Despite the victory of surviving cancer, losing a breast (or two) can be devastating. That's why many cancer patients choose to have breast reconstruction after mastectomy (total removal of a breast) or even after lumpectomy (removal of a breast tumor) if a large amount of tissue was removed.
Having reconstruction at the time of mastectomy makes cancer recovery emotionally easier...and does not significantly delay chemotherapy or increase the risk for complications. It is also possible to have reconstruction months or years after a mastectomy or lumpectomy.
There are two main surgical options-implants and tissue flaps (in which the patient's own tissue is used to create a new breast mound). Each has its advantages and can provide good cosmetic results.
Tissue Flap Procedure
This involves rebuilding a breast using skin, fat and blood vessels from elsewhere on the body. The procedure takes about six hours. The new breast is in place when the woman awakens from her mastectomy, but it may require follow-up surgery to adjust shape and size. It generally feels and looks more natural than an implant. Results last forever, and you may get a tummy tuck in the bargain, because the tissue is often taken from the abdomen.
In my research, I have found less than a 1% incidence of abdominal hernia (when part of an organ or other tissue protrudes through the abdominal wall, which may have been weakened by the tissue flap procedure), a complication that requires additional surgery.
New finding: Patients who opt for the tissue flap procedure may be less prone to postsurgical infections than breast implant patients.
Best for: Women who have had no prior abdominal surgery that required a vertical midline incision...have sufficient fat on the abdomen, back, thighs or buttocks.. and have no other major medical problems.
Recovery: The hospital stay is about four days. A patient must avoid strenuous activity and heavy lifting for six to eight weeks.
Interesting: Since the reconstruction uses living tissue, breast size changes if a woman loses or gains weight, just as a natural breast does.
Implant Surgery
All implants are encased in a silicone shell. The inside is filled with silicone gel or saline solution
- Silicone implants tend to be softer and feel more natural than saline. Despite fears raised by past studies, recent clinical trials have shown no link between silicone implants and autoimmune disease.
- Saline implants are filled with salt water that is easily reabsorbed into the body if the implant leaks or ruptures. With saline implants, the breasts tend to feel slightly former and therefore less natural than with silicone-filled implants, and the skin may be more prone to rippling
Recent studies show no proven health risks from leaking implants. A saline leak is easy to detect--the skin around the implant contracts, and the breast looks smaller. A silicone leak is harder to detect-scar tissue keeps the implant in place, and the breast maintains its shape-but it can be found with a physical exam or MRI.
With both types of implants, manufacturers report a 1% to 5% rate of leaking—though in my practice, I have found it to be lower. Although no implant is guaranteed to last a lifetime, an implant can be left in place for the rest of a woman's life if no problem develops.
The procedure: Implant surgery is usually done in two steps. Part one can be done at the time of mastectomy or lumpectomy and takes an additional one to two hours. After the original breast tissue is removed, a tissue expander is placed beneath the chest muscle. Through a tiny valve buried beneath the skin, the expander is filled periodically with saline to gradually stretch the skin. A few months later, when the skin has stretched, an implant of the appropriate size is inserted during an outpatient procedure that takes 60 to 90 minutes.
Recovery: Hospitalization for the first surgery is one to two days...recovery takes one to two weeks. The second surgery generally causes only temporary mild discomfort. After each step, the patient should avoid strenuous activity for two weeks. After that, any activity is okay unless it involves direct pressure on your chest, such as deep-sea diving or going off a high diving board.
Best for: Women who need reconstruction on both breasts...or who are very thin. Implants can be more challenging in patients who have received radiation to the breast area-loss of tissue elasticity makes it difficult to create a realistic-looking breast.
Finishing Touches
A replacement nipple and areola can be constructed in the doctor's office under local anesthesia several months after completion of either type of reconstruction.
To create a nipple, skin flaps lifted from the reconstructed breast are wrapped around one another. In the past, the areola was grafted from skin elsewhere and sometimes a tattoo was applied to enhance the color. Like many surgeons today, I prefer to avoid additional surgical sites by creating an areola from a tattoo alone. Healing takes a few weeks.
Insurance: Policies that cover mastectomy also must cover reconstruction plus surgery on the other breast a lift, reduction or enhancement) if necessary to achieve symmetry.
If you're dissatisfied: Breast surgery can be revised or corrected. I've personally redone prior surgeries performed at our institution or elsewhere, with excellent results.
Follow-up: Different surgeons have different protocols. Once all is healed, I see my patients yearly to ensure that breasts are intact. Additional testing of the reconstructed breast usually is not necessary
Finding a Great Breast Surgeon
Interview at least two surgeons before making a decision.
Referrals: American Society of Plastic Surgeons (888-475-2784, www.plasticsurgery.org). Key questions...
- Are you board certified as a plastic surgeon?
Only acceptable answer: Yes.
- What is the ideal result?
Best answer: To make the two breasts look as similar and natural as possible.
- How many of this type of breast surgery have you done?
Best answer: At least 10 to 20 surgeries per year.
- Can I speak to some other patients of yours?
Best answer: Contact information for at least two references
Don't Worry—Many Breast Implants Require Repeat Surgery
About 30% of postmastectomy reconstruction patients develop wound infections, implant asymmetry or displacement, capsular contracture (contraction of the tissue surrounding the implant) or other localized problems, usually within the first year after the surgery. About 20% require follow-up surgery. Before undergoing a mastectomy, women should discuss the pros and cons of implants and what kind of reconstruction—if any-is best for their individual situations.
Relax! Yoga Helps Breast Cancer Patients
In a recent study of breast cancer survivors, it was found that engaging in the Iyengar method-one of the more active forms of yoga during treatment for breast cancer promotes psychological well-being...benefits the immune system and generally improves patients' quality of life.
Weight Loss May Ease Lymphedema
Overweight women are at higher risk for chronic arm swelling (lymphedema), a side effect that can persist for decades after breast cancer surgery. Lymphedema is abnormal swelling due to accumulation of lymph fluid in a limb. It can develop some time after the original surgery
Recent finding: Weight loss may alleviate lymphedema.
Calcium May Protect Bones From Cancer
About 70% of patients with advanced breast cancer also get bone tumors.
Study finding: Calcium deficiency makes it easier for cancer cells to penetrate bones...perhaps by causing bone breakdown. Increasing dietary calcium-from foods (such as milk) or supplements-may reduce bone breakdown.
Beware! Popular Supplement May Cause Cancer to Spread
Black cohosh does not increase a woman's breast cancer risk, but in women who already have breast tumors, it may make the cancer more likely to spread to the lungs and other organs. Products with black cohosh, including Remifemin, often are used to ease symptoms of menopause, but they are not FDA regulated. To be safe, women with breast cancer or at high risk for it should avoid any products containing black cohosh.
