Breast Reconstruction

If you are facing the loss of a breast due to cancer or other disease, you may have the option of breast reconstruction. Breast reconstruction is a surgical procedure to recreate the natural contour of your breast, using either a prosthesis or your own tissues.

Great strides have been made in the field of breast reconstruction in recent years, resulting in more natural breast shape and appearance. It is important for you to realize that your reconstructed breast will not look or feel exactly like your natural breast. While it is not for everyone, many women who have undergone breast reconstruction experience a faster and more complete emotional recovery from the loss of their breast.

This web page will introduce you to the most common breast reconstruction procedures used today, and will summarize some of the differences between them. Also included is a list of questions and a resource guide designed to help you to find more information for your breast reconstruction decision.

The timing of your breast reconstruction

The breast reconstruction process may begin at the time of your mastectomy (immediate) or weeks to years afterwards (delayed).

Immediate reconstruction means that the procedure begins at the same time as the mastectomy . It is important to know that any type of surgical breast reconstruction may take several steps to complete.

Two potential advantages to immediate reconstruction are that your reconstruction process is already underway when you wake up from the mastectomy, and there may be a cost savings in combining the mastectomy procedure with the first stage of the reconstruction. However, there may be a higher risk of complications with immediate reconstruction, and your initial operative time and recuperative time may be longer

A potential advantage to delayed reconstruction is that you can delay your reconstruction decision and surgery until other treatments, such as radiation therapy and chemotherapy, are completed. Delayed reconstruction may be advisable if your surgeon anticipates healing problems with your mastectomy, or if you just need more time to consider your options.

There are medical, financial and emotional considerations to choosing immediate versus delayed reconstruction. Talk with Dr. Jensen about the options available in your individual case.

Choices in reconstructive procedures

The type of breast reconstruction procedure available to you depends on your medical situation, your breast shape and size, your general health and lifestyle, and your goals. Every woman’s situation is unique.

Breast reconstruction can be accomplished by the use of a prosthesis (a breast implant) or your own tissues (a tissue flap). A breast implant is a fluid-filled breast form that is surgically implanted under your chest tissues to create a new breast. A tissue flap is a section of skin, fat and muscle that is moved from your stomach, back or other area of your body, to the chest area, and shaped into a new breast. The following is a brief discussion of these commonly used breast reconstruction procedures.

If you are considering breast reconstruction, Dr. Jensen can provide you with information that fully explains the risks and complications associated with breast implants, tissue flaps, and with surgery itself. It is recommended that you read all of the information provided before scheduling surgery, so that you have plenty of time to ask questions and evaluate all of your options. Breast implants have been used by an estimated 1-2 million women since the early 1960s for breast reconstruction after a mastectomy or for enhancing breast size. Compared to tissue flap reconstruction, breast reconstruction with a breast implant requires a shorter operative and recuperative time, and causes less trauma and stress to the body. Over the last fifteen years, it has been and continues to be the most commonly used breast reconstruction procedure.

Breast implants

The most common types of breast implants consist of a silicone rubber shell filled with sterile saline (salt water) or silicone gel. At this time, breast implants filled with silicone gel are only available on a limited basis in the United States. Saline-filled implants are available on an unrestricted basis from a licensed plastic surgeon. Saline is used to fill the implant because it is similar to the fluids in your body, and will be absorbed by your body should the implant leak or break.

For more information about the use of silicone materials in breast implants and other medical devices, see the “FDA Information For Women Considering Saline-Filled Breast Implants” reprinted at the end of the breast augmentation page. Other resources include the product package insert that is provided with breast implants, and the brochure, “What Is Silicone?” These materials are available from Dr. Jensen.

Who is a candidate for implant reconstruction?

Dr. Jensen will decide whether your health and medical condition makes you an appropriate candidate for implant reconstruction. Women with small or medium sized breasts are the best candidates for implant reconstruction, although larger breasts can be reconstructed with a combination of a tissue flap and an implant.

How are implants used in breast reconstruction?

Breast reconstruction with a saline-filled breast implant usually occurs as a two-stage procedure, starting with the placement of a breast tissue expander, which is replaced several months later with a breast implant.

Stage 1: Tissue expansion

Illustration 1: Side view, breast tissue removed.

During a mastectomy, the general surgeon often removes skin as well as breast tissue, leaving the chest tissues flat and tight. To create a breast-shaped space for the breast implant, a tissue expander is placed under the remaining chest tissues.

The tissue expander is a balloon-like device made from elastic silicone rubber. It is inserted unfilled, and over time, small amounts of sterile saline are added by inserting a small needle through the skin to the filling port of the device. As the tissue expander fills, the tissues over the expander begin to stretch, similar to the gradual expansion of a woman’s abdomen during pregnancy. The tissue expander creates a new breast shaped pocket for a breast implant.

Illustration 2: Side view, expander inserted & filled.

Tissue expander placement occurs under anesthesia in an operating room. Operative time is generally one to two hours. The procedure may require a brief hospital stay, or be done on an outpatient basis. Typically, you can resume daily activity after two to three weeks.

Because the chest skin is usually numb from the mastectomy surgery, it is possible that you may not experience pain from the placement of the tissue expander. However, you may experience feelings of pressure or discomfort after each filling of the expander, which subsides as the tissue expands. During this first stage of implant reconstruction, Dr. Jensen ensures that the pocket created by the tissue expander is positioned correctly and is the desired shape and size.

Illustration 3: Post Mastectomy Stage 1: Tissue Expander

Based on the result of the expansion, the surgeon selects a breast implant to replace the tissue expander.

Stage 2: Placing the breast implant

After the tissue expander is removed, the unfilled breast implant is placed in the pocket, and then filled with sterile saline. The surgery to replace the tissue expander with a breast implant (implant exchange) is usually done under anesthesia in an operating room. It may require a brief hospital stay or be done on an outpatient basis.

Illustration 4: Breast Implant and Nipple / Aerola Reconstruction

The type of breast implant used will be determined by you and Dr. Jensen by evaluating the dimensions and shape of your desired breast. Breast implants are available in round and anatomical shapes in a wide variety of sizes. Breast implants may also be custom designed for unique situations.

The BIODlMENSlONAL™ System

The BIODlMENSlONAL™ System for breast reconstruction consists of an anatomically shaped tissue expander and two matching styles of anatomically shaped breast implants. The shapes of the tissue expander and implants help Dr. Jensen recreate the natural shape of your desired breast. In addition to being anatomically shaped, the tissue expander and implants in this system have a patented textured surface. This surface helps keep the tissue overlying the expander softer during the expansion process. The textured surface also helps keep the tissue expander and breast implant in place.

Reconstruction with tissue flaps

The breast can also be reconstructed by surgically moving a section of skin, fat and muscle from one area of your body to another. The section of tissue may be taken from such areas as your abdomen, upper back, upper hip or buttocks. The reconstructed breast may be made from the tissue flap alone, or from the tissue flap plus a breast implant.

The tissue flap may be left attached to the blood supply and moved to the breast area through a tunnel under the skin (a pedicled flap), or it may be removed completely and reattached to the breast area by microsurgical techniques (a free flap). Operating time is generally longer with free flaps, because of the microsurgical requirements.

Flap surgery is a major operation. It requires a hospital stay of several days, and a longer recovery time than implant reconstruction. Flap surgery also creates scars at the site where the flap was taken, and possibly additional scars on the reconstructed breast. However, flap surgery has the advantage of being able to replace tissue in the chest area. This may be useful when the chest tissues have been damaged and are not suitable for tissue expansion, when extra tissue is desired to recreate a large breast without a breast implant, or when extra tissue coverage is needed over a breast implant.

The most common types of tissue flaps are the TRAM flap, from the abdomen, and the Latissimus dorsi flap, from the upper back. These flaps are discussed in more detail on the following pages.

Who is a candidate for tissue flap surgery?

If the remaining tissues on your chest are insufficient or inadequate to allow breast reconstruction with a tissue expander, you may be a good candidate for flap surgery. It is important for you to be aware that flap surgery, particularly the TRAM flap, is a major operation, more extensive than your mastectomy It requires good general health and strong emotional motivation.

If you are very overweight, smoke cigarettes, have had previous surgery at the flap site, or have any circulatory problems, you may not be a good candidate for a tissue flap procedure. Also, if you are very thin, you may not have enough tissue in your abdomen or back to create a breast with this method.

The TRAM flap (pedicle or free)

During a TRAM flap (transverse abdominus musculocutaneous flap) procedure, the surgeon removes a section of tissue from your abdomen and moves it to your chest to reconstruct the breast. The TRAM flap is sometimes referred to as a “tummy tuck” reconstruction, because it may leave the stomach area flatter.

Illustration 5: This reconstruction includes a Mastopexy to the other breast to improve symmetry

Illustration 6: Final Result with nipple/areola reconstruction

A pedicle TRAM flap procedure typically takes three to six hours of surgery under anesthesia, a free TRAM flap procedure generally takes longer The TRAM procedure and may require a blood transfusion. Typically, the hospital stay is two to five days. You can resume daily activity after six to eight weeks, however some women report that it takes up to one year to resume a normal lifestyle. You may have temporary or permanent muscle weakness in the abdominal area. If you are considering pregnancy after your reconstruction, you should discuss this with Dr. Jensen. You will have a large scar on your abdomen, and may also have additional scars on your reconstructed breast.

The Latissimus Dorsi flap

During a Latissimus dorsi flap procedure, the surgeon moves a section of tissue from your back to your chest to reconstruct the breast. Because the Latissimus dorsi flap is usually thinner and smaller than the TRAM flap, an implant may be used under the flap to provide more volume and shape to the reconstructed breast.

Illustration 7: Post Mastectomy and View Showing Back Scar

Illustration 7: Latissimus Dorsi Flap

The Latissimus dorsi flap procedure typically takes two to four hours of surgery under anesthesia. Typically, the hospital stay is two to three days. You can resume daily activity after two to three weeks. You may have some temporary or permanent muscle weakness and difficulty with movement in your back and shoulder. You will have a scar on your back which can usually be hidden in the bra line. You may also have additional scars on your reconstructed breast.

Note. The cost of breast reconstruction includes surgeons’ fees and hospital charges. The cost to you will vary depending on your medical circumstances and your insurance coverage.

In general, implant reconstruction is initially less expensive and less extensive than flap surgery and immediate reconstruction is less expensive than delayed reconstruction. Consult Dr. Jensen and your insurance company for more information.

Whether you have a breast implant or a tissue flap reconstruction, the following surgical procedures may be options for you in completing your breast reconstruction.

Nipple and areola reconstruction

The nipple is often removed with the breast tissue during mastectomy in case it contains cancer cells. Your nipple can be reconstructed using a small skin graft or by taking part of the nipple from the opposite breast. The dark circle around your nipple (the areola) may be reconstructed with a skin graft, or by tattooing the area to match the areola of the opposite breast. Nipple and areola reconstruction is usually a separate outpatient procedure after the initial reconstruction surgery is complete.

Improving symmetry: Mastopexy, reduction mammaplasty, or augmentation mammaplasty

In one-sided (unilateral) breast reconstruction, it may be difficult for Dr. Jensen to exactly match the remaining breast, particularly if you have large breasts or if your breasts have sagged with age or from bearing children. In order to help improve symmetry between your natural and reconstructed breasts, Dr. Jensen may suggest a breast lift (mastopexy), breast reduction (reduction mammaplasty), or breast enlargement (augmentation mammaplasty) to the remaining breast.

If it is important to you not to alter the unaffected breast, you should discuss this with Dr. Jensen, as it may affect the breast reconstruction methods considered or your case.

Mastopexy

The skin of the breast stretches over time and with pregnancy, causing the breast to droop or sag. Mastopexy, or breast lift, is done by surgically tightening the skin around the breast. Dr. Jensen removes a strip of skin from under the breast or from around the nipple, lifting and tightening the remaining breast skin.

Reduction mammaplasty

Dr. Jensen may recommend that you consider reducing the size of your unaffected breast to improve the symmetry between your natural and reconstructed breasts. Reduction mammaplasty is similar to mastopexy, but Dr. Jensen removes breast tissue as well as skin.

Augmentation mammaplasty

You may chose to have the size of your natural breast augmented (increased with a saline-filled breast implant) to help achieve symmetry between your natural and reconstructed breast.

The following list of questions may help to remind you of topics to discuss with Dr. Jensen:

  • What are all my options for breast reconstruction?
  • What are the risks and complications of each type of breast reconstruction surgery and how common are they?
  • What if my cancer recurs or occurs in the other breast?
  • Will reconstruction interfere with my cancer treatment?
  • How many steps are there in each procedure, and what are they?
  • How long will it take to complete my reconstruction?
  • How much experience do you have with each procedure?
  • Do you have before and after photos I can look at for each procedure?
  • What results are reasonable for me?
  • What will my scars look like?
  • What kind of changes can I expect over time?
  • Can I talk with other patients about their experiences?
  • What is the estimated total cost of each procedure?
  • How much is my insurance expected to cover?
  • How much pain or discomfort will I feel, and for how long?
  • How long will I be in the hospital?
  • Will I need blood transfusions, and can I donate my own blood?
  • When will I be able to resume my normal activity ;or sexual activity, or athletic activity?
  • Where can I get more information?

The following list of resources may help you to find more information and support for your breast reconstruction decision.

  • National Cancer Institute 1 -8004-CANCER
  • American Cancer Society 1 -800-ACS-2345
  • Reach to Recovery
  • American Society of Plastic and Reconstructive Surgeons 1-800-635-0635
  • Food and Drug Administration 1 -800-532-4440
  • (FDA) Breast Implant Information
  • Y-ME National Organization for 1-800-221-2141
  • Breast Cancer Information and Support
  • FDA Information for Women 1 -800-624-4261
  • Considering Saline-Filled Breast Implants
  • What is Silicone?
  • Medical Corporation
  • LaTour, Kathy. The Breast Cancer Companion, From Diagnosis Through Recovery. Everything You Need to Know For Every Step Along the Way. Avon Books, New York. 1993.
  • Bruning, Nancy Breast Implants, Everything You Need to Know. Hunter House Inc., California, 1995.
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