as the mastectomy. There are psychological benefits to IR. The ability to return to normal activities and routines is often enhanced when reconstruction follows immediately after mastectomy. A better final appearance may result from IR. There is less skin removal, often resulting in a shorter scar. The surgeon is better able to preserve the normal boundaries of the breast, so it is easier to more closely match the opposite breast.
There are disadvantages of IR as well. The surgery itself is longer, resulting in more time under anesthesia. Postoperative pain and recovery time will be greater than for mastectomy alone.
Other authorities contend that delayed reconstruction (DR) offers different physical and psychological advantages. The initial mastectomy procedure alone takes less time, and has a shorter recovery period and less pain than mastectomy and IR. The woman has more time to adjust to her diagnosis and recover from additional therapy. She is better able to review and evaluate her options and to formulate realistic goals for reconstruction. Some reconstructive surgery requires blood transfusions. With DR, the patient can donate her own blood ahead of time (autologous blood donation), and/or arrange to have family and friends donate blood for her use (directed donation).
The psychological stress of living without a breast is a disadvantage of DR. The extra procedure needed to perform DR results in higher costs. Although initial recovery is faster, an additional recuperation period is required after the delayed operation.
Type of reconstruction
There are two basic choices for breast reconstruction. The breast tissue can be replaced with an implant, or the breast is created using some of the woman's own tissues (autologous reconstruction).
ARTIFICIAL IMPLANTS. In general, implant procedures take less time and are less expensive than autologous ones. Implants are breast-shaped pouches. They are made of silicone outer shells, which may be smooth or textured. The inside contains saline (salt water). Implants made prior to 1992 were filled with silicone gel. In 1992, the Food and Drug Association (FDA) discontinued the use of silicone as a filling material.
An implant may be a fixed-volume type, which cannot change its size. Implants that have the capacity to be filled after insertion are called tissue expanders. These may be temporary or permanent.
The initial procedure for any implant insertion uses the mastectomy incision to make a pocket of tissue, usually underneath the chest wall muscle. In DR, the mastectomy scar may be reopened and used for this purpose, or a more cosmetic incision may be made. The implant is inserted into the pocket, the skin is stretched as needed, and sutured closed.
If there is inadequate tissue to achieve the desired size, or a naturally sagging breast is desired, a tissue expander is used. It resembles a partially deflated balloon, with an attached valve or port through which saline can be injected. After the initial surgical incision is healed, the woman returns to the doctor's office on a weekly or bi-weekly basis to have small amounts of saline injected. Injections can continue for about six to eight weeks, until the preferred size is obtained. In some cases, it may initially be overfilled and later partially deflated to allow for a more pliable, natural result. A temporary tissue expander is removed after several months and replaced with a permanent implant.
IR surgery using an implant takes approximately two to three hours, and usually requires up to a three-day hospital stay. Implant insertion surgery that is accomplished as part of DR takes one to two hours and can sometimes be done as an outpatient procedure. Alternatively, it may entail overnight hospitalization.
AUTOLOGOUS RECONSTRUCTION. Attached flap and free flap are two types of surgery where a woman's own tissue is used in reconstruction. An attached flap uses skin, muscle, and fat, leaving blood vessels attached to their original source of blood. The flap is maneuvered to the reconstruction site, keeping its original blood supply for nourishment; this is also known as a pedicle flap. The second kind of surgery is called a free flap, which also uses skin, muscle, and fat, but the surgeon severs the blood vessels and reattaches them to other vessels where the new breast is to be created. The surgeon uses a microscope to accomplish the delicate task of sewing blood vessels together (anastomosis). Sometimes, the term microsurgery is used to refer to free flap procedures. Either type of surgery may also be called a myocutaneous flap. This refers to the skin and muscle used.
The skin and muscle used in autologous reconstruction can come from one of several possible places on the body, including the abdomen (tummy tuck flap), the back (latissimus dorsi flap), or the buttocks (gluteus maximus free flap).
Finishing the reconstruction
Other procedures may be necessary to achieve the goal of symmetrical breasts. It may be necessary to make the opposite breast larger (augmentation), smaller (reduction), or higher (mastopexy). These, or any other refinements, should be completed before the creation of a nipple and areola. Tissue to form the new nipple may come from the reconstructed breast itself, the opposite breast, or a more distant donor site such as the inner thigh or behind the ear. The nipple and areolar construction is usually accomplished as an outpatient procedure. A final step, often done in the doctor's office, is tattooing the new nipple and areola to match the color of the opposite nipple and areola as closely as possible.
The diagnosis for breast reconstruction is almost always made on a visual basis. The underlying medical reasons include replacing all or part of breast tissue that has been removed during the course of cancer treatment, replacing breast mass that has been lost due to injury, or equalizing otherwise normal breasts that are markedly different in size. Underlying cosmetic reasons include personal preference for larger breasts among genetic females or the creation of breasts in male-to-female transsexuals.
Routine preoperative preparations, such as having nothing to eat or drink the night before surgery, are needed for reconstructive procedures. Blood transfusions are often necessary for autologous reconstructive surgeries. The patient may donate her own blood and/or have family and friends donate blood for her use several weeks prior to the surgery.
Emotional preparation is also important. Breast reconstruction will not resolve a psychological problem the woman had before mastectomy, nor make an unstable relationship strong. An expectation of physical perfection is also unrealistic. A woman who cites any of these reasons for reconstruction shows that she has not been adequately informed or prepared. Complete understanding of the benefits and limitations of this surgery are necessary for a satisfactory result.
Not all women are good candidates for breast reconstruction. Overall poor physical health, or specific problems such as cigarette smoking, obesity, high blood pressure, or diabetes, will increase the chance of complications. Also, a difficult or prolonged recovery period or failure of the reconstruction may be a result. A woman's physical ability to cope with major surgery and recuperation should also be considered.
The length of the hospital stay, recovery period, and frequency of visits to the doctor after surgery vary considerably with the different types of reconstruction. In general, autologous procedures require longer hospitalization and recovery times than implant procedures. For all surgical procedures, bandages and drainage tubes remain in place for at least a day. Microsurgical or free flap procedures are most closely monitored in the first day or two after surgery. The circulation to the breast may be checked as often as every hour. Complete breast reconstruction requires at least one additional surgery to create a nipple and areola. Scars may remain red and raised for a month or longer. They will fade to their final appearance within one to two years. The true, final appearance of the breasts usually will not be visible for at least one year.