Reconstruction of a breast that has been removed for the treatment of breast cancer or to lower the risk of a high-risk individual can be one of the most rewarding procedures performed today. Breast reconstruction can be done immediately at the time of mastectomy or in a delayed fashion, months to years later. Many options are available and include the use of breast implants, your own tissues or combinations of both.
WHAT IS BREAST RECONSTRUCTION?
Breast reconstruction is elective surgery that involves recreating a breast which has been removed in part (lumpectomy) or in its entirety (mastectomy). This is usually secondary to treatment of cancer or prophylactic removal of the breast for patients who are at high risk of developing breast cancer (Strong family history or BRCA gene mutation). Breast reconstruction is completely covered under the Ontario Health Insurance Plan (OHIP). This includes any balancing procedures or revision surgery in the future.
While there are many types of breast reconstruction, it is important to note that not all women are candidates for each type of reconstruction. The option(s) available to you will be discussed in consultation with Dr. Somogyi. It is also important to understand that no method of breast reconstruction will recreate a breast that looks and feels exactly the same breast as the breast that was removed. In cases of one- sided (unilateral) reconstruction, the new breast will often look and feel different from the opposite side. In the case of a unilateral mastectomy, part of your reconstruction may involve additional surgery to match your unaffected breast to the reconstructed side.
IS BREAST RECONSTRUCTION FOR ME?
Breast reconstruction is a personal choice. It can have both physical and psychological benefits, and will avoid the use of an external prosthesis. It can be a lengthy process requiring a number of surgeries and recoveries, and it is important that every woman is well informed and confident in their decision regarding breast reconstruction. For women with serious medical problems or advanced cancer, breast reconstruction may not be a reasonable option.
WHEN TO PERFORM BREAST RECONSTRUCTION?
Reconstruction can occur either at the same time as a mastectomy (immediate) or months to years after the mastectomy (delayed). The need for other cancer treatment – including radiotherapy or chemotherapy – may impact the timing of your reconstruction. Not all women are candidates for immediate reconstruction, particularly if there is planned postoperative radiation therapy. In some cases a woman may choose to delay the decision and choose breast reconstruction in a delayed fashion.
CAN I KEEP MY NIPPLES?
Traditional mastectomies have always included the removal of the nipple and areaola together with the underlying breast tissue. More recently, new techniques have been developed that allow for a Nipple Sparing Mastectomy. This approach, while providing an excellent aesthetic result, is technically more difficult and can only be performed when all of the following criteria are met:
1. Your tumor is of the correct type and in the right location that your breast surgeon feels can accommodate an oncologically safe resection of your tumor while preserving the nipple.
2. Your nipple is currently in the correct location. The position of a nipple cannot be changed during a nipple sparing mastectomy. Therefore, droopy breasts with low nipples are not appropriate for this approach.
3. Your breast is not too large. This is a decision that must be made on a case by case basis by your general surgeon. It is technically very difficult to remove all the breast tissue from a very large breast while safely preserving the nipple.
If you are not a candidate for a nipple sparing mastectomy, Dr. Somogyi will discuss the various options for nipple reconstruction with you. This is done at a second stage once the breast mound itself has been created.
OPTIONS FOR BREAST RECONSTRUCTION
There are two major categories of breast reconstruction: 1) Implant based reconstruction; and 2) reconstruction using your own tissue (usually from the abdomen). In some cases a combination of techniques using your own tissue (latissimus dorsi flap) combined with an implant may be offered. Each technique has a different length of surgery, recovery time, advantages and disadvantages.
Implant reconstruction is often simpler and faster that autologous (flap) reconstruction. Using an implant avoids additional surgery in a donor area and for this reason often results in a faster recovery. Implants, on the other hand, do not last forever and will often need to be adjusted or replaced at some point in the future. Implants having significantly higher complications rates in the setting of radiotherapy.
Two-stage Expander/Implant Reconstruction:
This staged method of reconstruction involves stretching the breast skin and tissue over a period of time prior to insertion of the final implant. Each stage involves a 2- hour surgery under general anesthetic but does not usually require an overnight stay in the hospital. Recovery after the first stage is 2-4 weeks, and after the second stage 1-2 weeks.
During the first stage a temporary inflatable implant, called a tissue expander, is placed under the skin and muscle to stretch the tissues to allow for creation of a breast mound. The expander is inflated in the clinic every 2 weeks over 2-3 months using saline.
Tissue expander in place under the skin and muscle of the mastectomy site. It is filled by a small needle placed through the skin at each clinic visit
The second stage is carried out 3-6 months after the final expansion. This involves removal of the temporary expander and insertion of a breast implant. Silicone implants are almost always recommended for use as the permanent implant in breast reconstruction. Silicone implants are completely safe and provide a more natural look and feel. Saline implants are heavier and result in a more unnatural look and feel of the breast.
In certain cases, the permanent silicone implant can be placed at the time of mastectomy without the need for a tissue expander stage. In most of these cases a specialized material made from the donated skin, known as acellular dermal matrix, must be used to further support the internal lining of the breast. Direct to implant reconstruction completes the majority of the reconstruction in one stage (2-3 hours) at the same time as the mastectomy. Often a second, smaller surgery, is needed several months later to make minor adjustments or refinements. Implant based reconstruction does not usually require an overnight stay in hospital.
If your treatment has included or will include radiation therapy, the risks of implant based reconstruction are significantly higher. Dr. Somogyi will discuss whether this is still a good option for you.
AUTOLOGOUS RECONSTRUCTION (USING YOUR OWN TISSUE)
Using your own tissue can result in a more natural feeling and appearing breast. Since this is your own tissue, it will age/change with the rest of your body, often with less need for revisionary surgery in the future. On the other hand, autologous reconstruction necesitates additional, often complicated, surgery at the donor site (abdomen or elsewhere). This can result in longer healing and recovery and potentially a higher rate of short term complications.
The most common method of using your own tissue to reconstruct the breast mound (autologous reconstruction) involves using your excess abdominal tissue. When reconstruction is performed with a Pedicled TRAM flap, the skin and fat of the lower abdomen remains connected to its blood supply via the underlying abdominal muscle (Rectus Abdomens). The muscle is transected at its lowermost point near the pelvis and rotated into the chest area, where the attached skin and fat are used to create a breast mound. In this manner, the abdominal muscle is sacrificed from its native position in the abdomen and transferred to the chest leaving a small amount of weakness and a higher chance of abdominal hernia or bulge in the future. This is a 3-4 hour surgery and requires an overnight stay in hospital.
A second option that uses abdominal tissue for breast reconstruction is the Deep Inferior Epigastric Artery Perforator (DIEP) flap. This is one of the ‘free flap’ options for breast reconstruction. The DIEP flap uses the same abdominal skin and fat as the TRAM flap but in a significantly more complicated way. Unlike the pedicled TRAM flap which remains attached to its blood supply, thereby sacrificing the abdominal muscle that is placed up in the chest, the DIEP uses these same tissues but uses microsurgical techniques to disconnect the skin and fat from its blood supply in the abdomen and reconnect it to a new blood supply in the breast area. This procedure has the advantage of leaving the abdominal muscle intact thereby decreasing abdominal weakness and lowering the risk of hernia that can sometimes be a problem with the pedicled TRAM flap. On the other hand, the DIEP involves a significantly longer and more complicated surgery (5-7 hours per side) with a small chance (1-3%) that the reconnected blood vessels do not flow properly. The DIEP procedure also requires a longer hospital stay (3-4 days) to allow for close monitoring of the flap.
Other Free Flap Options
There are a number of other free flap options that involve disconnecting skin and fat from various body areas and reconnecting them in the chest to create a breast mound. These procedures are not commonly performed but include flaps of tissue from the buttock (Gluteal Free Flap) or the inner thigh (Transverse Upper Gracilis). These flaps are rarely the first choice but Dr. Somogyi can discuss these options with you if they may be appropriate.
COMBINED IMPLANT & AUTOLOGOUS RECONSTRUCTION
Latissimus Dorsi Flap
In some cases, such as in the setting of previous radiation therapy, implant reconstruction may be considered in combination with using your own tissue from the back (latissimus dorsi flap). The first stage of this surgery takes 3 hours and requires an overnight stay in hospital. During this surgery, the latissimus dorsi muscle from your back is transferred to your chest – often a variable amount of skin and fat from the back is transferred together with the muscle. This muscle harvest requires a long incision on the back, which is placed so that it will be hidden by clothing or a bra. Once the muscle has been transferred to the chest, if additional volume/size is required, a tissue expander or implant can be placed beneath the latissimus dorsi muscle. Recovery time is 4-6 weeks following a lattisimus dorsi flap. If an expander needs to be exchanged for a permanent implant this is done during a second stage operation. This exchange operation is 1-2 hours long and requires 1-2 weeks of recovery.
OTHER OPTIONAL SURGERIES
The Opposite Breast
Dr. Somogyi’s goal is for you to have natural looking, symmetrical and aesthetically pleasing breasts following your breast cancer surgery. In some cases, small “touch up” procedures are required to make adjustments to the shape of the breasts or to improve the scars. In the case of a unilateral procedure, your unaffected breast may need to be adjusted to better match the reconstructed side. This can be accomplished with augmentation, reduction or lifting of the unaffected breast. This balancing procedure can be done at the same time as the reconstruction or at a second stage operation some months later.
The transfer of fat from one area of the body to the breast area is becoming exceedingly more common. Fat grafting is performed by harvesting the necessary fat using standard liposuction techniques. The fat is then prepared for re-injection and placed where needed though a narrow injection cannula (no additional surgical incisions are made). Fat grafting can be used to improve a breast reconstruction in many ways. Fat can provide healthy cells to rejuvenate damaged skin, it can be used to provide additional thickness to thin skin over implants and it can be used to fill in or correct divots or deformities. These procedures can be done at the same time as the main reconstruction and/or during revision or “touch up” procedures.
Nipple and areolar reconstruction are optional procedures usually discussed at a minimum of 3 months after final reconstruction of the breast mound. Many options are available to provide for the colour and appearance of a nipple/areolar complex. Options range from simple tattoo to 3D tattoo reconstruction. If true nipple projection is desired, this can be provided by creating and folding flaps of adjacent breast skin into the shape of a nipple. Alternatively, a graft can be taken from the contralateral nipple (if available) or from other areas such as the earlobe. Nipple/areolar reconstruction is generally performed under local anesthetic with minimal discomfort and recovery time.
MAKING THE DECISION
Personal factors including your body shape and treatment plan (especially radiotherapy) will impact the options available to you for breast reconstruction. It is important to understand the advantages and disadvantages of a surgical procedure before proceeding with reconstruction. In general, implant based reconstruction provides a beautiful result with no donor site concerns, shorter surgery and faster recovery. In unilateral cases, it is often hard to match an implant to a ‘normal’ contralateral breast. Finally, implants are not truly “permanent” and will likely require smaller revision surgeries in the future. Tissue based (abdominal flaps, latisimus dorsi) reconstructions can provide for a beautiful, natural looking breast which can be more easily matched to your contralateral ‘normal’ breast. Since your own tissues are used, they will age and change naturally with the rest of your body and rarely require additional surgery in the future. This comes at the expense of longer surgery and recovery as well as significant potential complications at the donor site. Finally, not all women have enough of their own extra tissue from which to reconstruct a breast.
The decision to proceed with breast reconstruction is a personal one. It is important that you are comfortable with your decision. Dr. Somogyi will spend as long as necessary with you to ensure that you understand the options and ultimately your decision. Together with Dr. Somogyi, you will come to a decision after considering your breast size, breast disease, body shape, other health concerns, lifestyle habits, fears and goals. Of course, you will also have a detailed discussion of the risks and benefits of the procedures that are right for you.
BREAST RECONSTRUCTION FAQs
- I have breast reconstruction?
All women who have (or are going to have) a mastectomy should have a discussion with a plastic surgeon about breast reconstruction. In the vast majority of cases, there will be good reconstructive options available to you. The only definite reason why you would not be eligible for breast reconstruction would be if you had other medical issues that would make additional surgery unsafe.
- Can I have breast reconstruction at the time of my mastectomy?
This is called “immediate reconstruction” and many women are candidates. Immediate Reconstruction is a great option during prophylactic mastectomies or in cases of breast cancer where no radiation therapy is anticipated. The alternative is called ‘delayed reconstruction’ and usually takes place 6-12 months after your mastectomy. There is no time limit for delayed reconstruction. In other words, your reconstruction can be done as early as several months after your mastectomy or as long as many years later. Your general surgeon and plastic surgeon together will advice you on whether immediate or delayed reconstruction is best for you.
- Is there a cost for breast reconstruction?
Breast reconstruction is recognized by OHIP as an important part of your breast cancer treatment. As such, OHIP covers virtually all aspects of your breast reconstruction including the costs of the implants, hospital stay (if necessary), nipple areolar reconstruction and even balancing surgery on the opposite breast if needed.
- Are breast implants safe?
All the breast implants we use are approved by Health Canada and have a long track record of safety and proven results. Silicone implants are the preferred choice for breast reconstruction but all implants have risks associated with them. The implants themselves may need to be replaced in the future due to a number of possible reasons including hardening of the scar tissue around the implant (capsular contracture), shifting of the implant from it’s intended position (implant malposition) or failure of the implant itself (implant rupture). None of these conditions are dangerous but may require additional surgery to correct them if necessary in the future.
- What are common problems that occur following breast reconstruction?
The most common problems that patients face following breast reconstruction are highly dependent on the type of reconstruction performed. In the short term, patients will have issues related to pain and recovery from surgery. Delayed (slow) healing can be a problem for some patients and minor asymmetries (differences between the two breasts) sometimes require additional minor surgery to correct. Long term potential problems should be discussed in detail with your plastic surgeon. As a general rule, you should understand the possible complication of implants (see question #4 above) as well as the complications from using your own tissues, the most common of which is weakness in the donor area as well as significant scars at these donor sites. Of course, all surgery will result in scaring and Dr. Somogyi will advice you on how to best manage your scar.
- How long from the time of my surgery until I feel back to normal/return to work?
This will vary significantly between patients and between types of reconstructions. In general, you can aim for return to normal activities by 2-4 weeks for implant-based reconstruction or 6-8 weeks if using your own tissues. Your recovery will be gradual from day one after surgery and Dr. Somogyi will guide you through this process.
- What will my reconstructed breast feel like?
The biggest change in here will be in sensation. Regardless of type of reconstruction, your mastectomy will remove many or most of the nerves to the breast skin leaving you with less sensation in the area. The feel or softness of the breasts themselves will differ depending on the type of reconstruction performed. Implant-based reconstructions tend to produce firmer, less mobile breasts whereas using your own tissue results in more natural feeling breasts. Whether or not you have radiation therapy will also influence both the sensation and softness of the reconstructed breast.
- What postoperative care can I expect after my breast reconstruction?
Your plastic surgeon will follow you closely in the short term and continue to follow you at regular intervals long term. Depending on the type of reconstruction, you will likely have bandages that will remain in place until your first follow up visit. You may have intravenous pain medication if you stay in hospital and you will be given oral pain medications and antibiotics to for your initial recovery at home. You will also likely have drains that can be removed at home by a home care nurse or during one of your follow up visits. Depending on the type of procedure and your support at home, it can be arranged for a nurse to come to your home at regular intervals to help with both drain care and bandages.
- What are my options to balance my reconstructed breast with the opposite side?
In the case of a unilateral mastectomy and reconstruction, you will have the choice to have additional surgery on the opposite side to better match the shape and/or size of the reconstructed breast if needed. Options include, reducing, augmenting or lifting the non-cancer breast depending on what can be achieved with the initial reconstruction.
- Are they any other additional surgeries I will need to consider?
Breast reconstruction is a process that can be divided into stages. Whether immediate or delayed reconstruction, the first stage is the creation of a breast mound using either your own tissues or a tissue expander. This will be separated by at least 3 months from Stage 2 which could involve finishing touches on the breast mound, nipple/areolar reconstruction and balancing of the opposite breast if desired. In the case of an implant reconstruction the time between stage one and two may be longer to account for the time required to expand the breast.
Nipple areolar reconstruction can be done during Stage 2 or can be done as a separate procedure at a later time. Generally, nipple areolar reconstruction itself is a two stage procedure with creation of the nipple in the first stage and tattooing of the areola (if desired) in the second stage. In summary, most breast reconstructions will require 2 surgical procedures with up to 2 or 3 additional procedures until the final result is obtained.
- Will I still require breast cancer screening after breast reconstruction?
Whether or not you have a reconstruction, a breast that has had a mastectomy does not require ongoing radiological investigation (MRI, Mammogram or Ultrasound). In the case of a unilateral mastectomy, the opposite breast would continue standard clinical and radiological breast cancer screening. Having breast reconstruction does not change these screening recommendations.
- How do I decide what type of breast reconstruction is best suited for me?
This decision will be made in consultation with Dr. Somogyi who will give you options based on whether one or both breasts is involved, the availability of your own tissue for reconstruction, previous or planned radiation therapy, overall health, and a host of other personal factors including adversity to larger procedures, longer recovery, support at home, etc. In most cases, there will be an option best suited to you, which will Dr. Somogyi will recommend to you. You will make the ultimate decision together.
MORE INFORMATION ABOUT YOUR CONSULTATION
Dr. Somogyi’s goal is for you to understand the options available and to be comfortable with the choice you make. At your initial consultation, together with Dr. Somogyi, you will review your general medical history, focus on your breast history and have a complete examination. You will then discuss the options that are available to you with the help of anatomical drawings and patient photographs. Finally, 3D photographs will be taken with the VECTRA 3D Imaging system to help in surgical planning and to help you visually understand the procedures being planned.
A second or third consultation is often necessary and can be booked after your initial meeting. You will also have phone and email access to Dr. Somogyi’s office to discuss question that arise during your pre and post operative journey.