What is breast reconstruction?

Breast reconstruction is a type of surgery for women who have had a breast removed (mastectomy). The surgery rebuilds the breast so that it is about the same size and shape as it was before. The nipple and the darker area around the nipple (areola) can also be added. Most women who have had a mastectomy can have reconstruction. Women who have had only the part of the breast around the cancer removed (lumpectomy) may not need reconstruction. Breast reconstruction is done by a plastic surgeon.
Here are some facts to help you better understand the process and the words used when talking about breast reconstruction. The words you may hear doctors use are also explained in the glossary at the end of this information.
The choice to have breast reconstruction is yours to make. We hope this information will help you make your decision. Try to learn as much as you can before you decide what to do. No one source of information can give you every fact or give you all the answers. You and those close to you should talk to your health care team about any questions and concerns you have about this type of surgery.
 

New choices in breast cancer surgery and reconstruction

Each year more than 254,000 American women face breast cancer. Today, the emotional and physical results are very different from what they were in the past. Much more is now known about breast cancer and its treatment. New kinds of treatment as well as improved reconstructive surgery mean that women who have breast cancer today have better choices.
Today, more women with breast cancer choose surgery that removes only part of the breast tissue. This may be called breast conservation surgery, lumpectomy, or segmental mastectomy. But some women have a mastectomy, which means the entire breast is removed. Many women who have a mastectomy choose reconstructive surgery to rebuild the shape and look of the breast.
If you are thinking about having reconstructive surgery, it is a good idea to talk about it with your surgeon and a plastic surgeon experienced in breast reconstruction before your mastectomy. This lets the surgical teams plan the treatment that is best for you, even if you want to wait and have reconstructive surgery later.
 

Why have breast reconstruction?

Women choose breast reconstruction for many reasons:

• To make their breasts look balanced when they are wearing a bra.
• To permanently regain their breast shape.
• So they don't have to use a form that fits inside the bra (an external prosthesis).

You will be able to see the difference between the reconstructed breast and the remaining breast when you are nude. But when you are wearing a bra, the breasts should be alike enough in size and shape that you will feel comfortable about how you look in most types of clothes.
Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery. Also, you may not be happy with how your breast looks and feels after surgery. You and those close to you must know the facts about what to expect from reconstruction.
There are often many options to think about as you and your doctors talk about what is best for you. The reconstruction process often means one or more operations. Talk about the benefits and risks of reconstruction with your doctors before the surgery is planned. Give yourself plenty of time to make the best decision for you. You should decide to have breast reconstruction only after you are fully informed.
 

Immediate or delayed breast reconstruction

Immediate breast reconstruction is done at the same time as the mastectomy. An advantage to this is that the chest tissues are not damaged by radiation therapy or scarring. This often means that the final result looks better. Also, immediate reconstruction means less surgery.
After the first surgery, there still may be a number of steps that are needed to complete the immediate reconstruction process. If you are planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take.
Delayed breast reconstruction means that the rebuilding is started later. This may be a better choice for some women who need radiation to the chest area after the mastectomy. Radiation therapy given after breast reconstruction surgery can cause problems.

Decisions about reconstructive surgery also depend on many personal factors such as:

• Your overall health.
• The stage of your breast cancer.
• The size of your natural breast.
• The amount of tissue available (for example, very thin women may not have enough extra body tissue to make flap grafts).
• Whether you want reconstructive surgery on both breasts.
• Your insurance coverage for the unaffected breast and related costs.
• The type of procedure you are thinking about.
• The size of implant or reconstructed breast.
• Your desire to match the look of the other breast.

Other important things to think about

• Some women do not want to think about reconstruction while coping with a diagnosis of cancer. If this is the case, you may choose to wait until after your breast cancer surgery to decide about reconstruction.
• You may not want to have any more surgery than needed.
• Scarring is a natural outcome of any surgery, but cell death (called necrosis) of the breast skin, the flap, or transplanted fat can happen. Immediate reconstruction may be more likely to result in necrosis. If this happens, more surgery is needed to fix the problem and can deform the new breast shape.
• Not all surgery is a total success, and you may not like the way it looks.
• You may be concerned if you tend to bleed or scar.
• Healing may be affected by previous surgery, chemotherapy, radiation, smoking, alcohol use, diabetes, some medicines, and other factors.
• Would you prefer to have reconstruction before or after you complete your cancer treatment?
• Breast reconstruction restores the shape, but not feeling, in the breast. With time, the skin on the reconstructed breast can become more sensitive, but it will not feel the same as it did before your mastectomy.
• Surgeons may suggest you wait for one reason or another, especially if you smoke or have other health problems. Many surgeons say that you must quit smoking at least 2 months before reconstructive surgery to allow for better healing. You may not be able to have reconstruction at all if you are obese, too thin, or have blood circulation problems.
• The surgeon may recommend surgery to reshape the remaining breast to match the reconstructed breast. This could include reducing or enlarging the size of the breast, or even surgically lifting the breast.
• Knowing your reconstruction options before surgery can help you prepare for a mastectomy with a more realistic outlook for the future.

Latissimus dorsi flap

The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.

Nipple and areola reconstruction

You can decide if you want to have your nipple and the dark area around the nipple (areola) reconstructed. Nipple and areola reconstructions are optional and usually the final phase of breast reconstruction. This is a separate surgery that is done to make the reconstructed breast look more like the original breast. It can be done as an outpatient after drugs are used to make the area numb (under local anesthesia). It is usually done after the new breast has had time to heal (about 3 to 4 months after surgery).
The ideal nipple and areola reconstruction requires that the position, size, shape, texture, color, and projection of the new nipple match the natural one. Tissue used to rebuild the nipple and areola also is taken from your body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks. A tattoo may be used to match the color of the nipple of the other breast and to create the areola.

Nipple-sparing procedures
In a newer procedure called nipple-sparing mastectomy, the nipple and areola are left in place while the breast tissue under them is removed. Women who have a small early stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple, may be able to have nipple-sparing surgery. (Cancers that are larger or nearby may mean that cancer cells are hidden in the nipple.) Some doctors give the nipple tissue a dose of radiation during or after the surgery to try and reduce the risk of the cancer coming back.
There are still some problems with nipple-sparing surgeries. Afterward, the nipple does not have a good blood supply, so sometimes it can wither away or become deformed. Because the nerves are also cut, there is little or no feeling left in the nipple. In some cases, the nipple may look out of place later, mostly in women with larger breasts. This type of surgery is not yet widely available.
Saving the nipple from the breast that has been removed to use it later (called nipple saving or nipple banking) is no longer favored by most surgeons. The tissue can be injured by the way it is stored or preserved, and there have been other problems with this surgery.