If you’ve been advised by your doctor to have a mastectomy, you may be wondering about breast reconstruction. Reconstructive surgery can be performed at the same time as your mastectomy surgery. This procedure is called immediate reconstruction.
Immediate reconstruction offers the benefit of eliminating at least one surgery. It may allow you to get back to life as usual more quickly. There is also the psychological benefit of waking up from your mastectomy with your new breast or breasts more intact than without reconstruction. What’s more, studies show that the cosmetic outcome of immediate reconstruction is often better than breast reconstruction that takes place later on.
The decision to do both surgeries at once is influenced by many factors. You’ll need to involve your breast cancer surgeon, oncology treatment team, and plastic surgeon to decide whether this is an appropriate option for you.
You will be under general anesthesia during your mastectomy and immediate reconstruction.
Your breast surgeon will usually make an oval-shaped incision over the nipple area. In some people with certain early breast cancers, the nipple can be preserved on the breast. This is done by using incisions at the bottom of the breast or near the nipple. From the incision, your surgeon will remove all of the breast tissue of that breast. They may also remove some or all lymph nodes from under your arm, depending on your stage of cancer and your surgical plan.
The plastic surgeon will then reconstruct the breast or breasts. In general, a breast may be reconstructed with an implant or with your own tissue from another part of the body.
Prosthetic reconstruction (breast reconstruction with implants)
Implants are often used in reconstructive surgeries following a mastectomy. There are different types you can choose from filled with either saline or silicone.
Immediate reconstruction with implants may be performed in several ways. The technique may depend on:
- the plastic surgeon’s preference and experience
- the condition of your tissue
- the kind of breast cancer you may have
At the time of mastectomy, some plastic surgeons will lift up the pectoralis muscle, located immediately behind the breast, and place the implant behind the extra layer of tissue. Others will place the implant immediately behind the skin. Some surgeons will also use an artificial skin layer within the empty breast pocket to give additional protection and support.
Some points to keep in mind about implants include:
Pros of implants
- Implant surgery is easier and takes less time than other reconstruction procedures.
- Recovery time with implants is shorter than with tissue flap reconstruction.
- There are no other surgical sites on the body to heal.
Cons of implants
- No implant will last forever. Your implant will likely need to be replaced.
- Silicone implants will need monitoring with MRIs every few years to detect rupture.
- Your body may have problems with the implants, such as infection, scarring, and implant rupture.
- Future mammograms may be harder to perform with implants in.
- An implant may affect your ability to breastfeed.
Tissue flap reconstruction (breast reconstruction with your own tissue)
Implants are more straightforward and take less time to insert, but some women prefer to have the more natural feeling of their own tissue in their reconstructed breast. Additionally, if you have had or will likely have radiation therapy, implants are more likely to cause complications. Your surgeon will then likely recommend tissue flap reconstruction.
This type of reconstruction uses tissue from various parts of your body, including your abdomen, back, thighs, or buttocks, to rebuild your breast shape. The types of flap procedures include:
|Flap procedure||Uses tissue from|
|transverse rectus abdominis muscle (TRAM) flap||abdomen|
|deep inferior epigastric perforator (DIEP) flap||abdomen|
|latissimus dorsi flap||upper back|
|gluteal artery perforator (GAP) flaps||buttocks|
|transverse upper gracilis (TUG) flaps||inner thigh|
Consider the following when thinking about this type of reconstruction:
- Tissue flaps generally look and feel more natural than implants.
- They behave more like the rest of your body. For instance, their size can fluctuate with the rest of your body as you gain or lose weight.
- You will not need to replace tissues like you would likely need to replace implants.
- Surgery generally takes longer than implant surgery, with a longer recovery time.
- The procedure is more technically difficult for the surgeon, and the tissue can fail to take.
- It will leave multiple surgical site scars because multiple areas of your body will be operated on.
- Some people may experience muscle weakness or damage at the tissue donor site.
Immediately after surgery
The duration of these surgeries (per breast) can take anywhere from 2 to 3 hours for a mastectomy with immediate implant reconstruction or 6 to 12 hours for mastectomy and reconstruction with your own tissue.
After the reconstruction is complete, your breast surgeon will attach temporary drainage tubes to your breast. This is to make sure that any excess fluid has a place to go during healing. Your chest will be wrapped with a bandage.
Side effects of immediate reconstruction are similar to that of any mastectomy procedure. They can include:
- pain or pressure
- scar tissue
Because nerves are cut during the surgery, you may have numbness along the site of the incision. Scar tissue may build up around the site of your incision. It can cause pressure or pain. Infection and delayed wound healing sometime happen after a mastectomy. You and your doctor should be on the lookout for signs of both.
During a mastectomy, your nipple may not able to be preserved. You will know before surgery whether your surgeon expects to keep the nipple after the procedure. If your nipple is removed during the mastectomy, nipple reconstruction is usually performed as a minor procedure several months after your breast reconstruction is complete.
Plan to be in the hospital for several days, depending on the type of reconstruction. You may be in the hospital overnight for an implant reconstruction, or up to a week or longer for a reconstruction with your own tissue. Your doctor will prescribe pain medication during the healing process.
For some time, you may be instructed not to sleep on your side or stomach. Visible scarring on your breasts, even after reconstruction, is normal. Over time, the visibility of the scars will go down. Massage techniques and scar removal creams can decrease their appearance, as well.
You won’t need to be on bedrest once you are released from the hospital. The sooner you can get up and walk around, the better. However, until the drains in your breast tissue are removed, you will be restricted from driving and other tasks that require the use of the upper body. Driving under the influence of some pain medications, such as Vicodin, is also restricted.
There are no special dietary concerns, but you should focus on eating foods that are high in protein. These will promote cell growth and healing. Your doctor will give you safe exercises to help you regain sensation and strength in your chest and upper body.
Besides immediate reconstruction and tissue flap reconstruction, there are other options for recreating the look of your breasts from before the mastectomy. These include having reconstructive surgery as a separate procedure and not getting reconstructive surgery at all.
Like immediate reconstruction, delayed reconstruction involves either flap surgery or breast implants. Delayed reconstruction is more commonly chosen by women that need radiation treatments for their cancer after the mastectomy has been completed. Delayed reconstruction will begin 6 to 9 months after your mastectomy. The timing will depend on you reaching certain milestones in your cancer treatment and healing process.
The risks and side effects of delayed reconstruction are similar to those of immediate reconstruction. The American Psychological Association has researched the effects of delayed reconstruction in women that have had mastectomies and concluded that immediate reconstruction was better for long-term mental health.
Alternatives to breast reconstruction
For women who are not good candidates due to health reasons, or who simply choose not to have the additional surgery, mastectomy will be performed without reconstruction. The surgery leaves the chest flat on that side.
In these cases, women can request an external breast prosthesis once their incisions are healed. It can fill the brassiere on the affected side and provide the external appearance of a breast under clothing.
As you weigh your options, ask your surgeon for a professional recommendation before making any decisions. Every person and clinical situation is unique. Depending on health factors such as obesity, smoking, diabetes, and cardiovascular conditions, having these two surgeries as part of one procedure may not be recommended.
For example, women with inflammatory breast cancer usually need to wait until they finish additional treatment, such as radiation, before reconstruction can be performed. Additionally, smoking is a well-known risk factor for poor healing after reconstructive surgery. If you smoke, your plastic surgeon will likely ask you to quit before they consider reconstructive surgery.
Any type of reconstruction can increase the risk of side effects from a mastectomy, but this is not dependent on if the reconstruction happens immediately or later on.
Many women are not aware of their options or the fact that health insurance companies will pay for the reconstructive surgeries after mastectomy. Depending on location and resources, women with breast cancer are not always offered the option of meeting with a plastic surgeon to discuss breast reconstruction after mastectomy. If you are not offered this option, speak up. Ask your breast surgeon for a consultation to discuss if breast reconstruction is appropriate for you.
There are many factors to consider before undergoing a breast reconstruction after a mastectomy. Here are some questions to ask your surgeon before choosing the best type of surgery for you:
- Am I a good candidate for breast reconstruction surgery?
- Would you recommend reconstruction surgery immediately after my mastectomy, or should I wait?
- How should I prepare for surgery?
- Will my new breasts look similar to my old breasts?
- How long is the recovery time?
- Will reconstructive surgery interfere with any of my other breast cancer treatments?
- If I choose to use implants for my reconstruction, will the implants ever need to be replaced? How long do they last?
- What kind of wound care will I need to do at home?
- Will I need a caregiver of some kind after surgery?
It can be difficult to wrap your head around the idea of a mastectomy, and the possibility of another surgery for reconstruction may seem even more daunting. Recovering from a mastectomy and reconstructive surgery at once may be more uncomfortable in the short-term. But in the long-term, it may be less stressful and painful than multiple surgeries.