Breast Reconstruction 101: A basic primer about reconstructing your breasts after cancer

Breast cancer has a prevalence of 1 in 8 American [and Australian] women, with its incidence ever-increasing as screening becomes more widespread. While breast cancer can be a trying and life-altering diagnosis, plastic surgical techniques for breast cancer reconstruction have improved significantly over the past several decades. Women facing mastectomy have a variety of options when it comes to breast reconstruction, and post-operative results are better than ever.

To Reconstruct or Not to Reconstruct?

Although I am a proponent of breast reconstruction as a way to rebuild a sense of normalcy after breast cancer, it is worth mentioning that breast reconstruction is not required. Some women, for a variety of reasons, opt not to proceed with breast reconstruction. As long as you are fully aware of your options (and you know that all American insurers are required to cover your plastic surgical reconstruction after cancer), opting not to reconstruct your breasts is a perfectly valid personal choice.

Immediate or Delayed?

The current standard of care is for most women to undergo immediate breast reconstruction, meaning that your breasts are recreated by a plastic surgeon at the time of your mastectomy. However, in some situations, women undergo delayed reconstruction, which can happen any time from days to years after the cancer operation. Delayed reconstruction can be an option as a result of patient choice, need for radiation or chemotherapy, need to expedite the surgical procedure, infection, comorbidity, or some combination of these reasons.

Implants or Tissue?

The major choice for a woman and her plastic surgeon to make regarding breast reconstruction is whether the breast mounds will be reconstructed with her own tissue or with breast implants. Currently, in the United States, the vast majority of breast reconstruction is performed with implant-based techniques, either in 2-stage (tissue expanders followed by implants 3 months later) or in 1-stage (implants placed at the time of mastectomy) procedures.

Both techniques have their roles, and neither one is superior to the other in all cases.

Implant-Based Breast Reconstruction

The benefits of breast implants include an easier, shorter operation, more predictable post-operative results in many patients, the lack of a second surgical donor site, and minimization of scarring. Most women, and interestingly, most female plastic surgeons prefer implant-based techniques. Implants can be especially helpful in very thin or athletic women, who have little extra body fat and desire a quick return to normal life after surgery. In addition, many women like the "augmented" look that can come with breast implants.

Breast implants can be problematic in women who require radiation therapy, women who smoke, and women who have a higher risk of infection (such as those with diabetes). In addition, breast implants carry with them higher risk of infection in all patients, as well as risks related to implant rupture, implant failure, and capsular contracture. Breast implants are not considered lifetime devices, so women who get implant-based breast reconstruction will likely need additional surgeries at later times. Moreover, many plastic surgeons feel that implants used in breast reconstruction look better initially than they do after several years.

Autologous Tissue Breast Reconstruction

Tissue-based reconstruction uses extra skin and fat on a woman's body to rebuild the breast. The most common donor site for autologous tissue reconstruction is the abdomen. Other donor sites, such as the inner thigh, buttocks, and outer thigh have also been described. The technique used for constructing a breast in this way is referred to as either a free or pedicled flap.

The major benefit of autologous tissue reconstruction is that it recreates a breast that mimics the normal human breast in tissue type and tissue feel. This means that it can look and feel quite natural, and that it ages with a woman and changes with her as her weight changes. Autologous tissue reconstruction is also regarded as the safer technique in many women who have radiation damage to their tissue or who will require radiation after surgery. Because there are no foreign bodies placed, risks of infection are lower overall.

The disadvantages of this technique include a long, technically complex operation, a protracted recovery, a second surgical site, additional scarring, and potential need for revision operations to sculpt the breast mounds.

Nipple Reconstruction

Three to six months after the breast mounds are reconstructed (either with implants or tissue), many women will be ready to progress to nipple reconstruction. As nipple sparing mastectomy becomes more common, this technique may become less popular overall and may play a role more prominently in those who have sub-areolar disease.

Nipple reconstruction is a short outpatient procedure wherein local tissues on top of the breast are rearranged as a flap in a configuration that gives the breast a nipple-like cylindrical projection. This procedure is generally tolerated well and can be performed under local anesthesia only in selected patients.

Areolar Tattooing

At least three months after nipple reconstruction, the areolae can be tattooed to mimic the pigmentation and three-dimensionality of an anatomic nipple-areolar-complex. Techniques in medical tattooing have evolved significantly, and very impressive results are achievable in skilled hands. For women who prefer to avoid tattoos, a full-thickness skin graft harvested from the groin is an alternative method to achieve areolar pigmentation.

Overall Care

In order to achieve the best possible aesthetic appearance after breast cancer surgery, it is essential for your plastic surgeon to perform a thorough pre-operative evaluation; consult with your breast surgeon, oncologist, and radiation oncologist; have a discussion with you about your preferences and desires; help you weigh the risks and benefits of the various types of breast reconstruction; and answer your questions about recovery and long-term care.

While breast reconstruction can be a long journey, many women feel that rebuilding their breasts after mastectomy has elements of both physical and psychological healing. Indeed, many of my patients have told me that undergoing breast reconstruction is what ultimately allowed them to put their cancer diagnoses behind them and move forward with their lives.

By Lara Devgan, MD, MPH, is a Yale-educated, Hopkins-instructed, and Columbia-trained plastic and reconstructive surgeon in private practice in New York City.

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