If
You're Considering Breast Reconstruction...
Reconstruction of a breast that has been removed due to
cancer or other disease is one of the most rewarding surgical
procedures available today. New medical techniques and devices
have made it possible for surgeons to create a breast that
can come close in form and appearance to matching a natural
breast. Frequently, reconstruction is possible immediately
following breast removal (mastectomy), so the patient wakes
up with a breast mound already in place, having been spared
the experience of seeing herself with no breast at all.
But bear in mind, post-mastectomy breast reconstruction
is not a simple procedure. There are often many options
to consider as you and your doctor explore what's best for
you.
This information will give you a basic understanding of
the procedure -- when it's appropriate, how it's done, and
what results you can expect. It can't answer all of your
questions, since a lot depends on your individual circumstances.
Please be sure to ask your surgeon if there is anything
you don't understand about the procedure.
The Best Candidates for Breast Reconstruction
Most mastectomy patients are medically appropriate for reconstruction,
many at the same time that the breast is removed. The best
candidates, however, are women whose cancer, as far as can
be determined, seems to have been eliminated by mastectomy.
Still, there are legitimate reasons to wait. Many women
aren't comfortable weighing all the options while they're
struggling to cope with a diagnosis of cancer. Others simply
don't want to have any more surgery than is absolutely necessary.
Some patients may be advised by their surgeons to wait,
particularly if the breast is being rebuilt in a more complicated
procedure using flaps of skin and underlying tissue. Women
with other health conditions, such as obesity, high blood
pressure, or smoking, may also be advised to wait.
In any case, being informed of your reconstruction options
before surgery can help you prepare for a mastectomy with
a more positive outlook for the future.
All Surgery Carries Some Uncertainty and Risk
Virtually any woman who must lose her breast to cancer can
have it rebuilt through reconstructive surgery. But there
are risks associated with any surgery and specific complications
associated with this procedure.
In general, the usual problems of surgery, such as bleeding,
fluid collection, excessive scar tissue, or difficulties
with anesthesia, can occur although they're relatively uncommon.
And, as with any surgery, smokers should be advised that
nicotine can delay healing, resulting in conspicuous scars
and prolonged recovery. Occasionally, these complications
are severe enough to require a second operation.
If an implant is used, there is a remote possibility that
an infection will develop, usually within the first two
weeks following surgery. In some of these cases, the implant
may need to be removed for several months until the infection
clears. A new implant can later be inserted.
The most common problem, capsular contracture, occurs if
the scar or capsule around the implant begins to tighten.
This squeezing of the soft implant can cause the breast
to feel hard. Capsular contracture can be treated in several
ways, and sometimes requires either removal or scoring of
the scar tissue, or perhaps removal or replacement of the
implant.
Reconstruction has no known effect on the recurrence of
disease in the breast, nor does it generally interfere with
chemotherapy or radiation treatment, should cancer recur.
Your surgeon may recommend continuation of periodic mammograms
on both the reconstructed and the remaining normal breast.
If your reconstruction involves an implant, be sure to go
to a radiology center where technicians are experienced
in the special techniques required to get a reliable x-ray
of a breast reconstructed with an implant.
Women who postpone reconstruction may go through a period
of emotional readjustment. Just as it took time to get used
to the loss of a breast, a woman may feel anxious and confused
as she begins to think of the reconstructed breast as her
own.
Planning Your Surgery
You can begin talking about reconstruction as soon as you're
diagnosed with cancer. Ideally, you'll want your breast
surgeon and your plastic surgeon to work together to develop
a strategy that will put you in the best possible condition
for reconstruction.
After evaluating your health, your surgeon will explain
which reconstructive options are most appropriate for your
age, health, anatomy, tissues, and goals. Be sure to discuss
your expectations frankly with your surgeon. He or she should
be equally frank with you, describing your options and the
risks and limitations of each. Post-mastectomy reconstruction
can improve your appearance and renew your self-confidence
-- but keep in mind that the desired result is improvement,
not perfection.
Your surgeon should also explain the anesthesia he or she
will use, the facility where the surgery will be performed,
and the costs. In most cases, health insurance policies
will cover most or all of the cost of post-mastectomy reconstruction.
Check your policy to make sure you're covered and to see
if there are any limitations on what types of reconstruction
are covered.
Preparing For Your Surgery
Your oncologist and your plastic surgeon will give you specific
instructions on how to prepare for surgery, including guidelines
on eating and drinking, smoking, and taking or avoiding
certain vitamins and medications.
While making preparations, be sure to arrange for someone
to drive you home after your surgery and to help you out
for a few days, if needed.
Where Your Surgery Will Be Performed
Breast reconstruction usually involves more than one operation.
The first stage, whether done at the same time as the mastectomy
or later on, is usually performed in a hospital.
Follow-up procedures may also be done in the hospital. Or,
depending on the extent of surgery required, your surgeon
may prefer an outpatient facility.
Types of Anesthesia
The first stage of reconstruction, creation of the breast
mound, is almost always performed using general anesthesia,
so you'll sleep through the entire operation.
Follow-up procedures may require only a local anesthesia,
combined with a sedative to make you drowsy. You'll be awake
but relaxed, and may feel some discomfort.
Types of Implants
If your surgeon recommends the use of an implant, you'll
want to discuss what type of implant should be used. A breast
implant is a silicone shell filled with either silicone
gel or a salt-water solution known as saline.
Breast implants are medical devices with a solid silicone,
rubber shell. The implant shell may be filled with either
saline solution (sterile salt water) or elastic silicone
gel. Both saline and silicone gel breast implants are approved
by the U.S. Food and Drug Administration (FDA). Approval
means that an implant has been rigorously researched and
tested, and reviewed by an independent panel of physicians
for safety.
The Surgery
While there are many options available in post-mastectomy
reconstruction, you and your surgeon should discuss the
one that's best for you.
Skin expansion. The most common technique combines skin
expansion and subsequent insertion of an implant.
Following mastectomy, your surgeon will insert a balloon
expander beneath your skin and chest muscle. Through a
tiny valve mechanism buried beneath the skin, he or she
will periodically inject a salt-water solution to gradually
fill the expander over several weeks or months. After
the skin over the breast area has stretched enough, the
expander may be removed in a second operation and a more
permanent implant will be inserted. Some expanders are
designed to be left in place as the final implant. The
nipple and the dark skin surrounding it, called the areola,
are reconstructed in a subsequent procedure.
Some patients do not require preliminary tissue expansion
before receiving an implant. For these women, the surgeon
will proceed with inserting an implant as the first step.
Flap reconstruction. An alternative approach to implant
reconstruction involves creation of a skin flap using
tissue taken from other parts of the body, such as the
back, abdomen, or buttocks.
In one type of flap surgery, the tissue remains attached
to its original site, retaining its blood supply. The
flap, consisting of the skin, fat, and muscle with its
blood supply, are tunneled beneath the skin to the chest,
creating a pocket for an implant or, in some cases, creating
the breast mound itself, without need for an implant.
Another flap technique uses tissue that is surgically
removed from the abdomen, thighs, or buttocks and then
transplanted to the chest by reconnecting the blood vessels
to new ones in that region. This procedure requires the
skills of a plastic surgeon who is experienced in microvascular
surgery as well.
Regardless of whether the tissue is tunneled beneath the
skin on a pedicle or transplanted to the chest as a microvascular
flap, this type of surgery is more complex than skin expansion.
Scars will be left at both the tissue donor site and at
the reconstructed breast, and recovery will take longer
than with an implant. On the other hand, when the breast
is reconstructed entirely with your own tissue, the results
are generally more natural and there are no concerns about
a silicone implant. In some cases, you may have the added
benefit of a improved abdominal contour.
Follow-up procedures. Most breast reconstruction involves
a series of procedures that occur over time. Usually,
the initial reconstructive operation is the most complex.
Follow-up surgery may be required to replace a tissue
expander with an implant or to reconstruct the nipple
and the areola. Many surgeons recommend an additional
operation to enlarge, reduce, or lift the natural breast
to match the reconstructed breast. But keep in mind, this
procedure may leave scars on an otherwise normal breast
and may not be covered by insurance.
After Your Surgery
You are likely to feel tired and sore for a week or two
after reconstruction. Most of your discomfort can be controlled
by medication prescribed by your doctor.
Depending on the extent of your surgery, you'll probably
be released from the hospital in two to five days. Many
reconstruction options require a surgical drain to remove
excess fluids from surgical sites immediately following
the operation, but these are removed within the first
week or two after surgery. Most stitches are removed in
a week to 10 days.
Getting Back to Normal
It may take you up to six weeks to recover from a combined
mastectomy and reconstruction or from a flap reconstruction
alone. If implants are used without flaps and reconstruction
is done apart from the mastectomy, your recovery time
may be less.
Reconstruction cannot restore normal sensation to your
breast, but in time, some feeling may return. Most scars
will fade substantially over time, though it may take
as long as one to two years, but they'll never disappear
entirely. The better the quality of your overall reconstruction,
the less distracting you'll find those scars.
Follow your surgeon's advice on when to begin stretching
exercises and normal activities. As a general rule, you'll
want to refrain from any overhead lifting, strenuous sports,
and sexual activity for three to six weeks following reconstruction.
Your New Look
Chances are your reconstructed breast may feel firmer
and look rounder or flatter than your natural breast.
It may not have the same contour as your breast before
mastectomy, nor will it exactly match your opposite breast.
But these differences will be apparent only to you. For
most mastectomy patients, breast reconstruction dramatically
improves their appearance and quality of life following
surgery.
