The American Cancer Society estimates that 232,340 women will be diagnosed with invasive breast cancer in 2013. Although many will be able to have breast conserving surgery, also known as lumpectomy, many will need or prefer a mastectomy, or complete removal of the breast.
Some women will choose to have a mastectomy because their cancer cannot be completely removed with a lumpectomy. Others prefer it, fearing a recurrence or hoping to avoid the weeks of radiation often required after a lumpectomy.
Additionally, hundreds of other women at very high risk of breast cancer will undergo a prophylactic mastectomy, or removal of their breasts to prevent breast cancer.
To many women, the loss of a breast is a devastating occurrence, one that strikes at their very sense of self. They may feel less feminine without a breast, find it awkward to have a missing breast or breasts under clothes, and find using a prosthesis, or rubber breast form, difficult. Thus, many women choose to undergo breast reconstructive surgery after mastectomy.
In 2012, 91,655 women underwent some form of breast reconstruction, according to the American Society of Plastic Surgeons (ASPS), up from 86,424 in 2009.
Overall, studies find that breast reconstructive surgery is underutilized, in part because many women are not made aware of all of their options by their health care providers. According to a 2009 report cited by the American Society of Plastic Surgeons, despite the increase in breast reconstruction surgeries, nearly 70 percent of women who are eligible for the procedure are not well informed about their reconstructive options.
If you choose to have breast reconstructive surgery, you have a few options: breast implants, using silicone shells filled with silicone gel or saline; a newly shaped breast constructed from your own tissue, known as a flap (a section of your own skin, fat or muscle that has been moved from another area of your body to your chest); or a combination of both. In many instances, breast reconstructive surgery can be performed immediately after mastectomy so you never wake up without a breast.
If you have health insurance, your carrier must pay for breast reconstructive surgery. The 1998 Federal Breast Reconstruction Law requires all health insurance companies to cover the reconstruction of the breast on which mastectomy has been performed, and surgery and reconstruction of the other breast to produce a symmetrical appearance. Beginning in 2014, it is assumed that most women will have some form of health insurance coverage as mandated by the Affordable Care Act.
If you don’t have health insurance, talk to your surgeon and the hospital about negotiating a discount rate. Many are willing to do that for women without insurance. You may also qualify for health insurance under your state’s Medicaid program or other health-coverage programs for low- and moderate-income individuals.
Regardless of why you had a mastectomy, the decision to undergo breast reconstructive surgery, use a breast prosthesis under your clothes or make no changes after mastectomy can be complex and difficult.
In making the decision, ask yourself the following questions:
- How do feel about my breasts?
- How important are my breasts to my self-image?
- How does my partner feel about my breasts?
- What will it be like living without one or both breasts after surgery?
- Will I be able to exercise with a prosthesis?
- Am I willing to undergo the surgery and recovery that is required?
- Will the fact that I may not have much sensation in the reconstructed breast bother me and/or my partner?
It’s also a good idea to talk with other women who have had mastectomies about their choices. Breast cancer support groups or even your doctor’s office can put you in touch with other women.
No matter what you think you might do about breast reconstruction, it’s important to involve a plastic surgeon early on as a part of your health care team, even before the mastectomy. It’s also important that you choose the right plastic surgeon. Your surgeon should be board certified by the American Society of Plastic Surgeons, have privileges at a local hospital and be trained in the technique you’ve chosen.
The plastic surgeon can work with your breast surgeon to ensure that the mastectomy is performed in such a way as to provide the best possible outcome for later breast reconstruction. Plus, your general surgeon, oncologist and plastic surgeon should make a joint decision with you on whether immediate breast reconstructive surgery is appropriate given your medical history. Keep in mind that even if you are sure you don’t want breast reconstructive surgery, you can always change your mind later—even years later—as long as you remain in good health.
Ask your breast surgeon about a skin-sparing mastectomy or a nipple-sparing mastectomy, particularly if you’re planning breast reconstructive surgery. A skin-sparing mastectomy is often performed when the breast removal and reconstruction will be completed during the same operation. In this procedure, the surgeon takes only as much skin as necessary to remove cancer and prevent its spread, leaving as much skin as possible to provide a pouch, or covering, for future breast reconstruction.
This procedure provides a better cosmetic result after breast reconstructive surgery because it enables the plastic surgeon to match the color and shape of the original breast. Your surgeon won’t do a skin-sparing mastectomy, however, if the tumor affects the skin, as with inflammatory breast cancer.
In some instances, your breast surgeon may also be able to preserve the nipple and areola (the dark skin surrounding the nipple). This may be an option for women with small to moderate breast size and who have tumors that are not near the nipple or areola. This option is becoming more popular, especially in women who are opting to have a prophylactic mastectomy.
Immediate vs. Delayed Breast Reconstructive Surgery
One of the first topics to discuss with your surgeon, even before your mastectomy, is whether you are a candidate for immediate breast reconstructive surgery. Immediate breast reconstructive surgery occurs while you are still under anesthesia from the mastectomy, so you never wake up without a breast.
The alternative is that you undergo a delayed breast reconstructive surgery, which occurs after you have recovered from the mastectomy. Delayed breast reconstructive surgery is possible even years after a mastectomy, so if you don’t want to have breast reconstructive surgery now, it remains a possibility down the road.
Studies find that immediate breast reconstructive surgery after mastectomy is safe and doesn’t delay the start of chemotherapy or affect its outcome. However, it may not be an option if you have an advanced stage of cancer requiring radiation. In these circumstances, it may increase the risk of post-surgical complications compared to mastectomy alone.
Studies also find that women who have immediate breast reconstructive surgery feel better emotionally and are happy with their decision.
Specifically, studies find women who have undergone immediate breast reconstructive surgery have better self-images and are less likely to be depressed than women who chose not to have breast reconstruction. Immediate breast reconstruction may be less expensive and more convenient because there’s often just one operation, one anesthesia and one hospital stay required. It should be remembered that secondary revisions may be necessary based on your expectations and the surgeon’s evaluation. These are usually performed as outpatient procedures.
Additionally, some studies find that it’s easier to make the new breast look more like the old breast with immediate breast reconstructive surgery, because the skin flaps left from the mastectomy are still flexible. With delayed reconstruction, the skin tends to become stiffer due to scarring. Although delayed reconstruction can result in a natural breast appearance, it is less likely to resemble the natural breast.
Immediate breast reconstructive surgery is not an option for every woman. If you have an advanced stage of cancer requiring radiation and/or high-dose radiation, some doctors prefer to wait. However, some patients and most plastic surgeons will offer immediate reconstruction even when radiation is necessary. Usually this is done with prosthetic devices and sometimes with flaps. Delayed reconstruction following radiation is almost always performed with a flap because the skin is too tight to be successfully reconstructed with an implant. Additionally, your own health and health habits play a role in your ability to have immediate breast reconstructive surgery. These include your weight, whether or not you smoke, if you have other diseases like diabetes or heart disease and your psychological state and willingness to invest the time required for healing.
For some women, the stress and trauma of having breast cancer is all they can handle; they prefer to wait for breast reconstructive surgery, even if they are eligible for immediate breast reconstruction. The most important thing is to do what feels right for you—both physically and emotionally.
There are a few types of breast reconstruction available for women today: implant reconstruction, in which silicone or saline implants are inserted into the breast area; a newly shaped breast constructed from your own tissue, known as a flap (a section of your own skin, fat or muscle that has been moved from another area of your body to your chest); or a combination of both.
Which procedure is right for you depends on several factors, including your overall health and any other medical conditions, whether or not you smoke, your size, the size and shape of the other breast and your past surgical history.
Breast Reconstructive Surgery with Breast Implants
Breast reconstructive surgery involves inserting a silicone shell filled with either silicone gel or a salt water (saline) solution behind the pectoral muscle. The majority of breast reconstructions are performed using a two-stage technique that includes a temporary tissue expander followed by a permanent implant. Some women are candidates for the one-stage technique that avoids using an expander and goes straight to an implant.
Breast reconstruction with prosthetic devices (tissue expanders and implants) has several advantages, including a shorter surgery and quicker recuperation than tissue flap breast reconstruction. Disadvantages include a greater risk of future complications that include infection, rupture, extrusion (in which the implant comes through the skin) or capsular contracture, in which scar tissue builds up around the implant, sometimes causing pain and distortion of the tissue. However, excellent aesthetic outcomes are possible using implants and occur in the majority of women.
Similar to other medical devices, breast implants—saline or silicone—are not lifetime devices. It is likely, that at some point in your lifetime they may need to be removed or replaced. In early 2011, the FDA released a safety report that said breast implants of any type may pose a very small risk of an extremely rare and treatable type of cancer. The cancer, anaplastic large-cell lymphoma (ALCL), involves the immune system and is speculated to occur in about one out of 500,000 women. It is not breast cancer, but in the cases linked to implants, the lymphoma grew in the scar tissue surrounding the implant. Symptoms may include lumps, pain, asymmetry of the breasts, fluid buildup or swelling after healing from the implant surgery. Removing the implant and scar tissue often gets rid of the disease.
Because the risk is very small, the FDA did not order removal of implants from the market. Instead, the agency encourages women considering implants to discuss the information with their doctors. The FDA is currently gathering more information on ALCL in women with breast implants and asking all health care providers to report all confirmed cases of ALCL in women with breast implants through their MedWatch Program.
You should talk to your surgeon about subsequent surgeries or complications prior to surgery. Also, check with your insurance company to see if it covers subsequent surgeries.
The decision regarding one- or two-stage reconstruction is made by the patient and surgeon. The two-stage surgical process will depend on how much skin is left in the breast area after mastectomy. The first stage involves placing a balloon-like tissue expander under the skin in the breast area, then adding saline every week or so for a month to several months to stretch the skin. This isn’t painful but may be uncomfortable.
Your surgeon may discuss with you the use of new biologic materials known as acellular dermal matrices to assist with the prosthetic reconstruction. These materials are commonly used and improve the shape and contour of the reconstructed breast, and they may also be used in nipple reconstruction.
After the skin is stretched enough, the expander is removed and the permanent breast implant is inserted in a second surgery, usually in an outpatient setting under general anesthesia. In some instances, however, the expander can be left in place as the permanent breast implant although this is not usually recommended. The advantage of a permanent implant is that the position, contour and symmetry of the breast is usually improved.
When reconstructive surgery with an implant is only performed on one breast, the difference between the new and old breast may be quite noticeable. In many cases, surgeons may recommend breast implant surgery on the unaffected breast as well to achieve a similar, balanced look. Even though this procedure is considered cosmetic, it is covered by health insurance under the 1998 Federal Breast Reconstruction Law.
If you choose breast implants, you need to decide whether you want a silicone gel-filled implant or a saline implant. Most women today will choose a silicone gel–filled implant because the breast will look and feel more natural. You and your surgeon should work together to decide which breast implant will better fit your needs and expectations.
In 1992, due to reports of leaking silicone and possible health implications, the U.S. Food and Drug Administration (FDA) called for a voluntary moratorium (delay) on the use of silicone gel-filled breast implants until new safety information could be thoroughly reviewed by the FDA’s advisory panel. Within three months, the FDA allowed silicone breast implants to be used again but only for reconstructive surgery and revision (implant replacement) surgery under clinical study protocols but not for cosmetic breast augmentation.
Since then, numerous studies have been conducted on the safety of silicone gel-filled breast implants in the United States and around the world. These studies find no increased risk of autoimmune disorders (lupus and rheumatoid arthritis) or connective tissue diseases (like scleroderma) or related disorders, breast or other cancers or neurological disorders in women who use silicone gel-filled breast implants.
As a result, the FDA now allows silicone gel-filled breast implants to be used again for breast reconstruction in women of all ages and for breast augmentation in women age 22 and over.
Today’s silicone gel-filled breast implants benefit from improved manufacturing technology and more stringent tolerance specifications, resulting in a more consistent manufacturing process that significantly reduces manufacturing errors. Major changes include thicker shells and more cohesive gel to reduce the risk of rupture and the likelihood that gel will leak into the body if the breast implants do rupture. Questions remain, however, about silicone gel-filled breast implant rupture rates. To better understand the long-term safety of breast implants, the FDA has required that the manufacturers of silicone gel-filled implants to conduct ongoing studies to assess potential safety issues.
Tissue Flap Breast Reconstruction
Tissue flap breast reconstruction, also called autologous reconstruction, involves taking fat, blood supply and, sometimes a portion of muscle from other parts of your body to create a breast. Most flap procedures use tissue from your back or abdomen, although some use tissue from your thigh or buttocks.
While this procedure tends to provide a more natural looking breast, it is much more difficult to perform than breast reconstructive surgery with breast implants and it requires a surgeon who is skilled with these methods. As with breast implants, this surgery can usually be performed immediately after mastectomy. In some cases in which radiation is necessary, your plastic surgeon may recommend placement of a tissue expander first, followed by a flap after the radiation. This is done to prevent radiation changes or damage to the flap itself.
In general, women who smoke or who have diabetes, connective tissue or blood vessel diseases are not good candidates for this procedure because these conditions can affect blood circulation. A healthy blood supply to the new breast is critical to the success of the surgery.
Also, women who are overweight or who have had previous surgery at the site from which the tissue will be taken may not be good candidates. A consultation with a plastic surgeon is necessary to assess eligibility.
All flap reconstructions carry certain risks, including the loss of blood supply to the new breast, which could lead to infection and/or the loss of some or all of the breast tissue. Procedures that use abdominal muscle to create the breast carry a slight risk of abdominal hernia or bulge. A hernia is a hole or weakness in the supportive layers of the abdominal wall that allows whatever lies behind the muscle to push through. A bulge is a laxity of the abdominal wall and not a hole. Additionally, recovery from all tissue flap procedures is much more extensive than from implants, usually requiring three to four days in the hospital and several weeks of recovery at home.
Several types of flap reconstruction may be performed to create the breast or a pocket for an implant.
DIEP (deep inferior epigastric artery perforator) flap procedures. This is the most common flap for breast reconstruction using your own tissues. This procedure transfers tissue from the abdomen to the breast. However, instead of transplanting the muscle as is done in some other flap procedures, the surgeon carefully teases the blood supply away from the muscle, sparing the muscle. This is a very delicate procedure requiring microsurgery and a specially trained surgeon to ensure a healthy blood supply in the new breast. It is the least disruptive of all the abdominal flaps, usually preserving full function.
TRAM (Transverse Rectus Abdominis Muscle) flap. This used to be the most commonly performed tissue flap breast reconstruction. The surgeon uses sections of artery and vein, as well as fat, skin and muscle from the lower abdomen, to shape a new breast. An added bonus is that you get a tummy tuck. This procedure takes about three to six hours and requires several days of hospitalization. But it provides a very natural looking breast, similar to the unaffected breast. Disadvantages include the possibility of a hernia or bulging in the abdominal wall and some loss of abdominal function, particularly if two abdominal muscles are used.There are two main types of TRAM flaps:
- Pedicle flap. In this procedure, the surgeon leaves the flap attached to its original blood supply and tunnels under the skin to bring it to the breast area.
- Free flaps. In this procedure, the surgeon cuts a portion of the abdominal muscle along with its blood supply out of the abdomen, and then reattaches it to the breast area using microsurgery to connect the blood supply. This procedure is more complex than the pedicle flap and requires a longer operating time and admission to a ward that specializes in the monitoring of flaps to ensure that the new breast’s blood supply works properly. It is particularly useful when tissues are damaged such as following radiation therapy and when tissue expansion is not an option. The free flap procedure is not performed as often as the pedicle flap, but it has a high satisfaction rate. Some doctors think it results in a breast with a more natural shape. There’s also less risk of abdominal bulges, or hernia, because only part of the muscle is used, and there may be less postoperative pain and discomfort, because there’s no “tunneling.”
- Gluteal free flap. During this procedure, the surgeon uses part of your gluteal muscle and tissue from your buttocks to create a new breast. It is similar to the TRAM flap in that the surgeon moves skin, fat, muscle and blood vessels from the buttocks to the chest area. Microsurgery is required to connect tiny vessels. In some cases, no muscle is removed, and this is referred to as a gluteal artery perforator (GAP) flap. A gluteal free flap procedure might be an option for women who cannot or would rather not use tissue from their abdominal areas due to thinness or other reasons. However, it’s not offered everywhere.
- Latissimus dorsi flap (LDF). In this operation, the surgeon transplants a section of tissue that includes skin, fat and muscle from your back to your chest to reconstruct the breast. This procedure is most appropriate for women with small breasts and heavy women in whom use of the TRAM or DIEP flaps (described below) is not possible. Downsides include the possibility of weakness in your upper back and chest, a noticeable scar on your back and a seroma or fluid collection.
- Inner thigh or transverse upper gracilis (TUG) flap. Another newer option, TUG flap surgery uses muscle and fatty tissue from the bottom of the buttocks and the inner thigh. The surgeon uses a microscope to connect the blood vessels to their new blood supply. It may be an option for women who don’t want to use TRAM or DIEP flaps; however, it isn’t available in all areas of the country. This procedures is best for women who need a smaller or medium sized breast and who have enough tissue in their inner thighs (their inner thighs should touch).
Reconstruction of the Nipple and Areola
Once your breast has been reconstructed, you can choose to have a nipple and areola (the surrounding dark tissue) created. This is done as a separate, outpatient procedure after the reconstruction heals, usually under local anesthesia. The nipple is usually reconstructed using the skin around the new breast mound. In some women, the skin is taken from other areas of your own body, such as from your opposite nipple, ear, eyelid, groin, upper inner thigh, buttocks or the newly created breast. The areola is created with tattooing a few weeks later. In some women who have had radiation to the reconstructed breast, nipple reconstruction may not be possible. In these women, options will include a prosthetic nipple or a 3-D nipple and areolar tattooing.
It’s important that you have realistic expectations about your breast reconstructive surgery. Among the issues to consider are:
- Scarring. There will be some scarring. How much depends on your individual situation. All scars will be pink to red for six to 12 months before they fade to a normal skin tone.
- Mismatched breasts. Your new breast may not match your old breast exactly, and you may need surgery on the unaffected breast to make the two look the same.
- Lack of sensation. Depending on how much skin was left after the mastectomy, you may not have much sensation in the reconstructed breast. Over time, the skin may become more sensitive but may never return to the level of sensitivity it had before the surgery. Reconstructions using flaps often remain without sensation.
- Repeat surgeries. In some instances, particularly with breast implants, you may need additional surgeries in the years ahead to correct any problems. Also, similar to other medical devices, breast implants—saline or silicone—are not lifetime devices. It is likely, that at some point in your lifetime they may need to be removed or replaced.
After Breast Reconstructive Surgery
After breast reconstructive surgery, you may not need mammograms on the reconstructed breast, although you should still continue breast self exams on the healthy breast to feel for any abnormalities. Make sure you continue following up with your surgeon and oncologist for signs of any recurrence. If the cancer recurs, your treatment will be the same whether or not you’ve had breast reconstruction. If breast imaging is advised, an MRI is usually recommended.
Facts to Know
- Many women who undergo a mastectomy to remove or prevent breast cancer choose to undergo breast reconstructive surgery. Overall, more than 91,000 women chose to have breast reconstructive surgery in 2012, according to the American Society of Plastic Surgeons (ASPS).
- There are two main forms of breast reconstructive surgery: breast reconstruction with breast implants, which involves the surgical implantation of a saline-filled or silicone gel-filled envelope under the chest muscle; and tissue flap breast reconstruction, in which a woman’s own skin, fat and, in most instances, muscle, are used to create a new breast.
- Under federal law, all health insurance policies must cover breast reconstruction after mastectomy, although there may be limits on the type of reconstructive surgery covered.
- Many women are eligible for an immediate breast reconstruction at the same time they undergo mastectomy.
- Women who undergo immediate breast reconstructive surgery tend to feel better emotionally than women who wait.
- Immediate breast reconstruction is less expensive than delayed reconstruction, less disruptive to a woman’s life and may provide better cosmetic results.
- You can have breast reconstructive surgery years after your mastectomy, if your health allows.
- There are two types of breast implants available—silicone gel-filled and saline-filled. Many surgeons think that women get a more natural-looking breast with silicone gel-filled implants than with saline implants.
- Tissue flap breast reconstruction is a more complex operation and requires a longer surgery and recovery than breast reconstructive surgery with breast implants. However, it can result in a more natural-looking breast.
- Women who smoke or have diabetes or other conditions that affect the health of their blood vessels are generally not good candidates for tissue flap breast reconstruction. Neither are thin women or those who have previously had surgery in the area from which the tissue will be removed.
- When can I have breast reconstructive surgery?When you have your breast reconstructive surgery depends on your medical condition, psychological condition and any postsurgical treatment required. Many women can have an immediate breast reconstruction. But if you need postsurgical radiation, your doctor may prefer that you wait until treatment ends before breast reconstruction.
- What types of breast reconstruction are available?There are two main forms of breast reconstruction: implants, which involve surgical implantation of a saline or silicone-gel-filled shell under the chest muscle; and tissue flap breast reconstruction, in which a woman’s own skin, fat and, in most instances, muscle are used to create a new breast. This tissue comes from the upper back, lower abdomen, thigh or buttocks.
- Why would I need a two-stage breast reconstruction?If you have large breasts or there is not enough skin left after the mastectomy to cover an implant, you may require a two-stage breast implant reconstruction. The first stage involves placing a balloon-like tissue expander under the skin in the breast area, then adding saline every week or so for a month to several months to stretch the skin. This isn’t painful but may be uncomfortable. After the skin is stretched enough, the expander is removed, and the permanent implant inserted in a second surgery.
- What are the advantages and disadvantages of breast reconstruction with breast implants?The surgery and recovery time are shorter, and the procedure itself requires less specialized skill than tissue flap reconstruction. However, there is a greater risk of long-term complications from breast implants and, like other medical devices, breast implants—saline or silicone—are not lifetime devices. It is likely that at some point they may need to be removed or replaced. When a single mastectomy is performed, some patients opt for breast implant surgery on the other breast as well to achieve a more symmetrical look to the reconstructed breast.
- What are the advantages and disadvantages of a tissue flap breast reconstruction?Tissue flap breast reconstruction is a much more complex surgical procedure, requiring more time in the operating room with the possibility for significant blood loss. It also requires a much longer recovery time than implants. However, tissue flap breast reconstruction results in a more natural-looking breast that lasts forever.
- Can I have a nipple and areola added?Your surgeon can create a nipple and the surrounding dark tissue, called an areola, on your new breast. This is done as a separate, outpatient procedure after your breast reconstruction has healed, usually under local anesthesia. The nipple is usually reconstructed with a tattooed skin flap, with skin taken from your own body, such as from your opposite nipple, ear, eyelid, groin, upper inner thigh, buttocks, or the newly created breast. The areola is created with tattooing a few weeks later.
- What if I don’t want breast reconstruction now but change my mind later?As long as you are in good health, you can have breast reconstruction at any time.
- Will my insurance cover the procedure? What if I don’t have any health insurance?One thing you don’t have to worry about is fighting with your insurance company to pay for the procedure. The 1998 Federal Breast Reconstruction Law requires all health insurance companies to cover reconstruction of the breast on which mastectomy has been performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. If you don’t have health insurance, talk to your surgeon and the hospital about negotiating a discount rate.
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