Breast reconstruction after mastectomy

What is breast reconstruction?

Breast reconstruction surgery is performed to rebuild a breast which was removed through surgery for the treatment or prevention of breast cancer. Breast reconstruction can be performed using an implant (artificial materials) or by using a tissue flap (tissue from another part of the body).

Patients planning mastectomy (breast removal surgery) should talk to their surgeon about breast reconstruction before the procedure. The mastectomy procedure performed will depend upon the type of reconstruction chosen.

Do I need breast reconstruction after mastectomy?

Breast reconstruction isn’t necessary after mastectomy and is a cosmetic procedure, depending upon the patient's choice. Some women are comfortable with only one or even no breasts after surgery, while others might feel cosmetically odd and would prefer to have a reconstruction. Having a breast reconstruction also helps in good posture and dressing.

What if I decide not to have reconstruction?

If left without reconstruction, the operated side would be flat and have a surgical scar. Some women can wear special bra with a soft plastic breast pocket to make clothing fit better and look more even.

When can I have my breast reconstructed?

Breast reconstruction isn’t an urgent procedure and can either be done along with the mastectomy or any time later. The timing for breast reconstruction may also be influenced by the type and stage of your cancer along with any future treatments required. If you want to delay the reconstruction for any personal reasons you can discuss it with your doctor too.

Immediate reconstruction means having breast reconstruction at the time of mastectomy and is usually preferred in patients with early stage cancer or those having a preventive mastectomy. The skin left during mastectomy is used as a pocket to hold the tissue or implant used as a new breast.

Later stage cancer patients or the ones with larger cancer may need radiotherapy after mastectomy to kill remaining cancer cells. Breast reconstruction has to be delayed ("delayed reconstruction") in these patients until after the treatment is finished. It’s delayed as the reconstructed breast tissue can hinder radiation from reaching target regions. Also, the radiation can cause damage to the reconstructed breast too.

What are the different ways that surgeons can reconstruct a breast?

Breast reconstruction is usually performed in 2 ways:

  • With implants
  • With flaps (different types based on the muscle used)

The choice of reconstruction approach depends on:

  • Breast size
  • Extra body fat and its locations
  • Factors like smoking, overweight, diabetes, heart or lung diseases, etc.
  • History of past surgeries, as a scar can affect the usability of that tissue as a flap

How does reconstruction with an implant work?

A breast implant, is a breast shaped container filled with saline or silicone which is inserted under the muscle layer in the chest.

There are two steps for inserting a breast implant:

  • The surgeon inserts an expander that stretches the chest skin and muscles, allowing them to hold the implant. The surgeon keeps adding fluid to the expander until it stretches the skin and muscles enough for the implant to fit.
  • The surgeon performs another operation for the implant to be inserted.

Implants are recommended for smaller breasted women whose breasts don’t droop.

How does reconstruction with a flap work?

The reconstruction depends on the type of flap being used. Most common ones are:

TRAM flaps

TRAM flaps are made up for skin along with fat and muscles and taken from the belly.

Pedicle TRAM flap is the one in which the blood vessels supplying the muscle remain attached to the flap. This flap type is tunneled under the skin to the breast pocket from the belly.

Free TRAM flap is the one that’s totally disconnected from the belly, including it’s original blood supply. This type of flap is connected to the blood supply in the chest and doesn’t need to be tunneled.

Both types of TRAM flaps are performed in women with sufficient fat in abdomen. The belly looks flat after the surgery and leaves a scar from hip to hip along the bikini line.

Lat Dorsi flap

A flap taken from the back is called Lat Dorsi flap. It also consists of skin, fat and muscle tissue. The Lat Dorsi flap is tunneled from beneath the skin from back to chest and remains connected to it’s own blood supply. This type of flap leaves a scar beneath the bra line on the back. These patients also often receive a breast implant, as the back fat isn’t enough to give proper shape to new breast.

DIEP flap

DIEP flap, taken from the abdomen, is different from the TRAM flaps as it doesn’t contain any muscle tissue. This type of surgery is more complicated and lengthier as connecting this type of flap to a good new blood supply is harder.

Flaps taken from other places

Patients with less abdominal fat for a good TRAM or DIEP flaps may have flaps taken from other places like inner thigh or rear end.

Will my nipple be reconstructed?

Nipple reconstruction is a patient’s choice and is performed a few months after the main breast reconstruction procedure. Nipple reconstruction can be done using the tissue already in that region or from another part of the body. Giving proper color to the nipple might include tattooing it and the area around it too.

Will my new breast match my other breast?

The reconstructed breast can’t be identical to the one before surgery or look exactly the same as the other one, however, it can be as close as possible. Surgeons might suggest operating on the normal breast to make it look similar to the reconstructed one. Also note that the skin sensation in the reconstructed breast may not also be the same as the other breast.

Can I choose which kind of reconstruction to have?

In some cases you can, while in others you can’t. This is because the types of reconstruction possible in each case might vary. However, if you prefer one type of reconstruction to any other, discuss it with your surgeon to check if it is an option and also to understand what’s best in your case and why.