Reconstruction of the breast is an option for most women who have had a mastectomy. You may choose immediate reconstruction, which starts at the same time as your mastectomy. Or you may delay reconstruction and start the procedure after your initial surgery and other treatments are complete. For some, starting reconstruction right away helps reduce the trauma of losing a breast; immediate reconstruction also eliminates the need for an additional hospitalization and anesthesia. For others, particularly those who need radiation, reconstruction is delayed. Radiation therapy can sometimes cause damage to the skin that makes breast reconstruction challenging. Our affiliated plastic surgeons have extensive experience with reconstruction for patients who have already had radiation therapy.
There are two methods for reconstruction: using an implant to replace the lost tissue or using tissues from elsewhere in the body to replace the lost tissue (autologous). A new nipple/areola complex is built and the nipple area can be tattooed to have a similar color to the other. An implant or your own tissue can also be combined.
The Margie Petersen Breast Center Nurse Navigator and breast surgeon will discuss the types of reconstruction with you prior to beginning your treatment.
One type of possible reconstruction is oncoplastic surgery.
Oncoplastic surgery combines the latest plastic surgery techniques with breast surgical oncology. When a large lumpectomy is required that will leave the breast distorted, the remaining tissue is sculpted to realign the nipple and areola and restore a natural appearance to the breast shape. The opposing breast may also be modified to create symmetry.
This is a good option for patients who are candidates for breast conservation therapy or lumpectomy, and are also candidates for breast reduction or mastopexy (breast lift).
At the time of your lumpectomy, the plastic surgeon may perform a bilateral breast reduction or lift, removing breast tissue from the cancerous breast as well as modifying the normal breast. These procedures generally involve an incision around the nipple and areola, a vertical incision from the nipple to the lower fold of the breast, and a horizontal incision in the fold of the breast.
Sometimes surgeons have difficulty preserving blood supply to the nipple during surgery. In these cases, a free nipple graft is the only way the nipple may be preserved. This involves removing the nipple and replacing it after the breast reduction or lift is complete.
There are many upsides to having bilateral breast reduction or lift at the same time you’re undergoing a lumpectomy:
- Only involves one surgery.
- Surgery is completed prior to radiation, so you avoid the risks of wound-healing problems that can occur with post-radiation surgery.
- Symmetric breasts after lumpectomy.
- Relief of symptoms of large breasts, if this was a problem before surgery.
Implants may be best for women with small- to medium-size breasts and those who have not had any radiation therapy to the breast area. In most cases, a tissue expander is placed at the time of the mastectomy with the tissue expander later switched for an implant at a later date (staged procedure). In some cases, an implant can be placed at the time of mastectomy (one stage) In the staged procedure, a pocket is formed from the pectoralis major, or chest, muscle and a tissue expander is placed in that space. Over the next several months, saline is injected through a valve into the expander sac to slowly stretch the skin and muscle in preparation for the permanent implant. During a second, shorter operation, the expander is removed and the implant is inserted in its place.
Implants come in different shapes and sizes and are made of saline or silicone. A plastic surgeon will help determine which type of implant is best for you.
Tissue transfer (autologous reconstruction)
Another method for reconstructing the breast is to use tissue transferred from somewhere else in the body. The new breast mound is built using fat and muscle from one of three locations:
- TRAM (transverse rectus abdominus myocutaneous) Flap. An oval-shaped section of fat and skin removed from the abdomen and shaped into a breast on the chest wall.
- Gluteal Free Flap. Tissue is taken from the upper or lower buttocks and shaped into a breast on the chest wall.
- Latissimus Dorsi Flap. Skin and muscle are moved from the upper back to the chest area and shaped into a breast.
In reconstructing a breast, surgeons often prefer to use fat. Fat is harvest with a newer technique known as Deep Inferior Epigastric Artery Perforator (DIEP) flap. Skin and tissue is commonly taken from the abdomen in order to recreate the breast.
The type of reconstruction that is most appropriate for each patient depends on the amount of skin remaining on the chest wall, the size and shape of the other breast, the amount of body fat and tissue available elsewhere, the patient's general health, her smoking history, and her personal preferences.
Once the breast mound is completed, the other breast may be altered (with an implant, a reduction, or a lift) to achieve symmetry. In the final step, a new nipple-areola complex is built if the nipple has been removed, and the area can then be tattooed to have a similar color to the other side.
Women who decline or cannot undergo breast reconstruction can use a silicone breast prosthesis for symmetry. Breast prostheses come in firm, medium, and soft silicone textures, as well as a variety of sizes, shapes, and skin tones to match the other breast. Prostheses can be placed in a special pocket in a bra or bathing suit. A properly fitted and weighted prosthesis provides the balance needed for correct posture.
Custom-made prostheses are also available.