Overview of Breast Reconstruction Surgery

Breast Reconstruction Surgery After Mastectomy

Breast implants

Breast reconstruction surgery, a procedure to restore the natural appearance of the breast, is frequently performed after partial and total mastectomy procedures for breast cancer. Patients who have a lumpectomy procedure frequently do not require reconstruction, as the amount of tissue removed is far smaller. Some patients have no desire to have surgery to reconstruct the breast after it is removed, but the majority opt to have the breast cosmetically reconstructed.

In most states, reconstruction after a mastectomy for breast cancer is covered by insurance, as reconstruction is considered part of the mastectomy process. Patients considering a prophylactic, or preventative, mastectomy may want to confirm that insurance covers both the initial mastectomy and the reconstruction.

For women who choose not to have reconstruction, there are bras available with prosthetic inserts that provide balance with the remaining breast.

Once the decision is made to have a mastectomy, a choice regarding reconstruction should be made prior to surgery. The decision should be made after consulting with a board certified plastic surgeon with experience in breast reconstruction procedures. This is because the reconstruction can be “immediate” and completed during the same surgery as the mastectomy or “delayed” and performed at a later date.

Breast reconstruction is an inpatient procedure and is performed using general anesthesia. Patients remain in the hospital for at least one day after surgery.

For women with large breasts or breasts that will look notably different in size or shape than a reconstructed breast, a breast reduction may be necessary to provide symmetry. Another option is an implant procedure or breast lift on the remaining breast.

Immediate Breast Reconstruction With Breast Implants

Immediate reconstruction of the breasts occurs during the same procedure as a mastectomy and is typically performed by a plastic surgeon. Experts recommend immediate reconstruction for patients who expect to have radiation after the mastectomy procedure. The elasticity of the skin, the ability of the skin to heal and the appearance of scar tissue can be altered by radiation therapies. By completing the reconstruction prior to radiation, the skin has a greater potential for healing leading to a more cosmetic result.

During immediate reconstruction, at the conclusion of the mastectomy portion of the procedure, a breast implant is inserted in the place of the removed breast tissue. The type of implant, silicone or saline are most common, is a choice made by the patient after discussion with the plastic surgeon.

One of the benefits of immediate reconstruction is that there is no need for an additional surgery after immediate reconstruction. The procedure is performed once the mastectomy portion of the surgery is done, eliminating the risk associated with a second surgery. Some women find this option to be more attractive than other types of reconstruction for emotional reasons. The patient doesn’t see the breast between the removal of tissue and the placement of an implant.

Breast Reconstruction Surgery With Breast Implants

Two step immediate reconstruction of the breast is a reconstruction process that begins during the same surgery as the mastectomy procedure, but is finished at a later date. This procedure is appropriate when the remaining breast skin is tight and is not able to accommodate an implant at the time of the surgery.

Typically, an inflatable balloon implant is placed under the skin and inflated with saline over weeks or months to stretch the skin and underlying tissue. When the skin has stretched enough to accommodate an implant, a second surgery is performed to replace the balloon with a permanent implant. In some cases the expander can be left in place instead of a standard saline or silicone breast implant.

This procedure may also use a flap, or a graft of tissue from elsewhere in the body, to supplement the remaining breast tissue or instead of an implant. The decision to use a flap should be made in consultation with a plastic surgeon as it is not appropriate for all patients.

Two Stage Breast Reconstruction Surgery With Breast Implants

Delayed two stage reconstruction, much like immediate two stage reconstruction, is a two surgery process used to reconstruct breast tissue after a mastectomy. Unlike the immediate two stage procedure, the surgical procedure to insert a tissue expander balloon is performed separately from the mastectomy surgery and requires a third and final surgery to complete the process.

Once the expander is in place it is inflated slowly by injecting a saline solution over the course of weeks or months to stretch the skin of the breast. When the expander is inflated enough to accommodate an implant of appropriate size, surgery can be performed to insert the implant that will remain permanently. In some cases, the expander can be left in place instead of a silicone or saline implant.

This procedure may also use a flap, a tissue graft from another area of the body, to supplement the remaining breast tissue or instead of an implant. The decision to use a flap should be made in consultation with a plastic surgeon as it is not appropriate for all patients.

Breast Reconstruction Without an Implant

Reconstruction of the breast after a mastectomy can be done with a surgical flap instead of an implant. This is a procedure where tissue is removed from another area of the body such as the abdomen or back and moved to the breast to replace the tissue that was removed. This type of reconstruction uses the patient’s own muscle, skin and fatty tissue to reconstruct the breast instead of an implant.

There are several types of flap procedures. The TRAM flap (transverse rectus abdominus muscle) utilizes abdominal skin and muscle tissue to create new breast tissue. In some cases the tissue is completely removed from the abdomen and placed in the breast area. This type of flap, where the tissue is removed and placed in another area, is called a free flap.

Another type of procedure that utilizes abdominal tissue is the abdominal pedicle flap surgery. The tissue of the abdomen is not severed from the blood vessels that feed it, but the vessels are guided under the skin to the breast area where the tissue is then sewn into place. This type of flap, with the blood supply remaining attached to its original source, is referred to as a pedicle.

A DIEP flap (deep interior epigastic arter perforator) also uses abdominal tissue, removed and replaced in the breast area as a free flap. This procedure is unique because the removal of tissue approximates a stomach lift (tummy tuck) and does not use muscle tissue, only fat and skin.

The latissimus dorsi flap procedure uses tissue from the major muscle in the back that moves the shoulder. A pedicle flap procedure, the latissimus dorsi flap is left attached to the its blood supply and is guided into place under the skin of the chest and sewn into place.

Flap procedures are not appropriate for patients who are currently smoking, are diabetic or have any other condition that slows healing of the skin.

Nipple Reconstruction Surgery

Without nipple reconstruction surgery a reconstructed breast has the skin of a normal breast, but the nipple and areola are not present. Patients who opt to have nipple reconstruction surgery typically do so at a later date than the reconstruction surgery.

A nipple reconstruction is performed by taking tissue from another part of the body and grafting it to the breast, suturing it into place in such a way that a nipple is formed. At this point, the nipple graft is skin colored unless the graft was taken from the other nipple, and there is no areola surrounding the nipple. If an areola or a skin color matching the original nipple color is desired the color is applied permanently by tattooing the color onto the skin.

Unlike the main reconstruction surgery, nipple reconstruction can typically be done on an outpatient basis with local anesthesia. Some women opt not to have the nipple and areola reconstructed, it is a personal decision, and the procedure is purely cosmetic, providing balance with the other breast.

The reconstructed nipple does not have the same sensitivity as the original nipple, but does provide for a more natural appearance. After reconstruction the nipple may appear erect, projecting from the breast, making some women feel self conscious with the appearance of the nipple in day to day life. If this is a concern, it should be discussed with the plastic surgeon when planning the procedure.

Recovery After Breast Reconstruction Surgery

It is normal to feel fatigued for several weeks after reconstructive breast surgery. Patients are very sore after the procedure and may have increased pain with lifting or movement of the arms. Patients are able to return to most activities within six weeks, but vigorous activity, especially those that produce a bouncing movement, such as running, may take slightly longer. Patients are typically able to return to an active sex life at that time as well.

It is important to note that treatments for cancer can delay healing and increase fatigue. If a patient is receiving therapies for cancer, the recovery from reconstruction surgery may be prolonged as the side effects of both chemotherapy and radiation can include fatigue, diarrhea, nausea and vomiting. Some women choose immediate reconstruction simply because they don’t expect to feel well enough for reconstructive surgery in the months immediately following the mastectomy.

Many support groups are available, both online and in cities across the country, to help patients cope with the changes caused by breast cancer. These support groups give patients the opportunity to interact with others who have shared their experience and can provide friendship in addition to support and guidance.

Sex After Breast Reconstruction Surgery

Returning to an active sex life after a mastectomy and breast reconstruction surgery is both a physical and emotional issue. Pain from the reconstruction may prevent the patient from engaging in sexual activity, as the chest will be both sore and tender with many movements. As the soreness fades the decision to return to sexual activity may cause anxiety and stress.

Sex may be physically possible but the issue can be emotionally charged. Concern about the appearance of the newly reconstructed breast or breasts is natural and to be expected. Patients are often concerned about the surgical scars and the sensation in the breast, which is often different than it was prior.

An open discussion between the patient and her partner may help to clear the air and alleviate concerns either partner may have. The patient may be concerned about appearance and sensation while the partner may have concerns about hurting the breast or inflicting pain on a tender area.

Including a conversation about the way the breasts feel, how sensation differs from sensation prior to the surgery and what sensations are pleasurable may prove helpful when resuming sexual activity.

It is also important to remember that sex may not feel like a priority when dealing with a life-threatening illness, and a lack of sex drive may be part of the illness as a whole, rather than concern over the breast. A lack of desire may have more to do with cancer treatments and the side effects and less to do with the appearance of the breast.

Depression is common in patients with breast cancer, almost half of all people diagnosed experience depression in the year following diagnosis. Depression can severely diminish sex drive as the symptoms, including the fatigue and irritability, can make sex unappealing.

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