Breast Reconstruction

Information on Breast Reconstruction for Patients with a Breast Cancer Diagnosis

During the decision-making process for the surgical treatment of your breast cancer, you should give some consideration to issues related to breast reconstruction, if this is an option that you might wish to pursue. Decisions made with your general surgeon regarding your treatment can influence the options for, and quality of, a later reconstruction of your breast post-surgical deformity.

Reconstruction is a personal choice that is important to some patients and unimportant to others. The patients who are interested in a reconstruction should be aware of all the facts before they plan the initial surgery with their surgeon. Ideally, such patients should consult with a reconstructive surgeon during this decision-making process. All breast reconstruction procedures in Ontario are fully covered by OHIP.

The essential choice a patient has to make when considering her breast reconstruction is whether to use the implant technique or use her own tissues. Sometimes we advise a procedure that combines the use of both methods for best results.

The ideal candidate for breast reconstruction is a woman who is well informed about her choices, realistic in her expectations, not smoking, and of good general health.The information below is an introduction to the facts that you should understand during your decision making.

Lumpectomy Surgery and Minimizing Deformity

Lumpectomy surgery in patients with small or medium-sized breasts can leave significant deformity of the breast shape and asymmetry with the opposite breast. Deformity can be worsened by the post-operative radiation usually required after surgery. Techniques are available to reduce these deformities with the involvement of a plastic surgeon. These techniques involve some reshaping of the breast tissue, which is either performed at the same time or within a few weeks after the lumpectomy.

Women with larger breasts who need a lumpectomy can often avoid deformity by having the lumpectomy done at the same time as a breast reduction, with duel benefit.

Radiation and Breast Reconstruction

Radiation tends to impair the quality of a breast reconstruction performed at a later date. For this reason, patients who are undergoing a lumpectomy and post-operative radiation need to consider that they can often achieve a much better aesthetic result by having a mastectomy and reconstruction, and avoiding radiation. If a patient has had a lumpectomy and radiation, she is often not a good candidate for reconstruction using the breast-implant method. Many patients find themselves frustrated after the event by this situation.

If you have had your breast reconstructed with an implant or using your own tissues, and subsequently are advised to have radiation for any recurrence, this is feasible, but tends to harden your new breast mound. Some patients who are faced with this situation decide to replace their implanted breast with a new reconstruction using their own tissues.

Masectomy and Reconstruction

Patients who are considering a mastectomy should be aware that there are three different types. With the help of their general surgeons, these patients must decide which type will give them the safest and most aesthetically pleasing outcome. All three types remove all the breast tissue to remove the cancerous cells, but whether the nipple is removed or some or all of your breast skin is preserved is an option you need to discuss with your general and plastic surgeon.

Most patients undergo a standard, simple mastectomy with removal of all breast tissue, all of the nipple and areola, and most of the breast skin. This option only leaves the typical flat transverse mastectomy scar. While this option is suggested for patients with larger tumours, the mastectomy need not be so radical in patients with smaller, earlier tumours and in patients whose tumours are well apart from the nipple and areola.

These patients can then consider the less radical options of either a skin sparing mastectomy or a nipple sparing mastectomy.

In a nipple sparing mastectomy (NSM), all of your own breast skin and your nipple and areola are spared. In a skin sparing mastectomy (SSM), your nipple and areola are removed but all of your native breast skin preserved. The big advantages of these procedures is that the natural inherent shape of your breast mound is completed restored by the reconstruction, and the reconstruction is performed at the time of your mastectomy. It is the most ideal scenario if the patient is a candidate for this option.

Performing SSM or NSM is more demanding and time consuming for your general surgeon and involves close cooperation between your general and reconstructive surgeons. The need to coordinate this long procedure frequently means a delay in scheduling your mastectomy because of the need to find appropriate time in the operating schedule on short notice.

Choices in Breast Reconstruction

The decisions you and your reconstructive surgeon have to make before proceeding are:

What method to use: your own tissues or an implant, or both?
Whether to have an immediate reconstruction at the time of your mastectomy or delay this to a second, later operation.

Your reconstructive surgeon can guide you in these decisions, but the discussion needs to occur before your mastectomy proceeds.

The Implant Option

The appeal in the use of an implant to reconstruct your breast lies in the simpler nature of the operative procedure, the quicker recovery time, and the absence of any extra scars. This technique may be used to reconstruct your breast after any of the three types of mastectomies mentioned above.

With immediate reconstruction of your breast with the skin or nipple preserving techniques, an implant is placed under the skin and muscle of your chest when the mastectomy is complete. This is a very appealing option but has risks of delayed skin healing, which can lead to exposure of the implant and failure in about 10% of patients. It is not suitable for patients who have had previous radiation or for patients who smoke.

When you have had a traditional simple mastectomy, there is not enough skin to reconstruct your breast immediately with an implant. The process involves two stages. At the time of your mastectomy, a tissue expander, which is essentially an empty implant, is placed under the remaining skin and muscle, and the incision is allowed to heal. In the following two months, the expander device is injected weekly by your surgeon to stretch the overlying skin. It is a simple and painless process. At a second procedure, approximately three months later, the expander is removed and the permanent implant is inserted. This is a quick, simple and largely painless day surgery with a two-day recovery.

Implant reconstructions have great appeal but give the breast a somewhat unnatural round, erect appearance, which is quite different from the opposite, and usually somewhat droopy, breast. It is often necessary to lift the opposite breast to improve symmetry. This can be done at the same time as the second surgery.

With the implant/expander technique, one always has a small (less than 1%) risk of infection, which could lead to the need for implant removal and delay of the reconstruction. Furthermore, a small number of these patients may develop exposure of the implant in the incision due to delayed healing, which again can require the removal and delay of the completion of the reconstruction. These facts need to be considered with implant methods.

Breast Implants - The Autogenous Option

If you are eligible to have a skin or nipple sparing mastectomy, ideally you should have an immediate reconstruction at that time. There are circumstances where reconstruction may be delayed until a later date if radiation is planned.

If you are having a traditional simple mastectomy, then you have the choice of either an immediate or delayed reconstruction. Your reconstructive surgeon can help you make a decision based on your particular circumstances.

Psychologically, many patients benefit from an immediate reconstruction. Others prefer to deal with the ablative and treatment process first and reconstruction later. It is often a very personal choice, guided in conjunction with your surgeon.

One risk with an immediate reconstruction is that post-operative chemotherapy or radiation can be delayed if there are wound healing complications or if the reconstruction fails. If it is clear prior to your surgery that either might be necessary, you may want to elect to delay reconstruction for this reason.