Breast Reconstruction Surgery

Breast reconstruction surgery is a very personal decision. Often, women view breast reconstruction surgery as a way to mark their triumph over breast cancer and reclaim their bodies. For some, it's important to wake up from their mastectomy with a new breast in progress. Other women choose to wait, focusing on the cancer treatment first. Reconstruction can be performed later for these patients. 

In most cases, more than one surgery is required to complete the process. Nipple reconstruction is usually performed as a separate procedure. For some women breast reduction or a breast lift on the other breast is necessary to ensure the two sides are as closely matched as possible.

Breast reconstruction after mastectomy 

The most common motivation for breast reconstruction is having a more natural breast shape following a mastectomy eliminating the need to wear an external prosthesis in a bra. The reconstructed breast may not look exactly like your natural breasts and will usually not have fully normal sensation.  Many women experience an improved body image and self-esteem after breast reconstruction, but not all. 

Breast reconstruction can be either immediate (started at the time of the mastectomy) or delayed (started at a later date). Both immediate and delayed reconstruction can give good outcomes after careful individual consideration.  Your breast surgeon and plastic surgeon can do an evaluation and make recommendations that are individualized about the type and timing of breast reconstruction. These will take into consideration your type and stage of cancer, your overall health, the size and shape of your natural breasts, the likelihood of needing radiation therapy after total mastectomy, your smoking history, whether or not you have diabetes or history of healing problems, your weight and body size, and the type of reconstruction best suited to you.

Immediate reconstruction begins the reconstructive process at the time of the mastectomy and may decrease the number of operations needed.  Some women feel better waking to a breast mound after their mastectomy and knowing that they have started the reconstructive process. Good outcomes from immediate reconstruction require a breast surgeon and plastic surgeon who are experienced in working as a team, favorable tissue quality and blood supply, and absence of significant risk factors, such as smoking, obesity, malnutrition, or diabetes.

Delayed Reconstruction may be a better option for women who will choose chest wall radiation therapy after mastectomy and is usually the preferred timing for women who are having a tissue flap-based reconstruction, are smokers, who have diabetes, who have questionable blood supply to mastectomy skin, or who are uncertain about how they wish to proceed.  

The two primary types of reconstruction are implant-based and tissue- or flap-based. Both methods, through different means, achieve the goals of creating a “skin envelope” of the desired breast size and shape, creating a substitute for the missing breast tissue. In some situations a hybrid reconstruction is performed: a combination of tissue from elsewhere on the body with an expander and/or implant.

With implant based reconstruction, the first step is placement of a device called a tissue expander behind the chest wall muscles. Over time the expander is injected with salt water to develop the new breast to good form and size. The tissue expander can then be replaced with an implant filled with either salt water (saline) or silicone gel. The nipple areolar complex can be reconstructed as an additional procedure.

Tissue based procedures (TRAM, DIEP, Latissimus, and others) refer to breast reconstruction that is performed using skin, fat, and possibly muscle from elsewhere on the body (abdomen, back, buttock, thigh) to substitute for the breast tissue. The re-located tissue may require connection of the flap blood vessels to a chest area blood supply.

There are pros and cons to both implant-based and tissue-based reconstruction as well as immediate or delayed reconstruction will be discussed fully when you meet with your surgeon.