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After Mastectomy: Breast Reconstruction or Breast Prosthesis

Breast reconstruction after a mastectomy is of great importance for many women, whose self-esteem and body image may be badly damaged by the loss of a breast. Breast reconstruction seeks to restore the lost breast's shape and contours. Almost all women who undergo a mastectomy are suitable candidates for breast surgery, although not all women choose this option, as many prefer the immediacy and convenience of a breast prosthesis to additional surgery, even reconstructive surgery.

Before Breast Reconstruction: Consider Your Options

Ideally, women should discuss breast reconstruction options with their oncologist and plastic surgeon prior to mastectomy. Often breast reconstruction can be performed, or at least begun, during the same surgical procedure as the mastectomy, thereby avoiding an extra operation. In other situations, immediate breast reconstruction surgery is simply not possible. If a mastectomy will be followed by radiation therapy, immediate breast reconstruction is not recommended, as radiation therapy requires the precise measurement and weight of the breast, which often changes in the weeks following breast reconstruction.

Whether a woman elects for immediate or delayed breast reconstruction depends not only on medical conditions, but also on personal choice: Some women prefer to wait until after the mastectomy to consider breast reconstruction.

Whether immediate or delayed breast reconstruction is chosen, selecting a plastic surgeon trained in breast reconstruction surgery is essential. Ask your doctor to recommend a plastic surgeon. In the U.S., the surgeon should be certified by the American Board of Plastic Surgeons. Don't be afraid to ask for second opinions on breast reconstruction options.

Limitations of Breast Reconstruction

Breast reconstruction helps restore the shape and curve of the lost breast, but the procedures have certain limitations. Ideally, breast reconstruction restores breast shape so the breasts appear normal when wearing most clothing. Breast reconstruction is a permanent solution and allows a woman to avoid the inconveniences of breast prosthesis.

This said, breast construction has some very real limitations. The difference between the natural and reconstructed breast will be apparent when nude. Often breast reconstruction cannot match the shape and contour of the natural breast precisely, or comes close only after several surgeries. Also, breast reconstruction is unable to reproduce the feelings and sensations associated with the original breast.

Finally, certain factors may prevent a woman from undergoing breast reconstruction. Factors that may rule out breast reconstruction include:

bleeding disorders
breast size
circulatory disorders
diabetes
excessive alcohol use
immune system disorders
obesity
overall health
excessive thinness
previous surgery
smoking
some medications
stage and type of breast cancer
vascular disorders.

If breast reconstruction is not possible, breast prosthesis is the only other option at this time.

Types of Breast Reconstruction

The two basic breast reconstruction procedures are breast implants and the use of tissue flaps from other areas of the woman's body. Each basic procedure includes different surgical techniques and options. At times, implants and tissue flaps are combined for breast reconstruction.

Regardless of the type of breast reconstruction chosen, the procedure will leave scars on the breast, and in the case of tissue flap procedures, on the area from which tissue is taken (most often the stomach, back, hips, or buttocks). Over time, scarring fades, but will never completely disappear.

Tissue Flap Procedures

Several different types of tissue flap breast reconstruction are available. Here are the more common procedures:

Transverse Rectus Abdominis Muscle Flap: Also known as a TRAM flap, this form of breast reconstruction uses tissue gathered from the lower abdomen, including skin, fat, blood vessels and muscle tissue. TRAM flap procedures are the most common type of breast reconstruction surgery.

There are two variations of the TRAM flap breast reconstruction:

Pedicle Flap: In the pedicle flap procedure, the blood vessels of the tissue flap remain attached to their original location and the flap is moved, or "tunneled," under the skin to the breast.
Free Flap: The free flap procedure is a more advanced reconstruction technique. The tissue flap is completely removed and the flap's blood vessels are then grafted onto chest muscle blood vessels. This requires microsurgery, necessitating a very experienced plastic surgeon. It is also a longer surgical procedure. However, the results of this form of breast reconstruction are often better than for pedicle flap.

Latissimus Dorsi Flap: A latissimus dorsi flap breast reconstruction takes tissue from the back. The tissue, which includes skin, blood vessels, muscle, and fat, is moved under the skin to the chest. The surgeon then uses the tissue to create a container for a breast implant.

Breast Implant Procedures

Most breast implants today are saline filled implants: a silicone container filled with saline solution. Silicone gel filled implants were once popular, but evidence suggests that if silicone leaks from the implant serious side effects can develop, so silicone gel implants are not often used today.

A breast implant can often be implanted during the mastectomy operation, reducing the number of operations needed for breast reconstruction. If the woman has tight chest muscles a two-stage process is needed to for breast implants. First the surgeon inserts a tissue expander directly beneath the chest muscle. Over time, the tissue expander is slowly inflated, like a balloon, using a small valve located below the skin.

The tissue expander gradually stretches surrounding tissue and skin. Once the area is sufficiently expanded, additional surgery removes the tissue expander and replaces it with a breast implant.

New Breast Reconstruction Techniques

Two relatively new breast reconstruction techniques are now available. A deep inferior epigastric artery perforator flap uses tissue from the lower abdomen, like a TRAM flap, but does not require the use of muscle tissue. A DIEP flap is a free flap procedure, requiring microsurgery to graft blood vessels from the tissue flap to the chest blood vessels. A gluteal free flap operation is also similar to a TRAM free flap, but in this case the tissue is taken from the buttock and includes a portion of the gluteal muscle.

New types of breast implant are also under investigation, using molds and fillers different from established implants. At present, these experimental implants are not available to the general public and only accessible through clinical trials.

Risks of Breast Reconstruction

All surgical procedures carry the risk of bleeding or infection and breast reconstruction is no exception. An infection after breast reconstruction with implants may require the removal of the breast implant until the infection clears.

Capsular contracture is a common complication of reconstructive surgery using breast implants—scar tissue contracts and squeezes the implant, making the breast feel hard. Capsular contracture often requires additional surgery to remove scar tissue and replace the implant. Women considering breast reconstruction with breast implants should also be aware that implants wear down over time and may need to be replaced periodically.

Tissue flap breast construction runs the risk of cell necrosis, or cell death of the tissue flap. Also, a newly reconstructed breast will "settle" into its permanent shape in the months after surgery. This may result in asymmetrical or mismatched breasts, requiring further surgery to correct.

Nipple Reconstruction and Nipple Prosthesis

Breast reconstruction does not reconstruct the nipple and areola (the darker area of skin that surrounds the nipple). Separate nipple reconstruction is required after breast reconstruction is complete. Although the nipple may sometimes be saved during a mastectomy, reattachment of the nipple is not recommended, due to the risk that cancer cells may be present in the tissue. Some women opt to use a nipple prosthesis, which attaches to the reconstructed breast.

Breast Prosthesis Options

Not all women elect to undergo breast reconstruction after a mastectomy. Some cannot due to health conditions and others do not feel that breast reconstruction and surgery are necessary. For these women, breast prosthesis can be used to give balance and hide the loss of the breast.

There are many different types of breast prosthesis brands, in many different shapes and sizes. Some clothing and swimwear offer special pockets or support for a breast prosthesis. Look for a prosthesis that moves and weighs the same as the remaining breast. It is possible to order a custom-made breast prosthesis that is individually made to match the surviving breast.

Resources

American Cancer Society (updated 2004).Breast reconstruction after mastectomy.

Breastcancer.org. (updated 2004). Prostheses (breast forms).

CancerBACUP (updated 2003). Breast reconstruction.

CancerBACUP. (updated 2004). Reconstructing the nipple.