Breast reconstruction is a series of surgical procedures performed to recreate a breast. Reconstructions are commonly done after one or both breasts are removed as a treatment for breast cancer. Also, a breast may need to be refashioned for other reasons, such as trauma or abnormalities that occur during breast development.
Purpose
Many authorities consider reconstruction an integral part of the therapy for breast cancer. A breast that appears natural offers a sense of wholeness and normalcy, which can aid in the psychological recovery from breast cancer. It eliminates the need for an external prosthesis (false breast), which many women find physically uncomfortable as well as inconvenient.
Precautions
Not all women are good candidates for breast reconstruction. Overall poor physical health, or specific problems such as cigarette smoking, obesity, high blood pressure, or diabetes, will increase the chance of complications. Also, a difficult and/or prolonged recovery period or failure of the reconstruction may be a result. A woman's physical ability to cope with major surgery and recuperation also need to be considered.
Description
Breast reconstruction is done in two stages, with the ultimate goal of creating a breast which looks and feels as natural as possible. It is important to remember that while a good result may mimic a normal breast closely, there will inevitably be scars and loss of sensation. The reconstructed breast cannot be exactly like the original.
The first step is to form a structure called a breast mound. This can be accomplished using artificial materials called breast implants, or by using tissues from other parts of the woman's body. The second step involves creating a balance between the newly constructed breast and the breast on the opposite side. The nipple and areolar complex (darker area around the nipple) are recreated. This is usually done several months after the mound is created, to allow swelling to go down. Other procedures may be necessary, such as lifting the opposite breast (mastopexy), or making it larger or smaller to match the reconstructed breast.
Timing, immediate or delayed reconstruction
While immediate reconstruction (IR) is not recommended for women with breast cancer who need to under-go other, more important treatments, breast reconstruction can be done almost anytime. It even can be done during the same procedure as the mastectomy, or it can be delayed. There are psychological benefits to IR. The ability to return to normal activities and routines is often enhanced when reconstruction follows immediately after mastectomy. A better appearance may result from IR. There is less skin removal, often resulting in a shorter scar. The surgeon is better able to preserve the normal boundaries of the breast, so it is easier to match the opposite breast more closely.
The cost of IR is generally lower than the cost of delayed reconstruction (DR). There is one fewer operation and hospital stay. Surgeon's fees may be lower for a combined procedure than for two separate surgeries.
There are disadvantages of IR as well. The surgery itself is longer, causing more time under anesthesia. Post-operative pain and recovery time will be greater than for mastectomy alone.
Other authorities contend that delayed reconstruction (DR) offers different physical and psychological advantages. The initial mastectomy procedure alone takes less time, and has a shorter recovery period and less pain than mastectomy and IR. The patient has more time to adjust to her diagnosis and recover from additional therapy. She is better able to research her options, and to formulate realistic goals for reconstruction. Some reconstructive surgery requires blood transfusions. With DR, the patient can donate her own blood ahead of time (autologous transfusion), and/or arrange to have family and friends donate blood for her use (directed donation).
The psychological stress of living without a breast is a disadvantage of DR. The extra procedure DR entails results in higher costs. Although initial recovery is faster, an additional recuperation period is required after the delayed operation.
Type of reconstruction
There are two basic choices for breast reconstruction. The breast tissue can be replaced with an implant or the breast is created using some of the woman's own tissues (autologous reconstruction).
ARTIFICIAL IMPLANTS. In general, implant procedures take less time, and are less expensive than autologous ones. Implants are breast shaped pouches. They are made of silicone outer shells, which may be smooth or textured. The inside may contain silicone gel, saline (salt water), or a combination of both.
An implant may be a fixed volume type, which cannot change its size. Implants that have the capacity to be filled after insertion are called tissue expanders. These may be temporary or permanent.
The initial procedure for any implant insertion uses the mastectomy incision to make a pocket of tissue, usually underneath the chest wall muscle. In DR, the mastectomy scar may be re opened and used for this purpose, or a more cosmetic incision may be made. The implant is inserted into the pocket, the skin is stretched as needed and stitched closed.
If there is inadequate tissue to achieve the desired size, or a naturally sagging breast is desired, a tissue expander is used. It resembles a partially deflated balloon, with an attached valve or port through which saline can be injected. After the initial surgical incision is healed, the woman returns to the doctor's office, on a weekly or bi-weekly basis, to have small amounts of saline injected. Injections can continue for about six to eight weeks, until the preferred size is obtained. In some cases it may be overfilled, and later partially deflated to allow for a more pliable, natural result. A temporary tissue expander will be removed after several months and replaced with a permanent implant.
IR surgery using an implant takes approximately two to three hours, and usually requires up to a three day hospital stay. Implant insertion surgery, as part of DR, takes one to two hours and can sometimes be done as an outpatient, or it or it may entail overnight hospitalization.
AUTOLOGUS RECONSTRUCTION. Attached flap and free flap are two types of surgery where a woman's tissue is used in reconstruction. An attached flap uses skin, muscle, and fat, leaving blood vessels attached to their original source of blood. The flap is maneuvered to the reconstruction site, keeping its original blood supply for nourishment. This may also be known as a pedicle flap. The second kind of surgery is called a free flap. This also uses skin, muscle, and fat, but severs the blood vessels, and
attaches them to other vessels where the new breast is to be created. The surgeon uses a microscope to accomplish this delicate task of sewing blood vessels together. Sometimes the term microsurgery is used to refer to free flap procedures. Either type of surgery may also be called a myocutaneous flap, referring to the skin and muscle used.
The skin and muscle used in autologous reconstruction can come from one of several possible places on the body, including the abdomen (TRAM flap or "tummy tuck"), the back (latissimus dorsi flap), or the buttocks (gluteus maximus free flap).
Finishing the reconstruction
Other procedures may be necessary to achieve the goal of symmetrical breasts. It may be necessary to make the opposite breast larger (augmentation), smaller (reduction), or higher (mastopexy). These, or any other refinements should be completed before the creation of a nipple and areola. Tissue to form the new nipple may come from the reconstructed breast itself, the opposite breast, or a more distant donor site, such as the inner thigh or behind the ear. The nipple and areolar construction is usually an outpatient procedure. A final step, often done in the doctor's office, is tattooing the new nipple and areola, to match the color of the opposite nipple and areola as closely as possible.
Insurance
Insurance coverage for breast reconstruction varies widely. Some policies will allow procedures on the affected breast, but refuse to pay for alterations to the opposite breast. Other plans may cover the cost of an external prosthesis, or reconstructive surgery, but not both. As of January 1998, 25 states had different laws regarding required insurance coverage for post mastectomy reconstruction.
Implants may pose additional insurance concerns. Some companies will withdraw coverage for women with implants, or add a disclaimer for future implant-related problems. Careful reading of insurance policies, including checking on the need for pre-approval and/or a second opinion, is strongly recommended.
Preparation
Routine preoperative preparations, such as taking nothing to eat or drink the night before surgery are needed for reconstructive procedures. Blood transfusions are often necessary for autologous reconstructive surgeries. The patient may donate her own blood, and/or have family and friends donate several weeks before the surgery.
Emotional preparation is also important. Breast reconstruction will not resolve a psychological problem the woman had before mastectomy, nor make an unstable relationship strong. An expectation of physical perfection is unrealistic. A woman who cites any of these reasons for reconstruction shows that she has not been adequately informed or prepared. Complete understanding of the benefits and limitations of this surgery is necessary for a satisfactory result.
Aftercare
The length of the hospital stay, recovery period, and frequency of visits to the doctor after surgery varies considerably with the different kinds of reconstruction. In general, autologous procedures require longer hospitalization and recovery time than implant procedures. Bandages and drainage tubes remain in place for at least a day for all surgeries. Microsurgical or free flaps are most closely monitored in the first day or two after surgery. The circulation to the breast may be checked as often as every hour. Complete breast reconstruction requires at least one additional surgery to create a nipple and areola. Scars may remain red and raised for a month or longer. The true, final appearance of the breasts will not be visible for at least one year.
Risks
Some women have reported various types of autoimmune related connective-tissue disorders, which they attribute to their implants usually involving silicone gel implants. Lawsuits have been filed against the manufacturers of implants. Food and Drug Administration guidelines, issued in 1992, now limit their use to women who need to replace an existing silicone gel-filled implant, have had surgery for breast cancer, or have a medical condition which results in serious breast abnormality. In addition, patients must sign a consent form which details the potential risks of silicone gel-filled implants, and become enrolled in a long range study. Saline filled implants are permitted for all uses, although manufacturers must collect data on possible risks.
The FDA issued a status report on Breast Implant Safety in 1995, and revised it in March 1997. It noted that studies so far have not shown a serious increase in the risk of recognized autoimmune diseases in women with silicone gel-filled breast implants. It also addressed concerns about other complications and emphasized the need for further study of this issue.
There are a number of risks common to any surgical procedure such as bleeding, infection, anesthesia reaction, or unexpected scarring. Hematoma (accumulation of blood at the surgical site), or seroma (collection of fluid at the surgical site) can delay healing if not drained. Any breast reconstruction also poses a risk of asymmetry and/or the need for unplanned surgical revision. Persistent pain is another potential complication possible with all types of breast reconstruction.
Implants have some unique problems that may develop. A thick scar, also called a capsule, forms around the implant, as part of the body's normal reaction to a foreign substance. Capsular contracture occurs when the scar becomes firm or hardened. This may cause pain and/or change the texture and appearance of the breast. Implants can rupture and leak, deflate, or become displaced. The chances of capsular contracture or rupture increase with the age of the implant. These complications can usually be remedied with outpatient surgery to loosen the capsule or remove and/or replace the implant as needed. There is some evidence that using implants with textured surfaces may decrease the incidence of these problems. An implant tends to remain firm indefinitely. It will not grow larger or smaller as the woman's weight changes. Asymmetry can develop if a woman gains or loses a large amount of weight.
The autologous procedures all carry a risk of flap failure—loss of blood supply to the tissue forming the new breast. If a large portion of the flap develops inadequate blood supply, another reconstructive technique may be necessary. TRAM flap procedures can result in decreased muscle tone and weakness in the abdomen and/or abdominal hernia. Arm weakness may occur after latissimus dorsi flap surgery.
Normal results
A normal result of breast reconstruction depends on the woman's goals and expectations. It will not be the same as the breast it replaces. In general, it should be similar in size and shape to the opposite breast, but will have less sensation and be less mobile than a natural breast. A reconstruction using implants will usually be firmer and rounder than the other breast. It may feel cooler to touch, depending on the amount of tissue over it. Scars are unavoidable, but should be as unobtrusive as possible.
BOOKS
Berger, Karen, and John Bostwick III. A Woman's Decision: Breast Care, Treatment and Reconstruction. St. Louis: Quality Medical Publishing, Inc., 1994.
Love, Susan M., with Karen Lindsey. Dr. Susan Love's Breast Book. 2nd ed. Reading, MA: Addison-Wesley, 1995.
PERIODICALS
Bostwick III, John. "Breast Reconstruction Following Mastectomy." CA: A Cancer Journal for Clinicians 45 (Sept./Oct. 1995): 289-303.
American Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA 30329-4251. (800) 227-2345. <http://www.cancer.org>.
American Society of Plastic and Reconstructive Surgeons. 44 E. Algonquin Rd., Arlington Heights, IL 60005. (847) 228-9900. <http://www.plasticsurgery.org>.
U.S. Department of Health and Human Services, U.S. Food and Drug Administration, Office of Consumer Affairs. 5600 Fishers Lane, Rockville, MD 20857. (800) 532-4440. <http://www.fda.gov/fdahomepage.html>.
Ellen S. Weber, MSN
KEY TERMS
Autologous—From the same person. An autologous breast reconstruction uses the woman's own tissues. An autologous blood transfusion is blood removed then transfused back to the same person at a later time.
Capsular contracture—Thick scar tissue around a breast implant, which may tighten and cause discomfort and/or firmness.
Flap—A section of tissue moved from one area of the body to another.
Free flap—A section of tissue detached from its blood supply, moved to another part of the body, and reattached by microsurgery to a new blood supply.
Mastopexy—Surgical procedure to lift up a breast. May be used on opposite breast to achieve symmetrical appearance with a reconstructed breast.
Pedicle flap—Also called an attached flap. A section of tissue, with its blood supply intact, which is maneuvered to another part of the body.
