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BREAST CANCER REVIEW

Breast Reconstruction

Introduction

Breast reconstruction is a surgical procedure for recreating a breast after mastectomy. The procedure is accomplished with breast implants or with the use of a woman's own tissue. In some cases, a combination of both methods is used. While not all mastectomy patients will choose breast reconstruction, every woman should be counseled in her reconstructive options prior to surgery. Women should also be informed about alternatives to breast reconstruction which include wearing an external breast prosthesis or wearing no breast replacement at all. 

Immediate or Delayed

Most women undergoing a mastectomy are candidates for breast reconstruction. (Reconstruction is usually not necessary for women who have had a lumpectomy.) Important clinical considerations include a women's overall health, coexisting illnesses, and potential for complications. Extreme obesity and heavy smoking are considered contraindications, as is poor general health. Women with a poor cancer prognosis and women with a short life expectancy are also not considered good candidates. However, advanced age, in and of itself, is not a contraindication. Any women who finds herself feeling unready or unsure should wait until certain before proceding.¹ Breast reconstruction does not impair the detection of any recurrence of breast cancer.

Breast reconstruction can be performed at the time of mastectomy (immediate reconstruction) or at any time later (delayed reconstruction). Two or more surgeries over the course of several months is typically required, although follow-up procedures are usually minor. The decision of when to begin depends upon a combination of a woman’s clinical characteristics and her personal preferences.² With either implant- or tissue-based methods, a woman should consider the number of surgical events she is prepared to undergo, as delayed reconstruction means having one additional surgery. Still, some women may prefer this to dealing with the stress of cancer and breast reconstruction at the same time. Another consideration with timing is the possibility of post -mastectomy radiation therapy (PMRT).^3 , 4  PMRT can complicate reconstruction and require additional procedures.

Advantages of Immediate Reconstruction:

• awaking from cancer surgery with a breast replacement
• having a hopeful, future-oriented event during a difficult emotional time
• fewer number of surgical procedures
• fewer number of recovery periods
• outcome may be improved with both cancer surgeon and plastic surgeon planning the procedure together

Disadvantages of Immediate Reconstruction:

• having less time to make decisions about reconstructive options
• stress of dealing with cancer and breast reconstruction at the same time
• possible increased risk with undergoing two surgeries at once
• potential difficulty of coordinating general and plastic surgical procedures
• potential interference with post-mastectomy treatments     

Types of Breast Reconstruction

There are two main types of breast reconstruction available to most mastectomy patients: breast implants and tissue reconstruction. Implant reconstruction is the simpler of the two.

Tissue Expander / Implant Reconstruction

Fig. 1	Fig. 2	Fig. 3

With implant-based reconstruction, a tissue expander is inserted through the mastectomy incision, under the chest muscle. The tissue expander is usually required in order to stretch the muscle and skin. The expander contains a valve through which small amounts of saline are periodically injected (over the course of several weeks) until the expander becomes inflated to an appropriate size. When the tissue has been adequately stretched, the expander is replaced with a permanent breast implant. Currently, saline and silicone gel implants are available for breast reconstruction. Women undergoing immediate reconstruction, and using the technique of a skin-sparing mastectomy, may sometimes avoid the need for an expander. Similarly, tissue expansion may not be necessary in patients who require reconstruction of a small breast.⁵

In the United States, permanent breast implants are filled with either saline or silicone gel. Silicone implants feel more like natural breast tissue than saline. Nevertheless, silicone implants have been the subject of a long-time safety controversy. Specifically, patient complaints led some medical experts to associate silicone leakage with immune-related disorders and other serious illnesses. While empirical studies failed to provide evidence of a link between silicone implants and disease, the 1992 ban imposed by the U.S. Food and Drug Administration remained for 14 years.⁶  Until recently, a woman who chose silicone gel-filled implants could do so only by participating in a closely monitored medical trial.⁷ In November, 2006, however, the FDA ban on the use of silicone gel breast implants was lifted. Still, women who choose silicone implants may require MRI monitoring to detect possible rupture.⁸ As for saline-filled implants, there are no similar concerns. If implants filled with saline leak, the saline is absorbed harmlessly into the body.

Advantages of Implant Reconstruction

• less complex, shorter surgical procedure
• does not involve tissue from other parts of the body (less scarring)
• briefer hospital stay and recovery time
• produces relatively predictable breast shape and size
• fewer scars

  Disadvantages of Implant Reconstruction

• may give a less natural breast shape
• final breast shape is not immediate
• possible rupture, migration
• possible capsular contracture
• possible rippling of implants
• may not respond well to subsequent radiation and/or chemotherapy
• insurance may not cover replacement

Tissue reconstruction, also called autologous reconstruction, is a flap procedure that uses the patient's own tissue to rebuild the shape of a breast. Tissue may be taken from the back, abdomen, buttocks, or more rarely, the thighs. The flap of tissue may be transferred without severing the tissue from its original blood supply (pedicled) or it may be severed from its original blood supply and microsurgically attached to new blood vessels near the chest (free flap, or free perforator flap). Because all tissue reconstruction methods involve the blood vessels, women who smoke or have diabetes, vascular, or connective tissue diseases may not be good candidates for this type of procedure.⁹ Generally, both surgery and recovery take longer with tissue reconstruction than with implants.

The most common tissue reconstruction techniques are the transverse rectus abdominis flap (TRAM flap) and the latissimus dorsi flap (LAT flap). Two newer flap techniques are the deep inferior epigastric perforator flap (DIEP flap) and the gluteal artery perforator flap (GAP flap).

Fig. 1	Fig. 2	Fig. 3	Fig. 4

TRAM Flap: The transverse rectus abdominis flap (TRAM flap) uses tissue from the lower abdomen. There are two types: pedicled and free. The pedicled is most common. With this procedure, the skin, fat, blood vessels, and at least one of the abdominal muscles are pulled through a tunnel under the upper abdominal skin to the chest area. There, the tissue is reshaped into the contour of a breast. The free TRAM flap removes less abdominal muscle but involves the severing of the flap from its original location before attaching it to blood vessels in the chest area. Both types of TRAM reconstructions result in a tightening of the lower abdomen. Potential complications include hernia, decreased abdominal strength and exercise tolerance, among others.

Fig. 1	Fig. 2	Fig. 3

Latissimus Dorsi Flap: The latissimus dorsi flap (LAT flap) is sometimes used for selected patients; this may include women whose abdominal tissue is insufficient or cannot otherwise be used. With this procedure, a portion of skin, fat and muscle is mobilized from the back and pulled through a tunnel under the skin of the axilla to the site of the mastectomy. Latissimus dorsi reconstruction does not compromise the abdominal wall, which may be an important consideration in women planning future pregnancy.¹⁰ In women with larger breasts, however, a LAT flap procedure may require the addition of an implant.

Deep Inferior Epigastric Perforator: Deep inferior epigastric perforator flap (DIEP Flap) is a newer type of free flap procedure that uses fat and skin from the same area as the TRAM flap but leaves the abdominal muscle in place. As a result, some of the potential complications with the TRAM flap (e.g., hernia, muscle weakness) are greatly minimized. Its disadvantage is that it requires microvascular surgery, which is technically more demanding and is only available in select settings. The same is true for all free flap procedures.

Gluteal Artery Perforator: Gluteal Artery Perforator (GAP) is another newer type of free flap surgery that uses tissue from the upper (Superior Gluteal Artery Perforator flap) or lower (Inferior Gluteal Artery Perforator flap) buttock region to create the shape of the breast. It is generally used for women who are too thin for procedures using tissue from the abdominal area, or for women whose abdominal tissue cannot be used due to scarring from previous surgical procedures.

Less frequently, tissue reconstruction is accomplished with the use of flaps from other areas of the body where there is enough fat and a suitable blood supply, such as the thigh (e.g., lateral thigh flap).

Advantages of Tissue Reconstruction

• soft and natural-appearing breast mound
• no implant necessary with most procedures

Disadvantages of Tissue Reconstruction

• major surgery, possible blood transfusions
• considerable post-operative discomfort , extended healing
• additional incision, scarring (abdomen, back, etc.)
• decreased strength in transfer site is common
• risk of flap failure

Women who want to achieve the most realistic appearance possible may also choose to have the nipple and areola reconstructed. Nipple and areola reconstructions are usually done after the initial breast reconstruction has had time to heal (usually two to six months). A new nipple may be molded with a flap of skin from the reconstructed breast or constructed with tissue from another area of the body, such as the earlobe or opposite nipple. Options for reconstructing the areola include a skin graft, tattooing, or a combination of both methods. In general, most patients who have had a breast reconstruction may opt for a nipple and areola reconstruction as well.

Potential Complications

Both implant and tissue reconstruction are associated with potential complications which vary with the type of procedure. Temporary pain, swelling, bruising, and tenderness are common with all surgeries. Rare complications from general surgery may also occur from breast reconstruction, such as bleeding, fluid collection, excessive scar tissue, infection, fatigue, and problems with anesthesia.¹¹

With breast implants, one of the most common problems is capsular contracture, a condition that occurs when the scar around the implant begins to tighten, causing the breast to feel hard. The condition may be treated with additional surgery to remove the scar tissue. In some cases, the breast implant will need to be removed and replaced. Another possible complication is leakage or rupture of the implant.

Tissue reconstruction is a major operation. All types of flap procedures leave scars both from where the flap is taken and on the reconstructed breast. If there is a poor blood supply to the flap tissue, part or all of the tissue used for recreating the breast shape may not survive (tissue necrosis). Infection and poor wound healing are also potential complications.  Additional surgeries may be required to correct problems.

Most breast reconstruction involves a series of procedures that occur over time. The initial reconstructive operation is usually the most complex. Follow-up surgery may be required to replace a tissue expander with a permanent implant or to reconstruct the nipple and the areola. Most often, the natural breast will require reduction, augmentation, or lifting (mastopexy) for optimum symmetry and balance.

Regardless of the type of surgery, a woman's decision to have or not to have breast reconstruction should be an informed, thoughtful process that compares all of the potential pros and cons. Many women choose this additional surgery as a way of restoring their sense of body identity and to feel more attractive. However, patients need to realize that the new breast, no matter how successful the surgery, will never match exactly their natural breast nor will it have the same sensations as the breast that they lost to cancer. Moreover, breast reconstruction will require additional time for healing and recovery and, as noted above, all surgery comes with some degree of risk.   

Finding a Plastic Surgeon

A woman who has decided to have breast reconstruction will need to find a qualified plastic surgeon. It is important to make sure that the plastic surgeon is certified by the American Society of Plastic Surgeons and has extensive experience with the specific type of procedure being considered. To find out if a surgeon is board certified, visit the web site

ASPS Symbol

of the American Society of Plastic Surgeons (ASPS). Surgeons can be searched by geographical area or name.  Also, look for the copyrighted ASPS symbol to ensure board certification. Only members of the American Society of Plastic and Reconstructive Surgeons can display this symbol.

The National Cancer Institute recommends that breast cancer patients ask their plastic surgeons the following questions before having breast reconstructive surgery:¹²

• What is the latest information about the safety of breast implants?
• How many breast reconstructions have you done?
• Which type of surgery would give me the best results?
• How long will the surgery take? What kind of anesthesia?
• When do you recommend I begin breast reconstruction?
• How many surgeries will I need?
• What are the risks at the time of surgery? Later?
• Will there be scars? Where? How large?
• Will flap surgery cause any permanent changes where tissue was removed?
• What complications should I report to you?
• How long will my recovery take? When can I return to my normal activities? What activities should I avoid?
• Will I need follow-up care?
• How much will it cost? Will my health insurance pay for breast reconstruction?

The Women's Health and Cancer Right Act of 1998 (WHCRA) contains important protections for breast cancer patients who choose breast reconstruction in connection with a mastectomy.¹³ For women whose group health plans, insurance companies or health maintenance organizations cover mastectomy, the law requires coverage also for:

• All stages of reconstruction of the breast on which the mastectomy was performed
• Surgery and reconstruction of the other breast to produce a symmetrical appearance
• Prostheses
• Treatment of physical complications at all stages of the mastectomy, including lymphedema

WHCRA is administered by the U.S. Departments of Labor and Health and Human Services. For more information, please visit the U.S. Department of Labor web site: Your Rights After A Mastectomy... Women's Health & Cancer Rights Act of 1998. Several states have their own laws regarding reconstructive surgery after a mastectomy, including California.  Several states have their own laws regarding reconstructive surgery after a mastectomy, including California. (See California Insurance Code 10123.8.)¹⁴  

Breast Prostheses

Breast prostheses are external breast forms that can be worn after a mastectomy to help achieve symmetry and balance the body. Choosing to wear a prosthesis is an option for women who either delay breast reconstruction or decide against the additional surgery.

Breast prostheses are made from a range of materials, such as silicone gel, foam, and fiberfill. Custom-made forms can feel similar to natural breast tissue and are usually weighted to match the remaining breast. Some prostheses attach directly to the chest and others fit into pockets of a post-mastectomy bra. Prostheses may also include an artificial nipple. Partial prostheses are available for women who have had part of their breasts removed.

As with surgical options, a woman should be informed about the various prosthetic products available to her before cancer surgery. In addition, healthcare providers should recommend that their patients contact their insurance companies to ask about coverage details. While usually not required, a prescription is recommended.

For women considering a breast prosthesis, the American Cancer Society has the following additional suggestions:¹⁵

• Contact a local chapter of Reach to Recovery, a support group for women with breast cancer, for information and suggestions.
• Wear a prosthesis while waiting for reconstructive surgery.
• Consider that small prosthesis "equalizers" that are available for women who have had a lumpectomy or a segmental mastectomy.
• Keep in mind that nipple prostheses are available for breast reconstruction when the nipple could not be saved.
• Make an appointment to go shopping for a prosthesis in a surgical supply store, lingerie and corset shop, or lingerie department of a department store. Call before you go to make sure a professional fitter will be there.
• Wear a form-fitting top when shopping for a prosthesis.
• Have your partner or a good friend go shopping with you.
• Select a prosthesis that feels comfortable (despite its weight), shows natural contour and consistency, and remains in place when you move.
• Ask if the prosthesis absorbs perspiration and how to care for it.
• Try many different types. Prostheses vary in shape, weight, and consistency. Custom-made forms are also available.
• Shop around; find the best fitting prosthesis at the right price.

Some women are comfortable with their body image after surgery and prefer not to wear a breast prosthesis. Wearing no replacement may be viewed as simpler and more convenient. It may also be viewed by some women as a way of coming to terms with the changes to their bodies. As with most things in life, people respond differently to similar situations. Whatever a woman's personal decision - reconstruction, no reconstruction, prosthesis or nothing - her adjustment to living with an altered body will be made easier with ongoing support from her healthcare team.

Notes

¹Kroll, SS. Who is not a candidate for breast reconstruction? In Breast Reconstruction Guide for Patients (Reece, JP, Ed.), (2006). Retrieved Jul. 21, 2006 at: http://www.mdanderson.org/Diseases/ BreastCancer/reconstruction/dIndex. cfm?pn=2E8DFE2E-0F37- 4ABF-B8489692A96B5674

²For a list of special considerations, please see: American Cancer Society. Breast Reconstruction After Mastectomy (revised, Aug. 23, 2004). Retrieved Jul. 21, 2006 at: http://www.cancer.org /docroot/CRI/content/ CRI_2_6X_Breast_ Reconstruction _After_Mastectomy_5.asp

³Reconstructive Breast Surgery. Surgical Options. Retrieved Mar. 13, 2006 at: http://www.breastreconstruction.ca/surgical.htm

⁴See note 2.

⁵See note 3.

⁶Rados, C. Making an Informed Decision About Breast Implants. FDA Consumer Magazine (Sep. - Oct. 2004). Retrieved Mar. 13, 2006 at: http://www.fda.gov/fdac/features/2004/504_implants.html

⁷National Cancer Institute. Breast Reconstruction. Retrieved Jul. 22, 2006 at: http://www.cancer.gov/ cancertopics/understanding -breast-cancer-treatment-defunct/page13

⁸U.S. Food and Drug Administration. Breast Implant Questions and Answers (2006). Retrieved Dec. 14, 2006 at: http://www.fda.gov/cdrh/breastimplants/qa2006.html

⁹People Living With Cancer. After Treatment for Breast Cancer: Breast Reconstruction. Retrieved July. 13, 2006 at: http://www.plwc.org/portal/site/PLWC/menuitem.169f5d85214941ccfd 748f68ee37a01d/?vgnextoid=363341eca8daa010VgnVCM 100000ed730ad1RCRD&cpsext currchannel=1

¹⁰Kim, JYS. Breast Reconstruction, Latissimus Flap (updated, Jun. 14, 2006). Retrieved Jul. 22, 2006 at: http://www.emedicine.com/plastic/topic137.htm

¹¹See note 4.

¹²See note 7.

¹³U.S. Department of Labor.Your Rights After A Mastectomy: Women's Health & Cancer Rights Act of 1998 (updated, April 2003). Retrieved Jul. 22, 2006 at: http://www.dol.gov/ebsa/Publications/ whcra.html

¹⁴FindLaw.California Insurance Code 10123.8. Retrieved Jul. 21, 2006 at: http://caselaw.lp. findlaw.com/ cacodes/ins/10110-10127.16.html

¹⁵American Cancer Society. Prostheses. Retrieved Jul. 21, 2006 at: http://www.cancer. org/ docroot/ MIT/ content/MIT_7_2X_Prostheses.asp?sitearea=MIT

Updated: June 4, 2008.

Source URL: http://qap.sdsu.edu/education/bcrl/Bcrl_reconstruction/bcrl_reconstruction_index.html

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