Reconstructive Surgery for Breast Cancer

Overview
Many women choose reconstructive surgery after a mastectomy or bilateral mastectomy in order to restore the appearance and feel of their breasts. There are many different options for reconstruction, including timing, types of surgery and materials. For instance, reconstructive surgery can be started or completed immediately after mastectomy during the same surgery, or be postponed until a later surgery. Depending on your breast cancer, the surgeon may or may not be able to use skin-sparing or nipple-sparing techniques during mastectomy that will allow for a more natural-looking reconstruction. Reconstruction material options include silicone, saline and using your own tissue from another part of your body. Each choice has its own benefits and risks. What type of reconstructive surgery you choose can depend on the specifics of your breast cancer, the size of your breasts and of your body in general, what type of insurance you have, and how important it is to you that your reconstructed breast and your healthy breast closely match.

One alternative to reconstructive surgery, either temporarily or permanently, is the use of prosthetics. Prosthetic breasts come in many sizes, shapes and materials, and can be worn in many different ways.

What does it involve?
You will meet with a surgeon in order to decide what type of reconstructive surgery is best for you. Together you will review your case, discuss the benefits and risks of each type of reconstruction, and develop a plan for surgery. Do not be afraid to ask questions and make sure you understand each option. Find out how many surgeries each option will require, and the timeline for each procedure.

Immediate reconstructive surgery can help women return more quickly to their previous appearance. In addition, since it is done following the mastectomy procedure, it avoids extra surgery and more scars. However, if you will need radiation therapy after mastectomy, it is usually best to receive radiation first, and then undergo reconstruction later. Radiation therapy can delay healing and cause additional scarring if it is given after reconstructive surgery. Immediate reconstruction also carries a higher risk for some side effects. Delayed reconstructive surgery allows you to take more time to decide what type of reconstruction you prefer. Some women prefer to complete treatment for cancer before considering this question. If you choose to delay reconstructive surgery, the surgeon can place an expander at the end of the mastectomy procedure that will help prepare your body for an implant later on.

Depending on your specific case of breast cancer, the surgeon may be able to use skin-sparing or nipple-sparing techniques during mastectomy. Although these techniques can furnish a more natural-looking reconstruction combined with implants or a tissue flap graft, they may also carry a slightly higher risk of breast cancer recurrence since they will contain some breast tissue. If the surgeon cannot spare your skin during mastectomy, reconstruction may require the harvesting of skin and tissue from another site on your body, most commonly your abdomen, thigh or back, in order to rebuild your breasts. This will necessitate one or more additional surgeries, along with all the risks of surgery, and you will have more areas that need to heal. If you are a small, thin person, you may not have enough extra skin for this type of reconstruction.

You will also need to consider what material you prefer for reconstructive surgery. Both silicone and saline implants require less surgery and recovery time than natural tissue flaps using grafts of your own tissue. However, either type of implant will need to be replaced approximately every 10 years. Tissue flaps create the most natural looking and feeling breasts, but require longer surgeries and recovery times. In addition, tissue flap procedures require surgery on other parts of your body to harvest tissue for the procedures. Silicone implants look and feel more natural than saline implants.

If your nipple is removed during mastectomy surgery, you may decide that you would like to undergo nipple reconstruction. Nipple reconstruction is usually done three or four months after initial reconstructive surgery, once the new breasts have had time to heal. Nipples can be crafted from artificial substances or tissues harvested from your body. Reconstructed nipples may later be tattooed to achieve realistic coloration. As an alternative to reconstruction surgery, dermabrasion or three-dimensional tattoos can provide the look of a nipple. As a temporary or permanent option, you can also attach removable polyurethane nipples.

Within the choices listed, there are many different surgical techniques used for reconstructive surgery. Most surgeons have a preferred technique.

It is important to note that breast reconstruction is rarely accomplished with one surgery. One or more follow-up procedures may be needed. For instance, small changes may be required to achieve the desired shape or size. If only one breast is reconstructed, some women want surgery to change the shape of the healthy breast to match it more closely. The entire process may require as long as nine months.

Intended Outcomes
Women choose reconstructive surgery to retain the look and feel of their natural breasts and to regain symmetry and balance. Successful reconstructive surgery can help a woman feel more comfortable with her body after mastectomy.

Results
Researchers surveyed 98 women who had undergone mastectomies and decided to delay reconstructive surgery. Each woman was interviewed before reconstructive surgery, six months after beginning the reconstruction process, and after the reconstruction was considered complete. The results, published in 2014, showed significant improvements in body image and sexual satisfaction after reconstruction, no matter what type of reconstructive surgery each woman had chosen.

A 2012 study found that infection occurs after as many as 35 percent of breast reconstructions after mastectomy.

Several studies have shown that smoking and being overweight contributed significantly to the chances for infection and complication after reconstructive surgery.

Constraints
A reconstructed breast may not look or feel exactly like you expect. Although the skin may regain more sensitivity over time, the skin and nipple will never provide the same sensation that they did before reconstruction.

Some women describe a lingering or permanent sensation of tightness in the chest after breast reconstruction.

Reconstructive surgery may not be possible if you are obese, too thin, or if you have bleeding or circulation problems.

Tissue flap surgery may leave you with long-term weakness or loss of function at the donor sites. For instance, if tissue is collected from the abdomen, you may experience bulging, bloating and discomfort even months after surgery.

Although most insurance pays for breast reconstruction after mastectomy, depending on your plan, you may have to pay a deductible as high as $10,000. Your insurance may not cover surgery on the healthy breast to make it match the reconstructed breast. Women on Medicaid may face long waits for surgery.

Cell death (necrosis) can occur in the skin flap and any donor tissue. This would necessitate further surgeries, and may alter the appearance of the reconstructed breast. This is more likely after immediate reconstruction.

After any surgery, there is increased risk for infection at the surgical site. While your reconstruction wound is healing, monitor the incision for swelling, redness, pain or heat. If you suspect infection, contact your doctor right away. Infections that are caught early should be easily managed with medications.

Any type of surgery carries risks including blood clots, blood loss, infection, breathing problems, reactions to medication, and heart attack or stroke during the surgery.