Affecting one in eight women, breast cancer has become a common topic in our society. Many women choose to undergo breast reconstruction to restore the size, shape, and symmetry of their breasts after undergoing surgery for breast cancer or to prevent breast cancer. Modern oncologic surgery has been able to stratify patients into different treatment regimens depending on the extent of breast cancer. Moreover, newer techniques in plastic surgery have also evolved to help create a more natural breast shape after a mastectomy. A breast mound can be created using your native tissue and transferring it to your chest or by using breast implants. These procedures can be done at the same time as your mastectomy (immediate reconstruction) or any time after your surgery (delayed reconstruction). The extent of the cancer and your preference will help determine the best plan for you. I work closely with breast surgeons to help guide you through your reconstructive process. Sometimes in large breasted women, I operate alongside the breast surgeon to perform an oncologic breast reduction where the breast cancer is removed as part of the breast reduction tissue on the breast cancer side and a symmetrizing breast reduction is performed on the opposite breast.
Goals of Reconstruction
Breasts have become analogous with femininity in our society. The loss of a breast through cancer or trauma can lead to self-consciousness, social anxiety, and difficulty dressing. The goals of breast reconstruction are to restore your natural silhouette through either implant-based or autologous reconstruction, using your natural tissue.
Stages of Reconstruction
Breast cancer reconstruction is a multi-step process from building the breast mound to creating a realistic nipple and areola. The process can start at the time of mastectomy or be delayed until a later date. My team includes specially trained permanent make-up artists who can recreate a 3D image of a nipple and surrounding areola in the office for a more natural reconstruction. Breast reconstruction has been demonstrated not to affect the recurrence of cancer or interfere with chemotherapy and radiation treatment.
Breast reconstruction is commonly performed using breast implants, in which the reconstruction relies on implants to create a new breast mound. Depending on the size of your breasts and your goal size, either implants (single-stage) or tissue expanders (two-stage) will be placed during the time of mastectomy. Both devices are placed beneath your pectoralis muscle to decrease the chance of capsular contracture- that’s when the capsule which your body naturally forms around the implant hardens, becomes painful or distorts the breast shape. Most commonly patients undergo a two-staged procedure in which a tissue expander, a temporary modified saline device is inserted under an envelope of muscle. The expander has a valve which allows more saline to be injected into it, inflating the device and slowly stretching your skin and muscle over the next few months to reach your desired size. The final volume is limited by the quality and size of the skin-muscle envelope. A second out-patient procedure is required for the expander to be replaced with a permanent implant. Reconstruction with tissue expansion allows for an easier and faster recovery than flap procedures but increases the length of the reconstructive process.
When breast reconstruction is performed using implants, it often occurs in two stages. The first image shows the breast immediately after mastectomy. There is no longer any breast tissue, only pectoralis muscle and skin. During the first stage of reconstruction, an expander is placed under the pectoralis muscle. Over the next few months, the expander is inflated until it reaches your desired size. In a second procedure, the expander is replaced with an implant. Later, a nipple is reconstructed in the office or in the operating room.
Autologous reconstruction relies on using your own tissue to create a breast mound. The tissue or flap is brought from another part of your body. Radiation therapy or more aggressive mastectomies can leave insufficient or poorly vascularized tissue on the chest wall to cover a breast implant, necessitating the need for a flap technique. The most common autologous reconstruction is using abdominal tissue through a TRAM, muscle-sparing TRAM or DIEP flap. The difference between these three procedures is the amount of muscle transferred and if the flap remains attached to the original blood supply and tunneled under your skin to your chest or if it is completely detached and then reattached to your chest. One benefit of this operation is the removal of excess skin from your abdomen, similar to a tummy tuck procedure. But most patients choose autologous reconstruction because the skin and soft tissue flaps tend to look and feel more like a natural breast than reconstruction with implants.
During a TRAM reconstruction, tissue is brought from the abdomen to reconstruct the breast mound. This is an excellent option for women who have undergone irradiation, enabling breast reconstruction with non-irradiated skin.
In the last few years, fat grafting has truly enhanced the results of breast reconstruction. Several studies have demonstrated that the addition of fat does not increase your risk of cancer recurrence nor does it decrease the chance of cancer detection. Fat grafting is a process in which fat is removed from one area of your body and injected into another. It is often used in breast reconstruction to soften the transition from the chest wall to the implant or to smooth contour irregularities.
Nipple and Areola Reconstruction
Creating a nipple and areola is the last surgical stage of the reconstructive process. For women who have undergone a nipple-sparing mastectomy, this procedure is not necessary. Most patients choose to undergo nipple and areola reconstruction as it leads to a more natural appearance and can help hide part of the mastectomy scar. The procedure is performed as an out-patient in the operating room or in the office depending on your comfort level and the extent of surgery. The nipple is recreated using skin from the reconstructed breast. The areola can either be tattooed on or grafted using a piece of skin from the groin area. The skin from the groin is naturally darker than the skin of the breast, giving the appearance of an areola. The scar in the groin is hidden in your bikini line. For women who do not wish to have another surgical procedure or who have had radiation, three-dimensional tattoos are an excellent option to create the look of a nipple and areola. The 3D tattoos are performed in my office.
All surgeries have the general risks of bleeding, infection, nerve damage, asymmetry and poor scarring. Unique to flap surgery is the risk of partial or complete loss of the flap and a loss of sensation at both the donor and reconstructed sites. Implant-based surgery has the risk of breast firmness due to capsular contracture and implant malfunction or rupture.
Choosing the Best Option
There are many factors in choosing the best option although there is no one best method. The type of mastectomy, need for radiation, and your body type are all important factors in deciding the best option for you. It is also important to understand your long-term goals and aesthetic desires. Both methods will likely require more than one operation.
Location and Recovery
Breast reconstruction is performed as an in-patient procedure under general anesthesia. Additional stages of reconstruction, implant exchange, fat grafting, nipple reconstruction, and nipple tattooing are performed as outpatient procedures in a surgical suite or in the office depending on the extent of surgery. Following the procedure, you will have gauze and bandages covering the incisions. A surgical bra is used to minimize swelling and support the reconstructed breast. Often drains, thin tubes, are used to remove any excess blood of fluid. Many patients will spend one or more nights in the hospital depending on the timing of your mastectomy and reconstruction and which technique for reconstruction is preferred. The recovery time is dependent upon the technique chosen. Most patients return to normal daily activities in seven to ten days and to their regular routine in one month.
An Oncologic Reduction
Given that one in eight women are diagnosed with breast cancer, it is not surprising that some women with breast cancer also suffer from having very large breasts. Advances in breast surgery have changed how we treat breast cancer. Women now have more options than just a lumpectomy or a mastectomy. In some breast cancer cases, it is possible to perform a breast reduction while performing a lumpectomy. Once you have healed, you can undergo radiation therapy as you would after a traditional lumpectomy procedure. In these situations, I work closely with your oncologic breast surgeon so that she/he removes the cancer and then I reduce, elevate and shape your breast. When only one breast is treated for cancer, the opposite breast is also reduced during the same procedure for symmetry, allowing the removal of the cancer and complete reconstruction to occur at the same time. This is a great option for many women, combining positive long-term oncologic results with beautiful cosmetic and functional outcomes.
The Women’s Health and Cancer Rights Act of 1998 requires group health plans, insurance companies and health maintenance organizations (HMOs) that pay for mastectomies to also pay for the reconstruction of the breast removed by a mastectomy, surgery and reconstruction of the opposite breast to achieve symmetry, breast prostheses, and treatments of any complications from surgery.
If you have been thinking about considering breast reconstruction, please call our office at (212) 600.4109 to arrange for a consultation. Our New York City practice accommodates out of town and international patients who need to travel in for surgery as well as those who are local to Manhattan.