Reconstructive surgery is an option that a patient may choose to restore the form of the breast. It may begin either at the time of mastectomy (immediate) or at a later date (delayed). Achieving optimal results often requires more than one surgery, done in stages. The opposite breast may be re-shaped (lifted, augmented or reduced in size) to improve the symmetry of the two breasts.

Immediate versus Delayed Reconstruction -- Why do it?

With the increasing improvement in breast reconstructive techniques and the advent of skin-sparing mastectomy incisions, many patients now opt for immediate reconstruction, seeking to avoid the trauma of two operations, two anesthesias, two hospital stays and two recoveries. Immediate reconstruction also offers the benefit of reduced cost, a potentially shorter mastectomy scar and, possibly, an improved aesthetic result.

Delayed reconstruction, on the other hand, allows patients time to recover from the mastectomy and adjunctive therapy and more time to make a decision. Most doctors recommend that patients with positive lymph nodes or cancer that has spread beyond the breast area have chemotherapy, hormonal therapy, radiation therapy or a combination of these therapies before breast reconstruction. 

Reconstruction with Available (Autologous) Tissue

Autologous Flap Breast Reconstruction

With the newer flap techniques for breast reconstruction, a woman's breasts can now be rebuilt with her own tissues (autologous) and usually without the need for a breast implant. Because the donor sites are usually areas of tissue excess such as the lower abdomen or buttocks, a full and natural breast can be rebuilt to closely resemble the size and shape of the opposite breast. Flap procedures are more complex, require longer recovery and are more expensive than implant procedures, but the results also prove to be more long-lasting and seem to improve over time. With this reconstructive approach, flaps of muscle or skin and muscle are transferred to the mastectomy site from another area of the body such as the back (latissimus dorsi reconstruction), abdomen (transverse rectus abdominus musculocutaneous {TRAM} flap reconstruction) or buttocks (gluteus maximus reconstruction). These flaps may be pedicle flaps (still attached to their blood supply and tunneled to the breast area where they are shaped and inset), or they may be free flaps (detached from their donor site and transferred to the new area where the blood vessels are reattached under the operating room microscope {endoscopic microsurgery}). New endoscopic techniques allow harvest of these flaps through small incisions, thereby minimizing the scars from these procedures. Depending on the amount of tissue transferred and the size of the other breast, a breast implant may sometimes be needed. Since the tissue is from the patient's own body, there is very little possibility of rejection of the transplanted muscle and tissue. 

Breast Implants

Breast reconstruction may include the insertion of internal prostheses known as breast implants. Implants are placed in the soft tissue in front of the ribs to replace the volume of the removed breast. There are two broad categories of implants: fixed-volume implants and implants in which the volume can be changed after they are implanted (tissue expanders). All current implants have a silicone envelope that contains the filling and is in contact with the body. Implants are either filled with saline (salt water) or silicone gel and are of the same style as the implants used for cosmetic breast enlargement. (Currently silicone gel implants are only available for breast cancer patients through participation in clinical trials testing their safety.) Often, a tissue expander is temporarily placed to stretch the skin prior to the insertion of the permanent implant.

Possible complications can include:

1. Capsular contracture -- a capsule or shell of scar tissue that may form around a breast implant, giving it a feeling of firmness.

2. Loss of symmetry due to a change in patientís weight.

3. Wrinkling (more likely with saline-filed breast implants).

Reconstruction with a Breast Implant

Breast reconstruction with the available tissue at the mastectomy site and implant placement is the simplest and least expensive form of breast restoration without the need for new scars or a lengthy hospital stay. With this reconstructive approach the surgeon places an implant (a fixed-volume silicone bag filled with saline) beneath the patient's skin and upper chest muscles to produce a breast shape. Additional procedures may be necessary to reconstruct the nipple-areola and to make needed adjustments in implant size.

Reconstruction with Tissue Expansion

This is currently the most common type of breast reconstruction because it has the advantages described for implant reconstruction while enabling the woman to have more control over the final breast size. Tissue expanders are adjustable implants that can be inflated with saltwater (saline) to stretch the tissues at the mastectomy site. The surgeon places the expander beneath the patient's skin and upper chest muscles. This device is then filled with saline solution and adjusted after placement. The saline solution is injected through the skin into a valve attached to the implant. After the breast has been expanded to the proper volume and shape, the expander is exchanged for a permanent fixed-volume implant. Tissue expansion requires additional office visits for expander inflation, implant placement and nipple-areola reconstruction. 

Nipple/Areola Reconstruction

To complete a breast reconstruction, the plastic surgeon can recreate a nipple and areola by molding local skin and/or grafting skin from another part of the body. Dye can be applied in a tattooing process by a plastic surgeon or plastic surgery nurse to match the skin color of the nipple-areolar complex with the opposite breast. This phase of reconstruction is not performed at the same time as the initial breast reconstruction to permit the reconstructed breast to settle and to ensure the proper placement of the nipple-areolar complex.

Modification of the Other Breast for Symmetry

Most women undergoing breast reconstruction want to avoid an operation on their remaining breast. Sometimes, however, the size or shape of the remaining breast cannot be easily duplicated. When this is the case, the plastic surgeon can perform an operation on the opposite breast to obtain symmetry. If the woman's existing breast is small, she may want to consider having it augmented so that it is fuller and rounder to match the reconstructed breast. If the woman's remaining breast is large, she may choose to have it reduced and lifted so that it can better match the restored side. A breast reduction may make the reconstruction easier to perform because less tissue will be needed for the new breast. If the opposite breast is of reasonable size but sags (ptosis), the surgeon may suggest a breast lift (mastopexy).

Breast Prostheses -- Availability and Fitting

External Breast Prostheses

If a woman chooses not to have breast reconstruction, she may choose to wear a breast prosthesis. Prostheses are available in different sizes, shapes and skin tones. A woman who has had a modified radical mastectomy may need a fuller prosthesis, while a woman who has had a segmental mastectomy may need just a "filler". Prostheses may be purchased in medical supply houses, through mail order catalogs or from lingerie or department stores. Some prostheses can be custom-made. Most insurance plans will reimburse patients for the cost of a breast prosthesis. Post-mastectomy bras and swimwear are also available to meet the special needs of women with breast cancer. For resources on where to purchase external prostheses and other special items for women following breast cancer surgery, please request a WIN ABC Breast Health and Breast Cancer Resource Guide, by calling WIN at (626) 332-2255 or email your request to mail@winabc.org. 

Back to Treatment Options

Last Updated: 02/12/2003

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