38 D Size Bras

Breast Reconstruction

Every year, many women face the loss of one or both breasts because of cancer or because of having a very high risk of developing breast cancer. For these women, there are options for breast reconstruction. The right choice for each women depends on her desires and expectations, as well as her general medical condition and her unique features such as breast and body shape. For women who are facing these choices, there are answers to the frequently asked questions.

Breast Reconstruction Overview

General Considerations

The purpose of breast reconstruction is to restore body image and enable you to wear all types of clothes without restriction. Most women can wear the revealing styles of clothing with confidence after their breast reconstruction and it is usually difficult, if not impossible, to tell which side is the reconstructed side while dressed. The need for an awkward and sometimes embarrassing external prosthesis is eliminated by surgical reconstruction of the breast.

Historically, breast reconstruction was only performed after the loss of a breast due to cancer treatment. However, with the availability of genetic testing, many women who are at very high risk of developing breast cancer are now considering "prophylactic" or "risk-reducing mastectomy" as a course of treatment and prevention. In these cases, both breast are removed before cancer has a chance to develop. The following introduction to breast reconstruction methods, in general, applies to both patients undergoing reconstruction following cancer treatment or risk-reducing (prophylactic) mastectomy.

Although there are several options in breast reconstruction, all methods ultimately involve the use of an implant or the patient's own tissue. No method of breast reconstruction will precisely duplicate a normal breast. It is not possible, for example, to restore normal sensation or eliminate the scar that results from the mastectomy, although it can be frequently integrated into the reconstruction so that it is less obvious. Despite these shortcomings, the vast majority of women are very pleased with the results achieved by breast reconstruction.

Breast reconstruction, by whatever method, should be viewed as a staged effort (typically two or three stages) directed towards achieving an attractive, symmetrical outcome. The first stage is a "rough draft" reconstruction where the breast mound is recreated. The second stage(s) is aimed at improving breast symmetry and fine-tuning the reconstructed breast in terms of size, shape, and position. During the second stage, minor revisions of the reconstructed breast and nipple reconstruction may be performed. It is during this second stage that some women consider surgery of the opposite breast, such as a breast reduction, lift, or enlargement, to further achieve breast symmetry. Later, a "tattoo" of the nipple areola is performed to obtain reasonable color match and help camouflage scars. Although the results of breast reconstruction are rarely perfect, they generally are quite effective at recreating the loss of the breast while helping to restore the patient's dignity and self-esteem.

Timing of Reconstruction

Breast reconstruction may be performed immediately after mastectomy during the same operation ("Immediate Reconstruction") or at a time weeks to years later ("Delayed Reconstruction"). The optimal timing is variable and depends on a number of factors including: the stage of the cancer, your medical history, your social and psychological situation, and the potential need for postoperative radiotherapy. While, both Immediate and Delayed Reconstruction may ultimately result in an aesthetic outcome, it is our preference to perform

Immediate Reconstruction whenever possible as the results tend to be better.

Radiation Therapy: Effects on Reconstruction

Currently, many women receive radiation therapy as part of their treatment. Radiation therapy has significant effects on tissues, the most important of which is fibrosis (scarring) of the skin. Following breast reconstruction with implants, this scarring can prevent adequate tissue expansion and is associated with an increased incidence of capsular contracture (scarring around implants). When using your own tissues for reconstruction (such as TRAM, latissimus, or gluteal flaps) radiation may cause shrinkage and distortion of the reconstructed breast.

Thus, if you will require radiation therapy, the decision to perform immediate reconstruction must be made carefully with the knowledge that this treatment may adversely affect the ultimate cosmetic outcome.

Prosthetic Breast Reconstruction: Expanders and Implants

A common form of breast reconstruction utilizes an implant to recreate the breast mound. This procedure takes about 60-90 minutes and may be performed immediately through the mastectomy incision or delayed through a pre-existing scar. This surgery works well for women whose opposite breast is modest size (A or B cup) and has minimal laxity (looseness) or drooping (ptosis).

This surgery does not work as well for women who have larger breasts (C or D cup), a very lax breast, or who are substantially overweight. A history of previous radiation to the breast (i.e.: a previous lumpectomy followed by radiation) makes this surgery difficult as the irradiated skin and muscle may not allow adequate expansion.

The First Stage procedure is done following the mastectomy, a pocket is created behind the pectoralis muscle and a temporary implant called a tissue expander is inserted. The expander is similar to the final implant, however it contains a magnetic valve, which allows fluid volume to be added after surgery. Beginning about two to three weeks after surgery, the expander is gradually filled with fluid, stretching the skin and muscle, creating room for the final implant. The expansion process requires weekly office visits for a few weeks. The expander will be slightly over-inflated to compensate for normal skin shrinkage after the final implant is placed.

If no additional therapy is required, the Second Stage procedure is performed 2-3 months after final inflation. During this outpatient procedure, the expander is removed and a final implant is placed. The final implant is made of a thin silicone shell and filled with either saline or silicone gel. The choice of implant is made by the patient, prior to the procedure. Implants are not guaranteed forever and have a limited lifespan of uncertain length. An implant may therefore need to be replaced during your lifetime.

In some selected cases, the expansion process may be omitted and an implant placed at the time of the mastectomy as a one-step procedure. This procedure involves inserting the final implant, rather than a tissue expander, under the chest muscle at the time of the mastectomy. This avoids the need for the expansion process after the initial procedure and may avoid the need for a second procedure. The ability to offer this procedure depends on each woman's breast size and the amount of skin remaining after the mastectomy.

48 year old female before and after left and right breast reconstruction with tissue expanders followed by silicone gel implants

Also at the time of the second stage operation, an opposite breast matching procedure (e.g. breast reduction, lift, or enlargement) as well as nipple reconstruction may be performed. The "matching procedure" may be recommended to enhance the overall aesthetic outcome, but is at the discretion of each individual patient.

Reconstruction With Your Own Tissues

Breast reconstruction with your own tissues is an excellent option for those women who wish to avoid the use of foreign materials. With this method, a breast mound may be created by borrowing tissue from another body area, such as the abdomen, buttock, or back. This technique is more complicated than use of a tissue expander and implant, however, once completed, are less likely to require maintenance as you age and usually provides the best cosmetic outcome.

Latissimus Dorsi Muscle Flap

Latissimus dorsi (LD) reconstruction uses the skin, fat and muscle from the back to replace the skin that is removed during a mastectomy or that has shrunk following radiation. This procedure can be used for immediate or delayed breast reconstruction. In addition, the LD may be used for reconstruction of both breasts either at the same time or at different times. The LD flap does not require microsurgery. This operation is usually done in conjunction with placement of a prosthesis (expander or implant), to reconstruct the breast and achieve adequate breast volume

Diagram of how the latissimus dorsi muscle is moved from the back to the breast to provide additional tissue for breast reconstruction. An implant is usually placed under the muscle.

A drawback of this procedure is that there will be a scar on the back. Similar to the "TRAM" flap, there is a risk of the loss of some of the transferred skin and fat, and a very rare possibility of a total loss of the transferred tissue (less than 1%).

38 year old female before and after immediate right breast reconstruction with a latissimus dorsi muscle flap and a silicone gel implant

TRAM Flap

TRAM stands for Transverse Rectus Abdominus Myocutaneous flap. With this technique, excess abdominal skin and fat is used to reconstruct the missing breast. The TRAM can be performed immediately or as a delayed reconstruction. There are three basic types of TRAM flaps.

Diagram of a pedicled TRAM where the abdominal tissue is remains attached to the body and tunneled into the breast under the skin.

abdominal strength. This flap has better circulation allowing more tissue to be transferred and accurate shaping of the tissues. This type of reconstruction is successful more than 95% of the time.

Diagram of a free TRAM breast reconstruction. The abdominal tissue, and a portion of the abdominal muscle, is detached from the body and reconnected using microsurigcal techniques.

Diagram of a DIEP breast reconstruction. The abdominal tissue is detached from the body, leaving all muscle intact, and reconnected using microsurigcal techniques.

The TRAM, DIEP, and SIEA flaps can be used for reconstruction of both breasts simultaneously. However, once they have been used to reconstruct a single breast, it cannot be used again in the future for the other breast.

51 year old female before and after delayed left breast reconstruction with TRAM flap

Gluteal Flap

The gluteal flap uses excess tissue of the buttock and is usually available even in thin women. In general, however, the gluteal flap is a second choice to the TRAM flap and is usually reserved for women who are not implant or TRAM reconstruction candidates. The gluteal flap can only be performed using microvascular surgery and is technically more difficult than the TRAM flap and harder to shape into a breast.

The advantages of breast reconstruction with the gluteal flap are similar to the TRAM flap and include all the advantages of breast reconstruction with your own tissues (listed above). In addition, the use of the gluteal flap avoids abdominal incisions and is therefore not associated with abdominal weakness or hernias.

The disadvantages of the gluteal flap include the disadvantages of microsurgical breast reconstruction (see Free TRAM above). It should be noted that the gluteal flap is a technically more difficult operation than the TRAM flap and is associated with a slightly higher (4 to5%) flap loss rate. In addition, scar and depression in the buttock area may require liposuction or lifting of the other buttock to achieve symmetry.

Microsurgery Information

Performing breast reconstruction with the Free TRAM, DIEP, SIEA, or Gluteal flap require the use of microsurgery. When using these microsurgical techniques the tissue from your abdomen or buttock is disconnected from its original blood supply and reconnected to a new blood supply in the breast region. This requires use of a microscope and sutures finer than a human hair.

After surgery, careful monitoring is required to ensure that the blood vessels do not clot. Clotting of the vessels is rare (approximately 2-5%) and necessitates an immediate return to the operating room to remove the clot. In most instances, the clot can be removed and the circulation restored. In a small number of cases (less than 1%), circulation cannot be restored and the flap is completely lost, thereby necessitating a different method of reconstruction.

Overall, microsurgery is successful about 97-98% of time.

Nipple Reconstruction and Areolar Tattooing

After the breast is reconstructed, most patients choose to have a nipple reconstruction also with tattooing to recreate the natural pigment around the nipple. This is often an office procedure that is done using a local anesthetic and lasts less than 20 minutes.

Nipple reconstruction and then tattooing.

Summary

Breast reconstruction is considered to be a highly successful procedure. That said, it must be cautioned that there are no guarantees of success regardless of the method selected. Unfortunately, there is always the possibility of one or more complications, or even total failure. In most cases, however, patients are quite satisfied with their results and, in retrospect, would chose to undergo the procedure again.

Which Breast Reconstruction Option is Right for You?

Since each option and technique has its advantages and disadvantages, and each patient has her unique goals, expectations and individual body type, there is no one choice that is best for all patients. Other factors such as radiation therapy, medical condition and if one or both breasts are being reconstructed will influence which options should be considered. Your plastic surgeon will offer you recommendations based on these variables after examining you and learning about your specific situation.

Summary of Reconstruction Techniques

Frequently Asked Questions about Breast Reconstruction

Includes Breast Reconstruction with Tissue Expanders, Breast Implants, Latissimus Dorsi Flap and TRAM Flap

What are my options for breast reconstruction?

There are three commonly used techniques for breast reconstruction.

A breast implant may be used to reconstruct a breast. In most cases, a tissue expander (a device similar to an implant) is placed at the time of mastectomy. Then, the expander is enlarged by injected a fluid during weekly clinic visits. As the expander stretches out the remaining skin on the breast, a pocket is created to allow for placement of a breast implant at a second surgery.

A second option is the use of your own tissue from your back (latissimus dorsi flap). This tissue is used to cover a breast implant and often eliminates the need for tissue expansion but still requires the use of an implant.

The third option is the use of the tissue from your abdomen (TRAM flap) and usually does not require an implant.

There are other options available but they are used only in unusual circumstances.

Each option has its advantages and disadvantages. Not all patients will be candidates for each reconstruction. The best option will depend on your wishes and expectations, your overall health, breast and body shape, and if you have any risk factors for reconstruction such as smoking, obesity or radiation treatment. The choice of reconstruction will be decided by both you and your plastic surgeon after examining you and reviewing your health history.

Is breast reconstruction covered by insurance?

Yes, in most cases all procedures associated with breast reconstruction are covered as required by federal law. This includes any treatment on the opposite breast to achieve symmetry.

How many surgeries are necessary?

The use of a tissue expander is a two stage process and will require a second surgery 4 to 6 months later to exchange it for a breast implant. Breasts can be reconstructed in one stage by using a latissimus dorsi flap to cover an implant or by using a TRAM flap. After the breast is reconstructed, most patients desire nipple reconstruction. This minor procedure is usually done 4 to 6 months later. At that time, minor revisions may be done to the reconstructed breast. After the nipple is reconstructed, the areola (pigmented skin around the nipple) may be reproduced with a tattoo. Some patients desire surgery on the opposite breast to have better symmetry with the reconstructed breast. This may involve a breast enlargement, reduction, or lift. If breast implants are used, you may need another surgery to replace them at some time.

Where will the procedure be done?

Most breast reconstruction procedures are done in a hospital. However, secondary procedures can frequently be done in a surgery center or a hospital.

What kind of anesthesia will I have?

How long does the procedure take?

Placement of a tissue expander or breast implant takes about 1 hour. Reconstruction with a latissimus flap or TRAM flap takes 3 to 5 hours. More time may be needed if both breasts are being reconstructed.

Will I need a blood transfusion?

It is very unlikely to need a blood transfusion for such cases.

How long will I stay in the hospital?

After reconstruction with only an expander or implant, most patients are able to go home the next day. Patients with a with a latissimus flap spend 2 to 3 days in the hospital while those with a TRAM flap reconstruction spend 3 to 4 days.

Will I have any drains after surgery?

This depends on the type of work you do. Those who perform mostly desk work will be able to return sooner than those who require heavy activity at work. After reconstruction with only an expander or implant, most patients are able to return to work in 1 to 2 weeks. Patients with a with a latissimus flap reconstruction may return to work in 2 to 3 weeks while those with a TRAM flap reconstruction may need 4 to 6 weeks before returning to work.

Will I need any therapy after surgery?

For most patients no therapy is needed. However, just be sure to move your arms in a full range of motion in a slow and gentle manner after surgery to prevent stiffness.

What can I do to minimize scars after surgery?

Silicone gel sheets have been shown to improve scar appearance after surgery.

Will my reconstructed breast match my remaining breast?

This depends on your breast size and shape. It is common to have additional procedures, such as a breast reduction, lift or enlargement, to have the breasts have a more similar appearance.

Are there any other sources of information available?

Many patients utilize the Internet to find information about surgery they are considering. Unfortunately, the Web at times contains information that may not be completely trustworthy. However, there are a few websites sponsored by professional organizations and the National Library of Medicine that we recommend:

plasticsurgery.org

susangkomen.org

cancer.org

networkofstrength.org

bebrightpink.org

medlineplus.gov

facingourrisk.org

breastimplantsafety.org

fda.gov/cdrh/breastimplants