Approximately 1 in 8 women will develop invasive breast cancer in their lifetime. As of January 2018, there are more than 3.1 million women with a history of breast cancer in the United States. While much effort is directed at research, prevention, screening, and early detection, there are a larger number of women who are still faced with the reality of having to undergo procedures where part or all of their breasts tissue is removed (lumpectomy vs mastectomy).
Ideally, the conversation for reconstructing or restoring the breast should begin at the time of the diagnosis, but we know that this is often not the case. In fact, only about 1/3 of women eligible for reconstruction actually undergo a procedure, and approximately 75% of women facing mastectomy or lumpectomy are not even aware of the existence of surgical breast reconstruction.
Major impediments that have been identified are:
- Lack of education or awareness by providers as well as patients.
- Misconception that a referral to a plastic surgeon must be ordered by their provide.r
- Reconstruction is considered cosmetic surgery and therefore not included as a health benefit by insurers.
To address each of the above, we work diligently to educate both patients and providers in our expanding region of coverage. Referrals by a provider to a plastic surgeon are not necessary, patients can call directly for consultation. Most importantly, we are fortunate in our immediate region to work closely with other physicians who are equally devoted to providing excellence in care to breast cancer patients.
As it relates to insurance coverage, the Women’s Health and Cancer Rights Act of 1998 is a federal law that provides protections to patients who choose to have breast reconstruction in connection with mastectomy. To summarize, the decision to undergo surgical breast reconstruction is a very personal one that patients make with the support of family and friends and under the advisement of their individual specialists. As with any decision in life, the better informed you are, the more confidently you can move forward with your treatment plan.
- 1 Breast Reconstruction Candidates
- 2 Before & After Photos
- 3 Risk
- 4 Types of Reconstruction Surgeries
- 5 Procedure
- 6 Flap Reconstruction
- 7 Follow-Up Procedures
Breast Reconstruction Candidates
The best candidates are women who are in good general health and whose cancer, as far as can be determined, can be treated with the combination of mastectomy and any additional treatments prescribed. In many cases, this can be coordinated at the time of the mastectomy (immediate reconstruction).
Still, there are legitimate reasons to wait. Many women aren’t comfortable weighing all the options while they’re struggling to cope with a diagnosis of cancer. Others simply don’t want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeon to wait, particularly if radiation is recommended to the cancerous breast. Women with other health conditions, such as obesity, high blood pressure, or smoking, may also be advised to wait (delayed reconstruction).
In any case, being informed of your reconstruction options before surgery can help you prepare for a mastectomy with a clear reconstruction plan and a more positive outlook for the future.
Before & After Photos
Virtually any woman who must lose her breast to cancer or cancer prevention can have it restored. But there are risks associated with any surgery and specific complications associated with this procedure.
This is not to imply that one’s reconstructed breast will always look like their pre-mastectomy breast. The goal, of course, is to achieve the best possible symmetry of size and shape, but there are factors inherent to the mastectomy procedure, different body habitus, previous breast operations (including prior cosmetic breast surgery), and other treatments especially radiation that make this an imperfect science.
As with any surgical procedure, there are associated risks and complications with these techniques. Each will be discussed later as they are often technique-specific. However, there are a number of general health factors that are important in determining whether or not immediate reconstruction is an option for them.
In general, the usual problems of surgery, such as bleeding, fluid collections (seroma), excessive scar tissue can and sometimes do occur. Difficulties with anesthesia, can occur although they’re relatively uncommon. And, as with any surgery, smokers should be advised that nicotine can delay healing, resulting in conspicuous scars and prolonged recovery. Occasionally, these complications are severe enough to require a second operation.
If an implant is used, there is a remote possibility that an infection will develop, usually within the first two weeks following surgery. In some of these cases, the implant may need to be removed for several months until the infection clears. A new implant can later be inserted.
Virtually any woman who must lose her breast to cancer can have it rebuilt through reconstructive surgery.
The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways, and sometimes requires either removal or scoring of the scar tissue, or perhaps removal or replacement of the implant.
Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment, should cancer recur. Your surgeon may recommend continuation of periodic mammograms on both the reconstructed and the remaining normal breast. If your reconstruction involves an implant, be sure to go to a radiology center where technicians are experienced in the special techniques required to get a reliable x-ray of a breast reconstructed with an implant.
Women who postpone reconstruction may go through a period of emotional readjustment. Just as it took time to get used to the loss of a breast, a woman may feel anxious and confused as she begins to think of the reconstructed breast as her own.
Types of Reconstruction Surgeries
Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction
In a DIEP flap, fat, skin, and blood vessels (but no muscle at all) are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. Because no muscle is used, most women recover more quickly and have a lower risk of losing abdominal muscle strength with a DIEP flap compared to any of the TRAM flap procedures.
Because the DIEP flap procedure requires special surgical training as well as expertise in microsurgery, not all surgeons can do a DIEP flap. If you’re considering a DIEP flap, Drs. Delatte, Mes & St. Hilaire have performed many procedures of this type right here in Lafayette, Louisiana.
Latissimus Dorsi Flap
The latissimus dorsi (LD) flap is a standard method for breast reconstruction that was first utilized in the 1970’s. The latissimus dorsi flap is most commonly combined with a tissue expander or implant, to give the surgeon additional options and more control over the aesthetic appearance of the reconstructed breast. This flap provides a source of soft tissue that can help create a more natural looking breast shape as compared to an implant alone. Occasionally, for a thin patient with a small breast volume, the latissimus dorsi flap can be used alone as the primary reconstruction without the need for an implant.
Tissue expansion is a relatively straightforward procedure that enables the body to “grow” extra skin for use in reconstructing almost any part of the body.
A silicone balloon expander is inserted under the skin near the area to be repaired and then gradually filled with salt water over time, causing the skin to stretch and grow. It is most commonly used for breast reconstruction following breast removal, but it’s also used to repair skin damaged by birth defects, accidents or surgery, and in certain cosmetic procedures.
Types of Implants
If your surgeon recommends the use of an implant, you’ll want to discuss what type of implant should be used. A breast implant is a silicone shell filled with either silicone gel or a salt-water solution known as saline.
While there are many options available in post-mastectomy reconstruction, you and your surgeon should discuss the one that’s best for you.
The most common technique combines skin expansion and subsequent insertion of an implant.
Following mastectomy, your surgeon will insert a balloon expander beneath your skin and chest muscle. Through a tiny valve mechanism buried beneath the skin, he or she will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has stretched enough, the expander may be removed in a second operation and a more permanent implant will be inserted. Some expanders are designed to be left in place as the final implant. The nipple and the dark skin surrounding it, called the areola, are reconstructed in a subsequent procedure.
Some patients do not require preliminary tissue expansion before receiving an implant. For these women, the surgeon will proceed with inserting an implant as the first step.
An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the back, abdomen, or buttocks.
In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat, and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself, without need for an implant.
Another flap technique uses tissue that is surgically removed from the abdomen, thighs, or buttocks and then transplanted to the chest by reconnecting the blood vessels to new ones in that region. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well.
Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about a silicone implant. In some cases, you may have the added benefit of a improved abdominal contour.
Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery may be required to replace a tissue expander with an implant or to reconstruct the nipple and the areola. Many surgeons recommend an additional operation to enlarge, reduce, or lift the natural breast to match the reconstructed breast. But keep in mind, this procedure may leave scars on an otherwise normal breast and may not be covered by insurance.
Find out how to prepare for your surgery here.
A tissue expander is inserted following the mastectomy to prepare for reconstruction.
The expander is gradually filled with saline through an integrated or separate tube to stretch the skin enough to accept an implant beneath the chest muscle.
After surgery, the breast mound is restored. Scars are permanent, but will fade with time. The nipple and areola are reconstructed at a later date.
With flap surgery, tissue is taken from the back and tunneled to the front of the chest wall to support the reconstructed breast.
The transported tissue forms a flap for a breast implant, or it may provide enough bulk to form the breast mound without an implant.