Doctors and other health professionals you may see
How is implant reconstruction done?
Latissimus dorsi reconstruction
Rectus abdominis reconstruction (TRAM flap)
In implant reconstruction, an implant is placed under the skin and muscle to recreate the shape of the breast. In flap reconstruction, skin, fat and muscle are taken from elsewhere on the body to make the new breast. Each type of surgery can be done in several ways. Some are more difficult than others-both surgically and for the woman to undergo. Some reconstructions involve two or more operations several weeks or months apart.
Your plastic surgeon will discuss the different methods with you and recommend the one that is best for you. This will depend upon:
Make sure that you understand why your surgeon recommends a particular method and ask to see photographs of women who have had a reconstruction using this method.
Specialists and other health professionals who care for women undergoing a breast reconstruction include:
Breast implants are made from a silicone (plastic) envelope and filled with either silicone gel or saline. They are used not only for women who have had mastectomy but also for cosmetic breast enlargement.
There are advantages and disadvantages in using implants in breast reconstruction. There are also some specific problems related to each type of implant. The main advantage in using an implant in reconstruction is simplicity, both surgically and for the woman. An implant reconstruction takes less time and is less complicated than other types of reconstructions. The implant can be used to create the shape of the new breast without having to bring tissue (muscle, skin or fat) from elsewhere in the body. There is a shorter recovery time, and the woman is left with only one scar. Implants come in a range of sizes and shapes. Pear-shaped implants that are designed to best match the remaining breast are available.
The main disadvantage of an implant is that it involves placing ‘foreign' material within the body, and the body will respond to this by creating a capsule of scar tissue around the implant (see ‘Possible problems'). Reconstruction with an implant alone will usually require two operations and a number of weekly visits between operations to ‘expand' the skin over the breast.
In making your decision about whether to have an implant, it will help to weigh up the good and bad points of the different types of operations. Your decision may also depend on the way you feel about having something foreign in your body. Some women are comfortable with this idea, while others will prefer not to have one, even if it means having a more complicated flap reconstruction.
You will need to discuss the use of an implant and possible problems with your plastic surgeon or general practitioner. You may also find it helpful to talk with someone who has had a breast reconstruction using an implant.
Silicone breast implants are a silicone envelope containing silicone gel. Silicone gel is a soft jelly-like substance. These types of implants tend to be softer and have a more ‘natural' feel to them than saline implants. Cohesive gel implants, which have a ‘semi solid' filling, are now commonly used. It is believed that even if the shell of these breaks there will be no leak of silicone. They do not feel quite as soft as the ordinary silicone gel implants.
There has been some controversy around the use of silicone implants. They were withdrawn from the market for a period of time. This was because of concerns about the effects of silicone if it was to leak outside the capsule that the body created around the implant. Research suggests that silicone implants are safe but it must be remembered that any surgical procedure carries with it risks such as infection, bleeding and scarring. Discuss any concerns you have about silicone implants with your plastic surgeon.
Saline breast implants are used for some forms of breast reconstruction. These implants have a solid silicone envelope containing salty water. If they break, the saline released into the body is not harmful. However, the long-term safety of saline implants is still being looked at.
Although they can give a good breast shape and feel, they are not quite as lifelike as silicone gel implants. Problems such as wrinkling of the skin around the new breast and ‘sloshing' may also occur. A saline implant may deflate without warning or it may wear out. In both circumstances it will need to be replaced. The implant will generally have to be replaced about once every 10 to 15 years. Most plastic surgeons recommend silicone implants rather than saline implants because of better cosmetic result.
If you have healthy chest muscle and enough skin to cover an implant, a breast implant can be inserted under the chest muscle. The implants come in various shapes and sizes. The plastic surgeon will choose one that best matches your own breast.
With this method of reconstruction, the mastectomy scar is usually re-opened for the implant to be put in.
If you don't have enough skin to cover an implant, an inflatable tissue expander can be used to stretch it. The expander, a balloon-like bag, is placed under the skin and muscle, either at the time of the mastectomy or some time later. Once the skin has healed, the balloon is gradually filled by injecting it with saline. These injections are given every couple of weeks until the new ‘breast' is about the same size as the other breast. Another small operation is then performed to remove the filling tube and injection point. If a temporary expander is used, it will be replaced with a permanent implant.
This results in less scarring than the more complex flap reconstruction methods, but the regular saline injections can cause discomfort for a few days afterwards. Check with medical staff about suitable pain relievers.
The texture and feel of a breast reconstructed using tissue expansion methods is unlikely to be normal: it may be firmer than your other breast or it may not ‘fall' naturally.
If you have larger breasts or do not have enough skin to cover an implant, one of several flap methods may be used. They are named after the muscles used in the reconstruction.
These methods use muscle and skin from other parts of the body to build a new ‘breast', which avoids some of the problems that can occur with implants. Once the reconstruction has healed, it is permanent. However, the surgery takes a longer amount of time, there is greater risk of infection, there is longer recovery time, and you will be left with more than one scar. Unlike implant reconstructions that tend to look best early on but not as good after ten years or more, flap reconstructions maintain their look and feel over the long term.
The latissimus dorsi is a broad, flat muscle on the back below the shoulder blade. With this method, the latissimus dorsi muscle and some skin are moved to the chest. An implant may be required under the flap to make your breast large enough to match the remaining breast. There is no need in this situation for a tissue expander, and the reconstruction, apart from the nipple, can be completed in one operation.
After surgery, you will have an oval-shaped scar on your new breast and a straight scar on your back. The scar on the back may be covered by a bra.
One of the pair of long, flat stomach muscles, called the rectus abdominis, is used for this reconstruction method. The plastic surgeon moves the muscle, along with some of the local skin and fat, to the chest area where it is shaped into the form of a breast.
About two weeks before the main operation, a smaller operation may be needed, particularly for women with larger breasts. The aim of the smaller operation is to improve the blood supply to the tissue that will be made into the new breast.
After TRAM flap reconstruction, heavy lifting-including lifting small children-should be avoided for about six weeks. Both methods will cause a tightening of the abdomen similar to a ‘tummy tuck' operation.
TRAM flap reconstructions leave a long scar across the hip area. There will also be a scar on the new breast, and no feeling in the skin moved to the new breast. Before a flap reconstruction the plastic surgeon may organise banking of your blood as you may need a blood transfusion during surgery.
In this method, the muscle is left attached and ‘tunnelled' under your upper tummy skin to the breast, with the blood supply kept intact. A reconstruction done in this way takes about three to four hours. It usually requires three to four days in hospital.
In this method, the plastic surgeon uses microsurgery to completely divide the muscle and the blood vessels, and re-attach them to the vessels in the chest or under the arm. This method can be better at recreating a larger breast, and makes it easier for the plastic surgeon to shape the breast, giving a more accurate final result, but is a more complicated and longer operation requiring special facilities and expertise.
A free TRAM flap operation takes five to seven hours and requires at least one week in hospital. Full recovery from the surgery takes at least six weeks. The removal of the abdominal muscle in a free TRAM flap operation can weaken the abdominal wall, which can result in a hernia. To reduce the risk of problems of this kind occurring in the future, the surgeon may insert a special mesh into the abdomen to replace the muscle. Some plastic surgeons now perform a reconstruction called a DIEP flap. This involves a slightly more complicated operation to leave the rectus abdominis muscle alone so that only the skin and fat are used to reconstruct the breast. In this case no mesh is required. Complications following a free TRAM flap can also include bleeding and loss of circulation to the flap due to clotting in or kinking of its blood vessels. For this reason it is strongly advised that women quit smoking before this operation.
After having a breast reconstruction, some women choose to have their nipple rebuilt. This includes rebuilding the nipple and the area around it called the areola.
Nipple reconstruction is usually a small operation, and can be done in a number of ways. Instead of having a nipple reconstruction, some women prefer to use ‘stick-on' nipples. These stick to the skin and will stay in place for several days. Because the new breast may sag slightly in the weeks after surgery, nipple reconstructions are generally not performed until at least three months after a breast reconstruction.
For many women, the small differences between their remaining breast and the reconstructed breast are not noticeable when they are wearing a bra. For others, particularly large-breasted women, the difference in size may be quite noticeable. Some women decide to have the remaining breast made smaller through surgical breast reduction. This can improve balance and posture.
Because of their particular type of breast cancer, some women may also be advised or choose to have a total mastectomy on their other breast. In this case, reconstruction would need to be considered for both breasts. Discuss this issue with your doctor, and seek a second opinion if you have any concerns about the advice you receive.
Updated Sept 2005
