Breast reconstruction offers much hope for a woman losing her breast to cancer. Reconstruction can often be performed immediately after the mastectomy, so the woman does not have to live without her breast(s). However, in some instances – based on the patient’s health and treatment plans – some mastectomy patients must wait before undergoing reconstructive surgery. In either case, reconstructive surgery holds much promise that the post-operative breast can match the natural breast again.
The Procedure Options
When reconstructive surgery is performed immediately following mastectomy, a breast mound is created in place of the breast that was removed. This is done in a hospital setting under general anesthesia. Dr. Cimino will work with your oncologist to ensure the best possible conditions for reconstruction.
Breast reconstruction usually involves more than one operation; follow-up procedures may be performed on an outpatient basis. Sometimes surgery is also performed on the remaining natural breast to match the reconstructed breast.
Skin Expander with Breast Implant
This is the simplest of breast reconstructions. In this procedure, a tissue expander is placed under the skin. Once sutures are removed, saline is added weekly to the expander, stretching the skin as it expands.
When the skin is sufficiently stretched, the tissue expander is removed and replaced by a permanent breast implant. Nipple reconstruction, if desired, is performed in a separate follow-up procedure.
Advantages: This is the simplest surgery for breast reconstruction and, typically, has the shortest recovery period making it the favored procedure for persons with health problems or who wish to avoid extensive surgery.
Disadvantages: The procedure requires multiple trips to the office over a period of weeks or months to undergo expansion. Other disadvantages can include scar tissue capsule formation or poor overall appearance due to thin skin.
Latissimus Dorsi Myocutaneous Flap
This breast reconstructive surgery involves repositioning the latissimus dorsi muscle from the patient’s back to the chest area, using overlying breast skin to create a new breast mound. The incision is usually made along the bra line so the scar is concealed. If necessary, a breast implant can be placed under the skin flap to balance a difference in breast size. Nipple reconstruction is performed later in a separate procedure.
Advantages: This is a very reliable reconstructive procedure that provides excellent physical room for a breast implant. The chances of scar tissue capsule formation around the implant are reduced.
Disadvantages: This procedure produces a scar across the back. In addition, there may be decreased strength in the back due to muscle loss. If scar tissue capsule formation occurs, additional surgery may be required.
- Circulation problems with the flap
- Formation of scar tissue capsulation around the implant
- Decreased strength resulting from loss of shoulder muscle
- Collection of fluid (seroma) under the incision requiring needle aspiration
Rectus Abdominus Myocutaneous Flap
This reconstructive procedure is the most complicated and longest surgical procedure, involving approximately four to five hours of surgery. An abdominal muscle (the rectus abdominus) is tunneled upward, along with the overlying skin, to the chest area where a breast mound is created to match the opposite side. For double mastectomies, two breast mounds are created. A synthetic mesh may be placed over the area where the muscle is moved. This strengthens the abdominal wall and minimizes the chance of herniation of the bowel.
Breast implants are not usually required. In the case of single mastectomies, existing tissue is generally adequate to match the size of the remaining breast. If the remaining breast is large or drooping, its size can be decreased in a simultaneous breast reduction.
Nipple reconstruction is done as a secondary procedure. Some contouring of the new breast mound may be necessary at the same time.
Patients wishing to have this procedure must stop smoking at least six weeks prior to and for six weeks after surgery to maximize blood circulation to the breast area. Failure to comply could result in loss of the flap.
Advantages: This provides the most natural looking breast reconstruction. Because no implant is used, capsule formation is not a risk. The scar is easily hidden under clothing.
Disadvantages: There is a risk of herniation of the bowel resulting from moving the rectus abdominus muscle. Abdominal strength is diminished. This is the longest procedure and has the greatest risk for requiring a blood transfusion.
- Inadequate tissue requiring the need for a breast implant
- Poor circulation to the flap resulting in tissue loss
- Weakness or herniation of the abdominal wall
- Potential off-center placement of the umbilicus (belly button)
- Fluid retention (seroma) under the skin requiring needle aspiration
- Infection, in particular of the mesh requiring surgical removal
Nipple reconstruction adds a very pleasing final aesthetic touch to the breast. This is a simple outpatient procedure that usually takes one to two hours and is most often done using local anesthesia. The goal of nipple reconstruction surgery is to create a nipple with the appearance of the nipple on the opposite breast (or, in the case of double mastectomies, the appearance of the patient’s breasts prior to surgery).
In a separate procedure, the healed nipple can be tattooed to improve the color match of the opposite breast or, in the case of double mastectomies, to restore the appearance of natural looking nipples.
- Excessive scarring
- Shrinkage of the projecting part of the nipple
- Blood clot under the nipple, which could result in loss of all or part of the new nipple
Reconstruction of the breast following mastectomy is a very rewarding procedure to both the patient and the surgeon. Many women describe a feeling of once again being whole. Advancements in medicine mean there are many materials available for the best and most aesthetically pleasing breast reconstruction.