Plastic and reconstructive surgeon Andrea Pusic talks to her patients about the many things to consider when choosing breast reconstruction, including timing, personal preferences, and surgical techniques.
At Memorial Sloan Kettering, you may choose to have immediate reconstruction, which means we’ll start the process of rebuilding your breast during mastectomy (the surgery to remove it). Or you can start the procedure after your initial surgery and other treatments are complete. It’s a personal choice. Some women say that starting reconstruction right away helps lessen the trauma of losing a breast, and you also don’t have to be hospitalized and go under anesthesia a separate time. But either option may be right for you.
There are two methods of replacing the lost tissue during reconstruction: using an implant or using tissues from elsewhere in the body. The new breast will not function like a normal breast, and it won’t have much sensation. But depending on the method of reconstruction, in clothes it can look almost exactly like the other breast.
To make your breasts symmetrical, we’ll provide you options for an implant, a reduction or a lift of your breast, or other strategies so that your breasts look similar in size and shape. In the final step, we’ll build a new nipple-areola that can be tattooed with a similar color.
The type of reconstruction that is best for you depends on several factors. These can include the amount of skin remaining on the chest wall, the size and shape of the other breast, the amount of body fat and tissue available elsewhere, and your general health, smoking history, and personal preferences.
If you know that you’ll want reconstruction, you should talk to your doctor about it early in your treatment — even before you have a surgical biopsy, if possible. Your choice might influence where incisions are made.
Implants are best for women with small- to medium-size breasts and for those who have not had any radiation therapy to the breast area. In the first step, a pocket is formed from the pectoralis muscle in the chest and an expander is placed in that space.
Over the next several months, we inject saline (a solution of salt in water) through a valve into the expander sac to slowly stretch the skin and muscle in preparation for the permanent implant. During a second, shorter operation, we remove the expander and insert the implant in its place.
Implants come in different shapes and sizes and are made of saline or silicone (a type of gel). A plastic surgeon will help determine which type of implant is best for you.
Another method for reconstructing the breast is to use tissue transferred from somewhere else in the body. The new breast is built using muscle from one of three locations:
- the TRAM (transverse rectus abdominus myocutaneous) flap, an oval-shaped section of fat and skin in the abdomen
- the gluteal free flap, from the upper or lower buttocks
- the latissimus dorsi flap, from the upper back to the chest
- the DIEP (deep inferior epigastric perforator) flap, which is similar to a TRAM flap, except that no muscle is used to form the breast mound
Once we finish creating the new breast, the other breast may be altered (with an implant, a reduction, or a lift) to achieve symmetry. In the final step, we’ll build a new nipple-areola, which can then be tattooed with a color similar to the other nipple.
Radiation therapy can sometimes cause damage to the skin that makes breast reconstruction challenging. Our plastic surgeons have extensive experience with reconstruction for patients who have already had radiation therapy.