The Best Candidates for Breast Reconstruction
Most mastectomy patients are medically appropriate for reconstruction, many at the same time that the breast is removed. The best candidates, however, are women whose cancer, as far as can be determined, seems to have been eliminated by mastectomy.
Still, there are legitimate reasons to wait. Many women aren’t comfortable weighing all the options while they’re struggling to cope with a diagnosis of cancer. Others simply don’t want to have any more surgery than is absolutely necessary.
All Surgery Carries Some Uncertainty and Risk
Virtually any woman who must lose her breast to cancer can have it rebuilt through reconstructive surgery. But there are risks associated with any surgery and specific complications associated with this procedure.
In general, the usual problems of surgery, such as bleeding, fluid collection, excessive scar tissue, or difficulties with anesthesia, can occur although they’re relatively uncommon. And, as with any surgery, smokers should be advised that nicotine can delay healing, resulting in conspicuous scars and prolonged recovery. Occasionally, these complications are severe enough to require a second operation.
Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment, should cancer recur. Your surgeon may recommend continuation of periodic mammograms on both the reconstructed and the remaining normal breast. If your reconstruction involves an implant, be sure to go to a radiology center where technicians are experienced in the special techniques required to get a reliable x-ray of a breast reconstructed with an implant.
Planning Your Surgery
After evaluating your health, your surgeon will explain which reconstructive options are most appropriate for your age, health, anatomy, tissues, and goals. Be sure to discuss your expectations frankly with your surgeon. He or she should be equally frank with you, describing your options and the risks and limitations of each. Post-mastectomy reconstruction can improve your appearance and renew your self-confidence — but keep in mind that the desired result is improvement, not perfection.
Your surgeon should also explain the anesthesia he or she will use, the facility where the surgery will be performed, and the costs. In most cases, health insurance policies will cover most or all of the cost of post-mastectomy reconstruction.
Types of Implants
If your surgeon recommends the use of an implant, you’ll want to discuss what type of implant should be used. A breast implant is a silicone shell filled with either silicone gel or a salt-water solution known as saline.
Because of concerns that there is insufficient information demonstrating the safety of silicone gel-filled breast implants, the Food & Drug Administration (FDA) has determined that new gel-filled implants should be available only to women participating in approved studies. This currently includes women who already have tissue expanders, who choose immediate reconstruction after mastectomy, or who already have a gel-filled implant and need it replaced for medical reasons.
The alternative saline-filled implant, a silicone shell filled with salt water, continues to be available on an unrestricted basis, pending further FDA review.
While there are many options available in post-mastectomy reconstruction, you and your surgeon should discuss the one that’s best for you.
The most common technique combines skin expansion and subsequent insertion of an implant.
Following mastectomy, your surgeon will insert a balloon expander beneath your skin and chest muscle. Through a tiny valve mechanism buried beneath the skin, he or she will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has stretched enough, the expander may be removed in a second operation and a more permanent implant will be inserted. Some expanders are designed to be left in place as the final implant. The nipple and the dark skin surrounding it, called the areola, are reconstructed in a subsequent procedure.
An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the back, abdomen, or buttocks.
In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat, and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself, without need for an implant.
Another flap technique uses tissue that is surgically removed from the abdomen, thighs, or buttocks and then transplanted to the chest by reconnecting the blood vessels to new ones in that region. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well.
Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about a silicone implant. In some cases, you may have the added benefit of a improved abdominal contour.
After Your Surgery
You are likely to feel tired and sore for a week or two after reconstruction. Most of your discomfort can be controlled by medication prescribed by your doctor.
Depending on the extent of your surgery, you’ll probably be released from the hospital in two to five days. Many reconstruction options require a surgical drain to remove excess fluids from surgical sites immediately following the operation, but these are removed within the first week or two after surgery. Most stitches are removed in a week to 10 days.
Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. Most scars will fade substantially over time, though it may take as long as one to two years, but they’ll never disappear entirely.
Follow your surgeon’s advice on when to begin stretching exercises and normal activities. As a general rule, you’ll want to refrain from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following reconstruction.