Virginia Center for Plastic Surgery

For most women, the diagnosis of breast cancer and the possibility of a
mastectomy can be devastating. Although some women are spared total
mastectomy, the changes that occur in the breast as the result of surgery may still be drastic enough to warrant reconstruction. A number of women make the decision to simply accept these changes, be they major or minor, and may or may not choose to use an external breast prosthesis (an artificial breast worn outside the body) to regain their feminine contours. But for others, the loss of these natural contours is unacceptable and they want an alternative to a prosthesis. The alternatives all require surgical procedures.

One of the alternatives is to have a breast implant. Breast implants are made of the same materials as those used for breast augmentation. They are silicone shells filled with either silicone gel or saline water and are not considered lifetime implants. This means they will need to be replaced and/or possibly removed sometime during your lifespan. Although the materials are the same as for breast augmentation, the procedure for implanting them is different and more complex. The implants are always placed behind the muscle in your chest (pectoral muscle) rather than having the choice of placing it in front of the muscle. This is necessitated by the fact that after a mastectomy, the skin is too fragile to support the implant.

Depending upon the outcome of the mastectomy, the surgeon may be able to immediately place a breast expander under the chest muscle and skin. The breast expander is a balloon that is periodically injected with a salt-water solution, which stretches the skin over time to the point that the area can accept an implant. In some cases, the breast expander is considered as an implant and no further surgery is necessary.

The most common problem resulting from breast implants is capsular contracture. This occurs if the scar or capsule around the implant begins to tighten and causes the soft implant to feel hard. Capsular contracture may require removal or replacement of the implant.

The alternative to breast implants is the use of one's own body tissues. There are two types of surgery in this category: pedicle flap and free flap. Pedicle flap surgery means the surgeon tunnels tissue and blood vessels under your skin from another part of your body to the chest area to create a new breast mound or pocket for an implant. In free flap surgery, the surgeon disconnects the tissue from one part of your body and reattaches it to new blood vessels near your chest. Free flap surgery is a longer procedure because of the intricacy of reattaching the blood vessels.

The surgeon uses one of the two flap surgeries in different ways based on what area of the body is chosen as the tissue donor. The areas of your body that are potential donor sites are the abdomen, upper back, and possibly the buttocks. In all cases, your surgeon will discuss the pros and cons of using any of these areas, including the amount of muscle loss that can occur or be maintained with either of the two types of flap surgeries. There is a third type of flap surgery called deep inferior epigastic perforator (DIEP) that can be performed if there is enough skin and fat available on the abdomen. This surgery takes only the skin and fat so as not to disturb the abdominal muscles. This procedure is not possible on a thin or muscular body.

Choosing breast reconstruction means at least two surgeries, and possibly more. The first is obviously the mastectomy, and reconstruction is performed in a second separate operation. It is highly unusual that it can all be accomplished in one surgery. As pointed out earlier, if implants are involved, another surgery will be required in the future to remove and/or replace the original implant.

Breast reconstruction is available to almost any woman regardless of age. However, there are certain physical conditions that may preclude reconstruction. This includes smokers, those with diabetes, vascular disease or connective tissue disorder, and possibly those who are obese. Because of the risks of infection and delayed healing, it is imperative that your health history be thoroughly discussed with your physician.

Getting back to normal activities will take at least six weeks, but more will be required depending upon the extent of the reconstruction process. This is especially true if transplanting of tissues is involved because two separate areas are undergoing surgery. Your doctor will discuss the restrictions to be placed on your activities and pain medication during the recovery period.

Above all, be realistic about the outcome of reconstruction. The surgery will improve your contours but you will not be exactly as you were before or have the same sensation. There will be scarring, which will fade over time but not completely disappear. There is also the possibility of nipple reconstruction that can be augmented with tattooing to define the dark area around the nipple to resemble the areola.

Finally, you may choose to have surgery on your opposite breast, even if it's healthy, so that it more closely matches the shape and size of your reconstructed breast.

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