Reconstruction of the breast is an option for most women who have had a mastectomy. You may choose an immediate reconstruction, in which the procedures are started during the same surgery as your mastectomy. Or, you may delay reconstruction and start the procedures after your initial surgery and other treatments are complete. Some women say that starting reconstruction right away helps reduce the trauma of losing a breast; immediate reconstruction also eliminates one hospitalization and anesthesia.
Reconstruction is elective surgery -- it is entirely up to you to decide if you want to take this step. Many women say that reconstruction helps them feel more confident and happy with their self-image after surgery. They needn't bother with a prosthesis, and they can wear all types of clothing. Other women are just as happy without reconstruction. Some prefer to avoid any further surgery, and have no problem using a prosthesis. The choice is yours.
Reconstruction will not replace your breast. The new breast will not function like a breast, and it won't have much sensation. But, depending on the method of reconstruction, in clothes it may look almost exactly like your other breast.
In the first step, a new breast mound is built. There are two primary choices for this: using an implant to replace the lost tissue or using tissues from elsewhere on the body to replace the lost tissue. Once the breast mound is completed, the other breast may be altered (with an implant, a reduction, or a lift) to achieve symmetry. In the final step, a new nipple-areola complex is built, and the nipple area may be tattooed to look like the other. (As of October 1998, a Federal law requires insurance companies to cover all aspects of reconstruction including operations to make the opposite breast match the reconstructed breast.)
The type of reconstruction best for you depends on the amount of skin remaining on the chest wall, the size and shape of your other breast, the amount of body fat and tissue available elsewhere, your general health, and your personal preferences.
If you know you want reconstruction, talk to your doctor about it early on - even before you have a surgical biopsy, if possible. Your choice might influence where incisions are made.
Complications are not common, but may include:
- capsular contracture (a hardening of the scar tissue that the body naturally forms around the implant and sometimes, distortion of shape)
- loss of the skin flap from damage to the blood supply
- infection
- hematoma (a collection of pooled blood under the skin)
- delayed wound healing
- rippling of the skin
- uneven contour
- size discrepancy between the two breasts.
Reconstruction does not hide local recurrences of cancer or increase the risk that cancer will recur or spread.
If you choose not to have reconstruction, you may find that a prosthesis will help you to look your best in clothes.
Reconstruction with Implant
This is the least complex way to build a new breast. Using the same incision that was made for the mastectomy, the surgeon places a tissue expander under the skin and muscle remaining on the chest wall. The expander is similar to an implant: it is a small, roundish envelope of plastic with an integrated valve. When inserted, it is flat. Over the next several weeks, saline solution is injected through the valve. This gradual enlargement allows the skin and muscle to slowly stretch to the size of the other breast.
A second operation is performed to insert a permanent saline implant and do a final shaping of the skin.
Implants work best in women who have small to medium-sized breasts and who have not had any radiation therapy to the breast area. (Radiation therapy impairs the skin's circulation and its ability to expand.)
Reconstruction with Body Tissues
There are several methods that surgeons may use to create a new breast using tissue from the body. In each, fat, skin, and muscle tissue are taken from elsewhere on the body, moved to the chest wall, and shaped into the form of a breast. The advantage of these procedures is that there is usually no need for an implant, and they usually can be performed on women who have had radiation (which often makes them unsuitable for tissue expansion and implants). On the minus side, these are complex surgical procedures that can take several hours in the operating room, as well as follow-up procedures to refine the shape of the breast. Smoking can interfere with the blood supply to the breast mound, so before having this kind of surgery, it is extremely important that you stop smoking.
In a TRAM flap (transverse rectus abdominus myocutaneous) reconstruction, the surgeon removes an oval-shaped section of fat and skin from the abdomen and shapes it into a breast on the chest wall. The tissue maintains its original blood flow: it is never completely cut from the body, but rather is moved by sliding it under the skin to the chest area. In a variation of this procedure, the entire complex of tissue is detached from the body, then reattached to the blood supply using microsurgery. The scar left on the abdomen is midway between the navel.
In a gluteal free flap reconstruction, tissue is taken from the upper or lower buttock. The tissue must be completely detached from the body and blood flow restored with microsurgery. This procedure is usually recommended for women under age 45 who are not candidates for implants and who don't have enough fat in the abdominal area to build a breast.
Another option is the latissimus dorsi flap, in which skin and muscle are moved from the upper back to the chest area. The tissues are tunneled underneath the skin, allowing the blood supply to be retained. This method provides plenty of skin but often not much fat, requiring the use of an implant. It is often a good choice for women who have had radiation.
A newer option is the "skin-sparing" mastectomy. The surgeon removes the breast tissue and nipple but leaves most of the skin shell in place. The breast tissue is then replaced with tissue from the abdomen.
The Prosthesis Option
Breast prostheses, just like breasts, come in different shapes: heart, teardrop, triangular, and asymmetrical. They also come in firm, medium, and soft silicone textures as well as a variety of sizes and skin tones to match the other breast. Prostheses can be placed in a special pocket in the brassiere. A properly fitted and weighted prosthesis provides the balance needed for correct posture. Custom-made prostheses are now also available.
To purchase a prosthesis, ask your doctor or nurse for referrals to stores (some hospitals have their own stores on site), or call the local office of the American Cancer Society. These stores specialize in post-surgical prostheses and brassieres and have experienced sensitive certified fitters who will help you. The fitter will consider the type of surgery you had as well as the size, shape, and texture of your remaining breast to select what is best for you. Fitters also provide instructions on the care of the prosthesis.
Medicare, Medicaid, and most other insurance companies will cover the cost of the prosthesis and bras. Make sure you have a prescription from your doctor.
Some organizations also provide free "recycled" prostheses, donated by women who changed sizes or type of prosthesis. Check with the Y-Me program and other organizations.
