Breast reconstruction is a surgical procedure used to restore a woman's breast to a normal shape and size after mastectomy (entire breast removed) or after lumpectomy (part of the breast is removed). This can be achieved by either using the patient's own tissue or using implants (prosthetics). If the nipple and areola (darker area around the nipple) are also removed during the mastectomy, then both can be reconstructed following completion of breast “mound” reconstruction.

Although breast reconstruction is considered to be an integral part of the healing and recovery process, it is not appropriate for everyone. Reconstructive efforts should not interfere or complicate the treatment of breast cancer. The primary goal of the initial surgery is to treat breast cancer and at the same time plan for a reconstruction if the patient is a good candidate.

Who is a candidate for breast reconstruction?

First and foremost, everyone should be aware of the of the Women's Health and Cancer Rights Act of 1998 which mandates insurance carriers to cover the cost of restorative procedures following mastectomy. Restoration after cancer treatment does not necessarily include surgery. For some women it may be as simple as just wearing an external prosthesis or a form-fitted bra. Reconstructive surgery is another option for restoring one's femininity and womanhood, but it is clearly more involved.

The decision to have breast reconstruction is one that is highly personal and one that should be made by the patient without any outside influence from others. Sometimes reconstruction becomes secondary as one is learning how to cope with the diagnosis and treatment. Reconstruction is considered if the patient does not have any medical conditions that would significantly complicate the healing process (such as diabetes, obesity, smoking, high blood pressure, and history of chest wall radiation). Although breast reconstruction can improve a woman's self-image following a mastectomy or lumpectomy, it is likely that there will be some emotional adjustments in order to accept the results of breast reconstruction. Although breast reconstruction procedures can result in a natural looking breast, a candidate should be prepared to accept that a reconstructed breast may never look like or have the sensation of their natural breast.

When considering restorative options, a woman's first decision is whether or not she is interested in a reconstructive procedure. If so, then one has to consider the next question of whether reconstruction should be done at the time of the mastectomy or be delayed until the breast cancer treatment is completed. At times, even if a patient desires to have immediate (at time of mastectomy) reconstruction, their surgical team may recommend that a delayed procedure, which may carry less of a risk and less interference with the cancer treatment.

When is breast reconstruction performed?

If the patient is a good candidate for immediate reconstruction, optimally, it should be performed concurrently with a skin-sparing or even a nipple-sparing mastectomy. Nipple-sparing mastectomy should be considered if the patient is a good oncological and reconstructive candidate. The breast and plastic surgeon team will determine the safety of a nipple-sparing mastectomy. Immediate reconstruction allows the surgeon to replace the breast tissue with an implant while the skin is still pliable and makes it possible to recreate the original natural shape of the breast. Nipple-sparing mastectomy can only be offered if an immediate reconstruction is planned.

What are the different types of breast reconstruction procedures that are available?

The two types of breast reconstruction are implant of a prosthetic device and the use of one's own tissue to reconstruct the breast (autologous reconstruction). According to The American Society of Plastic Surgeons statistics, 75% of women in the U.S. have prosthetic reconstruction and 25% have autologous reconstruction.

Implant reconstruction: This procedure replaces the patient's tissue with a saline or silicone implant. Depending on the patient's chest wall characteristics, the implant can be placed immediately at the time of the mastectomy. However, in a majority of patients, a temporary implant known as an “expander” will be placed into the pocket of empty space of the mastectomy breast. The expander's role is to keep the future pocket for the implant open as the skin heals from the mastectomy. Expansions will be performed to create a breast mound that is generally smaller than the final implant. Patients often find this process helpful as they can progressively decide what size of implant they may want to have. Some surgeons also utilize Botox to paralyze the chest muscle, in order for the expanders to be more comfortable for the patient and overall have less pain. (Patients are responsible for the cost of the Botox as insurance carriers do not reimburse for the procedure since it is considered an off-label use of the product.) Once the patient's breast is fully expanded, then the choice between three types of implants can be made. One choice includes saline implants which have a silicone shell on the surface with saline inside. The second choice includes round silicone implants which have the same external shell except for they are filled with “cohesive silicone” on the inside. The third choice includes the next generation of silicone implants (5th generation), known as the “highly cohesive silicone” implants or as the “gummy bear” implants. The highly cohesive nature of the gel makes the implant more stable giving it a more anatomical look.

Autologous reconstruction: This group of procedures includes procedures where one's own tissue is used. The options of tissue that can be used include tissue from the following areas: abdomen, back, upper or lower buttock, and inside of the thighs. Another type of reconstruction that has been recently utilized is a series of procedures that utilize the patient's own processed fat to create a breast. This procedure is termed “fat injection” and is sometimes used in a combination with implant-based or autologous reconstruction.

Is breast reconstruction surgery possible after radiation?

Radiation therapy can change the breast reconstruction options that are available for a woman. Some may decide not to have the surgery if there is concern about monitoring the chest wall for recurrence. If the plan for chest radiation is known prior to the mastectomy, the surgical team may recommend a delayed reconstruction. On the other hand, some surgeons now also place a temporary implant, the expander, into the pocket prior to the radiation therapy. All of these efforts are to minimize complications after the final reconstructive procedure since the risk of complications is now higher after the breast is radiated. Radiation therapy changes the skin often causing the skin to “shrink wrap” and be very difficult to stretch.

What is the recovery like after breast reconstruction surgery?

Like any surgery, recovery varies after breast reconstruction surgery. Healing will continue for several weeks and one should follow the surgeon's instructions during this period. It is important not to lift, strain, or exert excessive force around the surgical area during the recovery period. The plastic surgeon will give the instructions that will include how to care for the surgical site, possible warning signs to watch for, and which medications to take to increase healing and reduce the risk of infection. It is generally recommended to take sufficient time off work to allow for the healing to take place. In addition, good nutrition is important as the body is working overtime to heal the surgical areas. Physical therapy is a crucial component of healing phase and it is recommended for all the types of procedures that are performed. Knowing the limitations of physical activity is important and continuous support of the new chest with a supportive bra for 2 to 3 months following the reconstruction is essential. The body heals over a period of time. Unusual breast sensations, twitching, and some discomfort are part of the entire healing process that can take a couple of years.

Breast reconstruction with a breast implant carries the possibility of complications, including:

• Breasts that don't match each other in size or appearance (asymmetry)
• Breast pain
• Implant rupture or deflation
• Poor healing of incisions
• Increased risk of future breast surgery to replace or remove the breast implant
• Changes in breast sensation
• Infection
• Bleeding
• Scar tissue that forms and compresses the implant and breast tissue into a hard, unnatural shape (capsular contracture)
• Risks associated with anesthesia
• Very low, but increased risk of a rare immune system cancer called anaplastic large cell lymphoma (ALCL) that's associated with textured breast implants, though more research is needed to understand the relationship between ALCL and breast implants

Correcting any of these complications may require additional surgery.

If you need adjuvant radiation therapy to the skin and chest wall after a mastectomy (post-mastectomy radiation), you might not be an ideal candidate for breast implant reconstruction. Having a breast implant may make it more difficult to deliver the radiation therapy effectively, and the implant may need to be deflated. There may also be a higher risk of complications. The skin and underlying tissue may become firmer, discolored and swollen due to radiation therapy.