This article in the series on "After Treatment for Breast Cancer" explores the latest techniques in breast reconstruction after a mastectomy (removal of the entire breast) and topics to discuss with the doctor before the surgical procedure. For an overview of the issues a woman faces and the options available after treatment for breast cancer, read the Cancer.Net Feature: After a Mastectomy: What to Know.

About breast reconstruction

Breast reconstruction is surgery to shape a new breast after breast cancer surgery. For many women, reconstructions help gain back a sense of femininity and sexuality that may have been lost after surgery, and helps reduce feelings of self-consciousness. Most women who have had a mastectomy are candidates for reconstruction. A woman who has had a lumpectomy, in which only a segment of the breast is removed, usually doesn’t need reconstructive surgery.

Typically, three techniques are used to shape a new breast: (1) a breast implant uses saline-filled or silicone gel-filled forms to reshape the chest wall; (2) a tissue flap procedure uses muscle and tissue from the stomach and upper back to reshape the chest wall; and (3) newer techniques use other body tissues and muscles to reshape the chest wall. Reconstruction is usually completed in multiple stages. The initial operation is the longest and most complicated in the reconstructive process, and it usually occurs at the same time as the mastectomy. The remaining stages are commonly done on an outpatient basis. The secondary procedures usually include reconstruction of the nipple and areola (the darker area surrounding the nipple), and exchanging expanders for implants. Less common are procedures to reshape the remaining breast to make it symmetrical with the reconstructed one (more common with the flap procedures) or to address complications that may result after surgery. Years later, it may be necessary to make implant exchanges because breast implants usually don't last a lifetime. For example, there can be scarring around the implants, which alters their shape. Tissue for the nipple and areola reconstruction is taken from various areas of the body including the opposite breast nipple, ear, or upper thigh. The skin is then medically tattooed to color-match the remaining nipple and areola.

Depending on a woman's desire and treatment options, breast reconstruction can either be done at the time of the mastectomy, eliminating the need for extensive surgery later, or reconstruction can be delayed for months or years. In general, the reconstruction results are better when done at the time of the mastectomy because the skin and other soft tissues surrounding the area haven't tightened and scarred. Delaying surgery may be recommended, however, when radiation therapy is necessary after a mastectomy, because radiation therapy may cause tissues to contract.

Many other factors play a role in the breast reconstruction decision-making process, including:

• A woman's overall health
  
  
• The stage of breast cancer
  
  
• The size of the natural breast
  
  
• The amount of tissue available (for example, a very thin woman may not have enough body tissue to make flap grafts possible)
  
  
• A woman's desire to match the appearance of the opposite breast
  
  
• A woman's personal preference

Other factors to discuss with the doctor:

• The results of surgery vary. Talk with your doctor about your expectations and all possible outcomes before surgery.
  
  
• Although breast reconstruction restores the shape of the breast, it does not restore normal breast sensation.
  
  
• The ability to heal may be affected by previous surgeries, chemotherapy or radiation treatments, smoking, alcohol use, diabetes, and various medications.
  
  
• It may be necessary to have surgery on the remaining breast to reshape it to match the reconstructed breast.

Types of breast reconstruction procedures

Implants. Currently, there are two types of breast implants available: saline-filled and silicone gel-filled implants. The saline-filled implant is the one most commonly used and has an external silicone shell that is filled with sterile saline (salt water). Silicone gel-filled implants were thought to cause connective tissue disorder, but clear evidence of this has not been found. Talk with your doctor about the benefits and risks of silicone versus saline implants. Other important factors to consider when choosing implants include:

• Sometimes, saline implants "crinkle" at the top, or can shift with time, but many women don't find it bothersome enough to replace.
  
  
• There can be local complications with breast implants such as rupture, pain, capsular contracture (scar tissue around the implant), infection, and/or a poor cosmetic result. This is very unusual; however, it can happen, so talk with your doctor about the risks.

Tissue flap procedures. There are two common tissue flap procedures: the transverse rectus abdominis muscle (TRAM) flap, which uses muscle and tissue from the lower stomach wall, and the latissimus dorsi flap, which uses muscle and tissue from the upper back. Because blood vessels are involved and can increase the risk of complications from surgery, these procedures are usually not recommended for a woman with a history of diabetes, connective tissue disease, or vascular disease, or for a woman who smokes.

Two newer types of tissue flap techniques include the deep inferior epigastric artery perforator (DIEP) flap and the gluteal free flap. The DIEP flap, which is similar to the TRAM flap, does not use muscle to form the breast mound and does not require microsurgery to connect the tiny blood vessels. The gluteal free flap uses tissue and muscle from the buttocks to create the new breast. The surgery involved with these procedures is longer and the recovery time is longer, but the cosmetic result is usually better especially when radiation therapy is part of the treatment plan.

Questions to Ask the Doctor

After a breast cancer diagnosis, it's never too early to discuss treatment and post-treatment options, including breast reconstruction with the doctor or surgeon. If a woman chooses to have reconstructive surgery, a plastic surgeon will join the health-care team to work with the breast surgeon. After a thorough examination of a woman's health and consideration of other factors such as age, lifestyle, body type, and goals of the surgery, the surgeon will discuss the risks and benefits of each option. Consider asking the following questions:

• What type of reconstructive surgery do you recommend? Why?
  
  
• Will this surgery interfere with chemotherapy or radiation therapy?
  
  
• What kinds of changes to the reconstructed breast should I expect over time?
  
  
• What results can I realistically expect?
  
  
• When will I be able to return to daily activities, such as driving, exercising, and working?
  
  
• How will my reconstructed breast feel to the touch? Will it match my other breast in size and shape?
  
  
• What should I expect after surgery?

Recovery time should take between six to eight weeks. Consider the following information:

• It can take as long as one to two years for tissues to completely heal and for scars to fade, although they will never completely go away.
  
  
• It may take time to adjust emotionally to having a reconstructed breast. It may help to talk with other women who have had the procedure, or to a mental health professional about any feelings of anxiety or uncertainty.
  
  
• Breast reconstruction has no known effect on the recurrence of breast cancer and it should not cause problems with chemotherapy or radiation therapy if cancer does recur. Talk with your doctor, as each person is different.

More Information

Cancer.Net Feature: After Treatment for Breast Cancer: Choosing a Breast Prosthesis

Body Image and Cancer

Body Image and Sexuality