A woman who has surgery to treat breast cancer might choose to have additional surgery to rebuild the shape and look of her breast. This is called breast reconstruction surgery. If you are thinking about having this done, it is best to talk about it with your surgeon and a plastic surgeon experienced in breast reconstruction before you have surgery to remove the tumor or breast. This lets the surgical teams plan the best treatment for you, even if you decide to wait and have reconstructive surgery later.
Breast reconstruction is the creation of a new breast shape, or mound, using surgery. It may be done after removal of a whole breast (mastectomy) or part of the breast (breast-conserving surgery). You can have reconstruction at the same time as breast cancer surgery, known as immediate reconstruction; or months or years later, known as delayed reconstruction. Breast reconstruction often involves several operations to give you the best outcome possible.
The new breast shape can be created using an implant and/or your own tissue from another part of the body, usually the back or lower abdomen (belly). Reconstructed breasts don’t usually have a nipple but one can be created with surgery and tattooing. Prosthetic stick-on nipples can also be used.
The aim of breast reconstruction is to create a breast shape that looks as natural as possible and to try to match the breast on the other side in size, shape and position. However, even with the best outcome, there will be differences between the remaining breast and the reconstructed one, and sometimes surgery on the other side can help. This can be done at the same time as the reconstruction, but waiting for the reconstruction to heal and settle into position may be better. Your specialist team will give you an idea of how long this is likely to be.
Immediate or delayed reconstruction
Breast reconstruction can be performed at the time of mastectomy (immediate) or at a later date (delayed). The main advantage of immediate reconstruction is preservation of both the native breast skin envelope and the inframammary fold, thus allowing for better aesthetics e.g. better ptosis. Another advantage of immediate reconstruction is that the emotional upset after the diagnosis of cancer and mastectomy is diminished, as well as preserving body image, femininity and sexuality. However, immediate reconstruction can delay adjuvant therapy if post-operative complications occur. Furthermore, immediate breast reconstruction is associated with a higher complication rate than delayed reconstruction. Further research is needed to provide reliable evidence for patients the best timing of breast reconstruction as there is no clear evidence supporting one over the other.
Patients who are uncertain about reconstruction are best advised to consider delayed reconstruction. Delayed reconstruction is for those who require cancer treatment and are unsure of which breast reconstruction option to choose. At the time of mastectomy, the native skin envelope is removed as patient has opted for delayed breast reconstruction. Therefore, extra skin must be recruited from a donor site or from skin expansion implants.
Advantages of immediate reconstructions
• Less risk of social or emotional difficulties (never without a breast)
• Better cosmetic results
• Possibly less surgery and lower cost
• No difference in the rate of development (growth) of local cancer recurrences
• No different in the ability to detect (find) local cancer recurrences
• No significant delays in getting other treatments (such as chemotherapy)
Disadvantages of immediate reconstructions
• Harder to detect mastectomy flap necrosis (when the skin remaining from the mastectomy has problems with blood supply)
• Longer time spent in the hospital than having mastectomy alone
• Longer time spent recovering than having mastectomy alone
• More scars and possible complications than having mastectomy alone
Advantages of delayed reconstruction
• Adjuvant therapy (treatments, such as radiation, occurring after the mastectomy) does not cause problems to the reconstruction site
• Gives patient more time to think about reconstructive options
Disadvantages of delayed reconstruction
• Mastectomy scar on chest wall
• Requires additional surgery and recovery time
• Sometimes harder to reconstruct after scarring occurs
• Less optimal cosmetic results
There are various approaches to breast reconstruction. For many patients, no reconstruction is sought after and therefore a simple external prosthesis or padded is all that is required. For selected small tumours, a lumpectomy may be performed which means the opposite breast may need surgery to improve symmetry. The process of breast reconstruction can take up to 24 months and multiple surgical procedures are usually required to achieve the aesthetically-pleasing outcome. The choice of reconstruction also depends may other factors such as patient choice, co-morbidities (obesity, diabetes, smoking), tumour type, and post-operative therapy (radiotherapy). Radiotherapy after breast reconstruction can have unfavorable effects, such as tissue fibrosis and micro vascular changes, on the aesthetic outcomes.
One option for breast reconstruction is implant-based reconstruction, which account for 61% and 37% of reconstructions in the US and UK, respectively. Current options for implant-based reconstruction include immediate reconstruction with a definitive fixed volume implant, or a two-stage reconstruction process with a tissue expander followed by an implant. A tissue expander allows saline to be injected weekly until a desired volume is reached. In the UK, two types of implants are commonly used silicone gel implants or saline implants.
Implant-based reconstruction involves the use of an implant under the pectoralis major muscle (to reduce risk of capsular formation). To achieve complete coverage, a portion of the serratus anterior muscle can be raised laterally and sutured to the pectoralis muscle. Cellular dermal matrices are collagen sheets derived from human, bovine and porcine tissues and thus can be used instead of recruiting the serratus anterior muscle. In addition, benefits include: shorter operative time, fewer post-operative expansions required, larger initial volume implants can be used and lower rates of capsular contraction.
In addition, triple antibiotic irrigation has been shown to be associated with low clinical incidence of capsular contracture. Implant-based reconstruction is a relatively simple procedure with few complications, but numerous visits may be required. Being foreign bodies, implants or expanders can suffer from problems such as infection, capsule formation or rupture however these complications can be reduced with sub-muscular positioning of the implant.
Can I have breast reconstruction?
You may be able to have breast reconstruction, if you have been:
• Diagnosed with breast cancer and had or will have a mastectomy (surgical removal of a breast)
• Diagnosed with breast cancer and had or will have breast conservation surgery, such as partial mastectomy or lumpectomy (surgical removal of the tumor and surrounding breast tissue)
• Found to have a genetic mutation and will have prophylactic mastectomy (removal of non-cancerous breast to prevent cancer)
Do I have to have breast reconstruction?
No. Some patients decide that they are not ready to have reconstruction for many reasons. Or, they decide not to have any more surgeries. Many may choose to wear a breast prosthesis (an artificial device to replace a missing part of the body). This allows a better fit in clothing and reduces the lop-sided feeling that a missing breast or breast tissue may create for some after their breast cancer surgery. Living a long cancer-free life is our goal. Keeping your femininity is just as important, too.
What about my other breast?
There are options. Most women leave the breast as is. Some women have the breast without cancer removed (prophylactic mastectomy) and most follow with breast reconstruction. Other women have surgery on the remaining breast to match or balance the other side. This surgery can be a breast lift, breast reduction or breast enlargement. These surgeries are usually done at a later date. As an example of surgery done at a later date: during implant reconstruction, the balancing surgery is done at the time when the expander is removed and the implant inserted (see page 6 about the expander).
Risks of breast reconstruction
• Discomfort and pain.
• Blood clots in the legs.
• Blood clots to the lungs (rare).
• Bleeding, which may need urgent surgery.
• Sensation to the breast may be temporarily absent. In most women sensation returns. In a small group of women sensation is lost permanently and does not return after surgery.
• Infection, the expander/implant may need to be removed.
• Capsular contracture. This is a condition when the tissue around the implant becomes scarred, hard and painful. The implant may need to be remove if painful.
• Implant breaks through the muscle wall and skin.
• Saline implants may deflate.
• Silicone gel implants – microfractures (very tiny cracks) may develop.
• The implants may not look natural.
• Folds of the implant can be seen through the skin.
• Implant may move, a shift resulting in a change in the appearance of the true reconstructed breast
Can breast reconstruction hide cancer or make it come back?
Studies show that reconstruction does not make breast cancer come back. If the cancer does come back, reconstructed breasts should not cause problems finding the cancer or treating it. If you are thinking about breast reconstruction, either with an implant or flap, you need to know that reconstruction rarely, hides a return of breast cancer. You should not consider this a big risk when deciding to have breast reconstruction.