| Breast prostheses & reconstruction | Breast prostheses | Prostheses wear & care |
| Types of breast reconstruction | After the operation | Seeking support |
Types of breast reconstruction
On this page: Who will do the reconstruction? ι Types of reconstruction ι Implant reconstruction ι Flap reconstruction ι Nipple reconstruction ι The remaining breast ι Bilateral mastectomy ι Therapeutic mammaplasty ι Information reviewed by
Who will do the reconstruction?
If you wish to have a breast reconstruction, your own breast cancer surgeon may have the expertise to do this or you may be referred to a reconstructive surgeon (also known as a plastic surgeon). Often a breast cancer surgeon and a reconstructive surgeon work together to do the breast cancer surgery and reconstruction during the same operation.
Ask to be referred to a surgeon who is an expert in breast reconstruction. Make sure that they are a Fellow of the Royal Australasian College of Surgeons and, if a reconstructive surgeon, a member of the Australian Society of Plastic Surgeons. For information about other health professionals who will care for you when you have a reconstruction.
Types of reconstruction
There are two major types of breast reconstruction: implant and flap reconstruction. Both techniques can be done as immediate reconstruction or delayed reconstruction. They can be combined with total, skin-sparing or nipple-sparing mastectomy.
In an implant reconstruction, an implant is placed under the skin and muscle to recreate the shape of the breast. In a flap reconstruction, skin, fat and muscle are taken from elsewhere in the body to make the breast mound. These operations can be done in different ways. Some are more difficult than others - both surgically and for the woman's recovery.
Most reconstructions involve two or more operations several weeks or months apart. Your reconstructive surgeon will discuss the different methods and suggest the best one for you. Make sure you understand why your surgeon recommends a particular method. The recommendation will depend on:
- your preference
- your body shape and build
- your general health
- the experience of the surgeon
- the amount of tissue that has already been removed
- scars from other operations
- the quality of the remaining skin
- the breast size you would like
- whether you need radiotherapy or have already had it
- whether you smoke - this affects the type of flap you can have.
Your surgeon should show you photos of different types of reconstructions, including the type recommended to you. Make sure you see a range of photos of your surgeon's work before deciding. Remember that there are variations in results, so your reconstruction may turn out better or worse than others. For information see making treatment decisions.
The breast implants used for women having reconstructive surgery are also used for cosmetic breast enlargement.
Skin-sparing mastectomy and breast reconstruction
If you are medically suitable and wish to have an immediate breast reconstruction, you may have the option of a skin-sparing mastectomy or a nipple-sparing mastectomy. In these operations, the breast tissue is removed, as it is in a total mastectomy, but most of the skin (and sometimes the nipple) is preserved. This can make the reconstruction appear more natural.
Skin-sparing or nipple-sparing mastectomy may not be appropriate for all types of breast cancer so you should discuss this with your breast cancer surgeon.
Implant reconstruction
Implants are more common for women who are not going to have radiotherapy. They are made from a silicone envelope and filled with either silicone gel or a saltwater solution (saline). Saline implants used to be common but are rarely used now.
There are advantages and disadvantages in using implants in breast reconstruction. There are also some specific problems related to each type of implant. You need to discuss the use of an implant and possible problems with your doctors. You may also find it helpful to talk with someone who has an implant.
Your decision to have an implant may also depend on how you feel about having something artificial in your body. Some women are comfortable with this idea; others prefer a flap reconstruction because usually only their own tissue is used.
Implant reconstruction advantages |
Implant reconstruction disadvantages |
|
|
Silicone implants
Silicone implants are made of a solid silicone envelope or shell that has soft silicone within it. They have a more natural feel than saline implants. Two types of silicone implants are available:
- Silicone gel - the original type of implant, which is made from a soft, jelly-like substance.
- Cohesive gel - a newer type of implant with a semi-solid filling that is not as soft as the original silicone gel implant but holds its shape longer. If the implant ruptures, cohesive gel is designed to minimise silicone leaking into the tissues.
There has been controversy around the use of silicone implants. They were withdrawn from the market in the 1990s due to concerns about the effects of the silicone gel if the implant ruptured and leaked into the body. Research now suggests that silicone implants are safe even if they do break.
Silicone implants may need to be replaced after 10-15 years. Discuss any concerns you have about silicone implants with your reconstructive surgeon.
Recently there have been reports of a type of lymphoma occurring in the capsule of breast implants. There are only about 35 cases to date out of the millions of implants used, but medical authorities are monitoring this issue. Talk to your surgeon about the risks.
Saline implants
Saline implants are no longer commonly used in reconstructions. They are made of a solid silicone envelope containing saltwater. They give a reasonable shape and feel but are not as naturally shaped as silicone implants. They may look rounder than a real breast, and problems such as the skin wrinkling and ‘sloshing' may occur.
A saline implant may gradually lose volume, deflate without warning or wear out. It then needs to be replaced. If the implant breaks, the saline released into the body is not harmful.
How is an implant reconstruction done?
If you have healthy chest muscle and enough skin, an implant can be inserted under the chest muscle. Implants come in many shapes and sizes. Your surgeon will choose one matching your own breast.
With this method of reconstruction, the mastectomy scar is usually re-opened for the implant to be put in. This is why there is no further scarring. The operation takes about an hour and you will probably be in hospital for one or two nights. You may feel some pain afterwards but you will be given medication for this.
Inflatable tissue expanders
After a mastectomy there is often not enough skin to cover an implant of the desired size. In this case an inflatable tissue expander can be used to stretch the skin.
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 through a port at the front, via the chest. These injections are given every couple of weeks until the tissue is about the same size as the other breast. This may take a few months.
Many women find that the saline injections don't hurt much because the chest is often numb after a mastectomy. However, you may feel discomfort for a few days due to the tissue stretching. Check with your doctor about suitable pain relievers.
Expanders are generally designed to be temporary, but there are also permanent ones. If a temporary expander is used, the surgeon will replace it with a permanent silicone implant in another operation.
A permanent tissue expander is also called a saline-gel implant. It has two layers - an inner layer that is filled with saline to expand the skin, and an outer layer that is already filled with silicone gel.
If a permanent expander is used, the implant remains in place after the tissue has stretched to the desired size. The filling tube and injection point may be removed in another small operation.
You won't need to stay in hospital when the expander is being filled, but if the expander is replaced with a permanent implant, the operation will take about an hour and requires a couple of days in hospital. Many women do not feel much pain afterwards.
A breast reconstructed with a tissue expander and/or an implant usually feels firmer than a natural breast. While it won't move and behave like a natural breast, it usually looks symmetrical in a bra.
Possible problems with an implant
Excess fibrous tissue - A capsule of scar tissue (fibrous tissue) tends to form around a breast implant. If this thickens over time, it may make the reconstructed breast feel firm. This condition is called a capsular contracture and is more likely if you have had radiotherapy. It can be uncomfortable and may change the shape of the implant. Some women find this painful. Further surgery may be needed and sometimes the implant has to be removed.
Implant rupturing - As implants are made of a type of plastic they will not last forever. At some stage they may leak or break (rupture) because of gradual weakening of the silicone envelope. A saline implant will immediately collapse after a rupture. It is possible to get a replacement, usually as day surgery.
With silicone gel implants, because the gel is often contained within the body's capsule of scar tissue, it may not be possible to tell whether the implant has ruptured. If the silicone leaks outside the capsule it tends to cause a lump, which may be painful. Usually, if the implant is known to have ruptured, it is replaced. The average implant lasts about 15 years.
Breast Implant Registry
The Breast Implant Registry is a government-endorsed public health initiative aimed at increasing patient safety. It is available online for patients to voluntarily register their implants for a small cost. The Australian Society of Plastic Surgeons manages the registry.
It has been created to provide patients with a secure environment to record their data following a breast implant procedure in case they ever need to get information about their surgery and implants. If you register, you can be contacted if there are any concerns about the style of breast implants you have.
All data remains confidential. However, with your consent, you can also allow information about your procedure to be used for medical research. For more information, talk to your plastic surgeon.
Flap reconstruction
Flap reconstruction is the use of muscle and skin from other parts of the body to build the shape of a breast. One of several flap methods may be used. The different types are named after the type of muscle used in the reconstruction.
Flap reconstruction is an option for most women. It is particularly suited to women with large breasts, women who don't have enough skin to cover an implant, and women who have had radiotherapy.
Flap reconstruction advantages |
Flap reconstruction disadvantages |
|
|
Latissimus dorsi reconstruction
The latissimus dorsi is a broad, flat muscle on the back below the shoulder blade. In this method, the latissimus dorsi muscle and some skin are rotated around to the chest. An implant is usually required under the flap to make your breast large enough to match the remaining breast. There is often a need for a tissue expander, depending on the final size desired. If an expander is used, a second operation will be needed to remove it. Otherwise, this reconstruction can be completed in one operation, apart from the nipple, which is done in a separate operation.
Depending on the prior mastectomy technique used, after reconstructive surgery, you may have an oval-shaped scar on your reconstructed breast and a straight scar on your back. The scar on your back may be covered by your bra strap.
TRAM flap reconstruction
TRAM flap reconstruction refers to a flap made out of tissue and muscle from the tummy (abdomen). It is short for a transverse rectus abdominis myocutaneous flap reconstruction. One of the pair of long, flat stomach muscles called the rectus abdominis is used to create the reconstructed breast.
The reconstructive surgeon moves the muscle, along with local skin and fat, to the chest where it is shaped into the form of a breast. There are two ways a TRAM flap reconstruction can be done: pedicle TRAM flap method and free TRAM flap method. TRAM flap reconstructions leave a long scar across the lower abdomen from one hip to the other. There will also be a scar on the reconstructed breast, and no feeling will remain in the skin over the breast.
About two weeks before the main operation, a smaller operation may be needed to improve the blood supply to the tissue that will be used in the breast reconstruction. This is more common for women with larger breasts. The surgeon may also arrange to bank your blood in case you need a transfusion during surgery.
Pedicle TRAM flap
In this method, the muscle is left attached to its original blood supply and tunnelled under the skin of your upper abdomen to the breast. A reconstruction done in this way usually takes about three or four hours. It will require 4-7 days in hospital.
Free TRAM flap
With a free TRAM flap, the reconstructive surgeon uses microsurgery to completely divide (detach) the muscle from its blood vessels, and then re-attach them to new vessels in the chest or under the arm. This method is better for creating a larger breast. It is also easier for the surgeon to shape the breast for a more accurate final result, but it is a more complicated and longer operation requiring special facilities and expertise.
A free TRAM flap operation usually takes 5-7 hours and requires at least one week in hospital. Full recovery from the surgery takes at least six weeks.
Possible problems with a TRAM flap
Hernia - Removing the abdominal muscle in both TRAM flap methods can weaken the abdominal wall. This can result in a hernia, which is when part of the bowel juts out through the abdominal wall. To reduce the risk of this occurring, the surgeon may insert mesh into the abdomen to replace the muscle.
Loss of the flap - Sometimes blood vessels supplying the flap can kink or get clots, causing bleeding and a loss of circulation. This may cause a partial or complete loss of the flap due to the tissue dying (necrosis). Quitting smoking decreases this risk.
Fat necrosis - An uncommon side effect is when fat used to make the reconstructed breast doesn't get a blood supply, which causes it to die (fat necrosis). These areas in the reconstructed breast can feel firm. They are easily seen and diagnosed on a mammogram. They can be left in place or surgically removed. The risk of fat necrosis is significantly increased in smokers.
DIEP flap reconstruction
Some surgeons now perform what is known as a DIEP flap method. DIEP is short for deep inferior epigastric artery perforator flap. It is a complicated operation, and uses only skin and fat to reconstruct the breast. As the rectus abdominis muscle is not used, supporting mesh is not required. Advantages of this method are a quicker return to normal activities and a smaller risk of hernia.
Possible problems with a DIEP flap
Loss of the flap - Occasionally the reconstructed tissue can die due to poor circulation and bleeding.
Fat necrosis - The problem of fat tissue dying can occur after a DIEP flap operation. It happens more commonly than in a TRAM flap operation but is not typical.
Other flap methods
If a TRAM flap or DIEP flap are not options for you, there are some less common procedures available. These use fat and a blood supply from other areas of the body, such as the buttock or inner thigh. Discuss these options with your surgeon.
Volume replacement of miniflap
Another kind of flap procedure is the volume replacement of miniflap. This may be an option for women with smaller breasts who have not had a full mastectomy so that the healthy part of their breast can be preserved. The surgeon takes a small flap of muscle and fat from the woman's back and puts it in the breast to fill the area where the breast cancer has been removed.
Nipple reconstruction
After a breast reconstruction, some women choose to get a nipple reconstruction too. This includes rebuilding the nipple and the area around it, which is called the areola. A new nipple will not have the same sensations in it as your other nipple because it will not have nerves.
A nipple reconstruction is a small operation that can be done in different ways. Tissue can be taken from your remaining nipple or created with skin from the new implant or flap. The new nipple can be tattooed to match the colour of the opposite one. Some reconstructive surgeons can do the tattooing, or you may prefer to have the nipples tattooed by a professional tattooist.
Because the reconstructed breast may sag slightly in the weeks after surgery, nipple reconstructions are generally not done until at least three months after a reconstruction.
Some women prefer to use stick-on (adhesive) nipples. These stick to the skin and will stay in place for several days. Stick-on nipples are available from breast prostheses suppliers.
The remaining breast
For many women, the small differences between their remaining and reconstructed breast are not noticeable when they wear a bra. For others, the difference in breast size may be quite noticeable.
Some women decide to have the remaining breast made smaller through surgical breast reduction, or lifted in a mastopexy (lift) procedure. This can improve balance and posture. Others choose to enlarge and lift the remaining breast to match the other side.
Bilateral mastectomy
Some women may be advised or choose to have bilateral mastectomy. This means both breasts are surgically removed. Reasons for women having this procedure include:
- the type of breast cancer they have
- the risks and anxiety of developing another breast cancer
- family history or carrying a gene for breast cancer
- the amount of surgery required to achieve a symmetrical result with the breast reconstruction
- choosing a TRAM flap reconstruction but not being able to repeat the procedure if cancer develops in the other breast.
Reconstruction will need to be considered for both breasts. Discuss this issue with your doctor, and seek a second opinion if you wish.
Therapeutic mammaplasty
This procedure combines a lumpectomy (lump removal) with a breast reduction. It is often able to be used as an alternative to mastectomy in suitable cases. Usually a reduction mammaplasty is done on the other breast at the same time.
Reviewed by: Staff from Westmead Breast Cancer Institute - Dr Thomas Lam, Plastic Surgeon; Dr Meagan Brennan, Breast Physician; Elisabeth Black, Jenny Cooper, Kim Kerin-Ayres and Mary Sweeney, Breast Care Nurses. Also Bronwyn Chalmers, Cancer Information Consultant, Helpline, Cancer Council NSW; Tracy Cosgrove, Breast Care Nurse, Royal North Shore Hospital; Marie Harland and Pauline Campbell, Breast Prostheses Fitters, Leila O'Toole Corsetry Salon; Lesley Jakes, Viviane Rubinstein and Kathryn Rutkowski, Consumers; and the Oncoplastic Subgroup of the Breast Surgeons Society of Australia and New Zealand (BreastSurgANZ).
Daffodil Day Get Behind Bowel Screening Forgotten Cancers Project Girls Night In Pink Ribbon Day Relay for Life