What is breast reconstruction surgery?

With advances in breast reconstruction surgery, more than one-third of women undergoing breast removal have their breast(s) rebuilt. According to the American Society of Plastic Surgeons, in 2002 more than 81,000 women had breast reconstruction. Even though medical, surgical, and radiation therapy treatments for breast cancer have increased the number of breast-sparing procedures available, nearly one-third of breast cancer patients still require a mastectomy - removal of the breast(s). In addition, other women have their breast(s) removed due to other diseases.

Breast reconstruction surgery involves creating a breast mound that comes as close as possible to the form and appearance of the natural breast.

The goal of reconstructive surgery is to create a breast mound that matches the opposite breast and to achieve symmetry. If both breasts have been removed, the goal of breast reconstructive surgery is to create both breast mounds approximately the size of the patient's natural breasts.

What are the criteria for breast reconstruction surgery?

In general, all women undergoing a mastectomy are candidates for immediate or delayed breast reconstruction. However, there are criteria for selecting the best candidates for the procedure:

• The size and location of the cancer - which determines the amount of skin and tissue to be removed in the mastectomy - are primary factors when making recommendations for reconstruction.
  
  
• Whether tissue has been damaged by radiation therapy or aging, and is not sufficiently healthy to withstand surgery.

• Other considerations include:
  
  
  • potential for complications
  • patient's desires
  • the amount of tissue removed from the breast
  • the health of the tissue at the planned operation site
  • whether radiation therapy is part of treatment
  • the patient's general health and physique
  • past medical history
  • co-existing illnesses
  • other risk factors such as cardiac disease, diabetes mellitus, smoking, and obesity

When is breast reconstruction surgery performed?

The patient is usually educated and counseled in breast reconstructive possibilities prior to mastectomy, so that she can make the decision for or against reconstruction before going into surgery. Based on the personal medical history of each patient, a recommendation will be made for either:

• immediate reconstruction - reconstructive surgery performed at the same time as mastectomy.

• delayed reconstruction - a second operation (to reconstruct missing breast tissue) is performed after recovery from the mastectomy is complete. If chemotherapy is part of the treatment protocol, the surgeon may recommend delayed reconstruction.

What complications are commonly associated with breast reconstructive surgery?

Any type of surgery carries some risk. Patients differ in their anatomy and their ability to heal. Some complications from breast reconstruction may include:

• bleeding
• fluid collection
• infection
• excessive scar tissue
• anesthesia problems

The most common complication of breast reconstruction surgery is capsular contracture, which occurs if the scar or capsule around the implant begins to tighten. Occasionally, this (and other) complications are severe enough to require a second operation.

What are the different types of breast reconstruction surgery?

The two most effective approaches available for both monolateral (one breast) and bilateral (both breasts) reconstruction are:

• expander/implant reconstruction - the use of an expander to create a breast mound, followed by the placement with a permanent filled breast implant.

Expanders are empty silicone “envelopes” placed under the pectoralis muscle, located between the breast and the chest wall. To enable the skin and soft tissues of the breast to grow, the expander is gradually filled with saline solution over a period of several weeks. The saline is injected into the expander through a valve or port in the expander. Once the expander has been completely filled, it is left in for several more weeks to months, allowing for maximal skin and soft tissue growth.

Implants are envelopes filled with liquid that are implanted into the breast tissue, and are used to form the shape of the breast. Implants may be filled with saline or silicone gel. Each type of implant has advantages and disadvantages. Your physician will discuss the types of implants with you and seek your input about the type of implant to be used.

Although there have been questions raised about the safety of silicone gel implants, the Institute of Medicine published a report in 2000 that refuted most of the claims about silicone implant hazards. Silicone gel implants are available; however, women who receive them must be enrolled in an ongoing study sponsored by the manufacturers of the implants, the US Food and Drug Administration (FDA), and the institutional review board of the facility where the implant procedure is performed.

• autologous tissue reconstruction - the use of the patient's own tissues to reconstruct a new breast mound. The common technique is the TRAM (transverse rectus abdominous muscle) flap. A TRAM flap involves removing an area of fat, skin, and muscle from the abdomen and stitching it in place to the mastectomy wound.

About the procedure:

• Location options include:
  
  
  • surgeon's office-based surgical facility
  • outpatient surgery center
  • hospital outpatient
  • hospital inpatient
    
    
• Probable length of procedure:
  
  
  • When performed at the time of a mastectomy, it adds about an hour or so to the surgery. Drains are put in place, and recovery time is longer due to the additional surgery, but the care afterward is the same as for mastectomy alone.
    
    
  • Delayed reconstruction, as second surgery, requires more than an hour, and drains are not routinely inserted. The recovery is much quicker than it is after immediate reconstruction because the mastectomy wound has already healed.

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