Candidates for Breast Reconstruction

Breast reconstruction is a highly individualized procedure utilized to restore a natural, feminine silhouette after mastectomy. You should do it for yourself, not to fulfill someone else’s desires or try to fit any ideal image.

You may be a candidate for breast reconstruction if:

• You can cope well with your diagnosis and treatment
• You do not have additional medical conditions or other illnesses that may impair healing
• You have a positive outlook and realistic goals for restoring your breast and body image

Although breast reconstruction can rebuild your breast, the results are highly variable:

• A reconstructed breast will not have the same sensation or feel as the breast it replaces
• Visible incision lines will always be present on the breast, whether from reconstruction or mastectomy
• Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the abdomen.

Major Types of Breast Reconstruction Surgery

Implant-based breast reconstruction may be possible if the mastectomy or radiation therapy have left sufficient tissue on the chest wall to cover and support a breast implant. For patients with insufficient tissue on the chest wall, or for those who don’t desire implants, breast reconstruction will require a flap technique (also known as autologous reconstruction). The most common method of tissue reconstruction uses lower abdominal skin and fat to create a breast shape.

There are several techniques that can be used for implant-based breast reconstruction. Make sure to discuss with your plastic surgeon what is appropriate for you.

Delayed breast reconstruction utilizing tissue expander:

The initial portion of this procedure entails the breast surgeon performing a standard mastectomy and possible axillary dissection. In many instances, a drain will be placed between the muscle and the skin of the mastectomy.

Once these procedures have been performed, the plastic surgeon will divide the lower pole of the chest wall muscle and elevate the chest wall muscle and the lateral chest muscle together upwards towards the collarbone. After that is done, the muscle and tissue below are elevated together to form the pocket for the breast expander at the base of the breast or the inframammary crease. The pocket is made large enough for the expander to be placed and the muscle closed. Occasionally, there is a need for the placement of a small amount of acellular dermal matrix (ADM) to assist in the closure of the muscle.

There are two types of breast tissue expander ports. One, like a chemotherapy port, is placed separate from the tissue expander, usually along the rib cage. This will require a separate small incision for the port. The second type is a port that is contained within the expander itself. In both instances, the ports will be used to inflate the tissue expander over several visits with saline solution. The port is accessed with a small needle and saline is injected into the expander through the port site.

Tissue expansion usually occurs weekly according to patient tolerance. The volume of the tissue expanders commonly exceeds the weight of the mastectomy tissue. Once the final tissue expansion, or stretching, is completed there will be a time of passive expansion where little to no volume is added to the tissue expanders. This allows the muscle and skin to stretch and relax. The length of time will vary from patient to patient. Once this is completed, a second outpatient procedure will be necessary to remove the tissue expander and place the permanent breast prosthesis.

Breast reconstruction with abdominal-based flaps:

Sometimes a mastectomy or radiation therapy will leave insufficient tissue on the chest wall to cover and support a breast implant. In these cases, breast reconstruction usually requires a flap technique (also known as autologous reconstruction). This is the most common method of tissue reconstruction, using lower abdominal skin and fat to create a breast shape. A woman may also choose not to have an implant for personal reasons.

The skin and fat used for this procedure are the tissue between your belly button and pubic bone that you can pinch. Once this tissue is taken to make a breast, you will typically have a scar from hip bone to hip bone and around your belly button.

Some women may not be candidates for abdominal-based flaps for various reasons:

• Not enough donor tissue in the lower abdomen
• Prior scars that may have damaged important blood vessels
• Previous flaps that have failed and seeking an alternative

DIEP flap:

The DIEP flap utilizes the same lower abdominal skin and fat as the TRAM and free TRAM flap; however, it spares the rectus abdominis muscle and fascia. Rather than taking the entire muscle or a small portion of the muscle, the small blood vessels – an artery and a vein – that come through the muscle to the skin and fat are identified; these vessels are then dissected through the muscle prior to being divided. Once they are divided, the tissue is again transplanted to the chest and the vessels are connected to blood vessels in the chest. Since your muscle is preserved, there is a lower risk of abdominal weakness or hernias and less postoperative pain.

Can Potential Mothers Breastfeed After Surgeries Like Breast Reconstruction?

The goal of breast reconstruction is to correct the aesthetic deformities resulting from mastectomy.  The goal of mastectomy is to remove all potentially cancerous breast tissue, including milk-producing ducts and sometimes the nipple/areola.  Breastfeeding is not possible after mastectomy.

How Can I Set Up a Consultation?

The first step to schedule a consultation would be doing thorough research. There are many ways to find a plastic surgeon. Arguably the best way would be to receive a referral from another physician, such as your breast surgeon or OB-GYN. These providers often see multiple patients with good results and can attest to those by referring their own patients somewhere. Friends are a secondarily good referral source, especially if they are patients themselves. When it comes to advertising, the most essential consideration is the plastic surgeon’s education, board certification ONLY by the American Board of Plastic Surgery, and before/after gallery. If those components match your desired outcome, then they would be a good source of information to seek in consultation. You will often come across taglines such as “no downtime surgery” or “no anesthesia required”. If it seems too good to be true, it probably is. There are no shortcuts to SAFE plastic surgery.

The next step would be to contact the office of a board-certified plastic surgeon to find a time to meet them. First impressions last a lifetime, so pay attention when speaking to the receptionist upon calling. Should you decide to have surgery, this is the team you will be dealing with multiple times per month for at least a year. The administrative team is a direct reflection of the surgeon’s ways of working. Another thing to clarify would be a potential timeline for surgery. This is sometimes best done before reaching out to qualified providers because they are booked one to six months out, on average. Knowing well enough in advance will give you adequate time to interview surgeons, get any preoperative lab work done, and feel confident moving forward with your scheduled procedure.