Breast reconstruction is one of the most complex but gratifying areas of plastic and reconstructive surgery. It demands a unique blend of sound medical judgement, technical expertise, a sense of body aesthetics, and a strong patient-surgeon rapport. The entire breast (mastectomy) or part of the breast (lumpectomy, also known as breast conservation therapy) can be reconstructed with an implant, or with the patient's own tissues. Moreover, numerous procedures to balance or revise the healthy or reconstructed breast, create a nipple, or further refine the scars or contours of the reconstruction are also offered.

A board certified plastic and reconstructive surgeon has the experience and training to not only offer and perform the most appropriate operation, but also ensure that it is performed at the appropriate time and in the appropriate sequence. Your board certified plastic surgeon will prioritize factors related to your breast cancer diagnosis and treatment, general medical health, body type, and expectations so that your reconstruction does not interfere with your breast cancer care and so your reconstruction can be performed to achieve the best appearance with the least risk.

Firstly, it is important to know that performed appropriately by a board certified plastic surgeon, breast reconstruction does not interfere with the treatment of breast cancer, nor does it prevent the diagnosis of future cancers. To make sure that this is the case, sound medical judgement is of paramount importance. Decisions related to the timing of breast reconstruction, and the sequence of steps related to breast reconstruction may be more important in some cases than the reconstructive procedure itself. Factors that your plastic surgeon must consider include the stage of your breast cancer, when and if chemotherapy or radiation therapy will be performed, and if they plan to perform a lumpectomy or mastectomy. Following a mastectomy, breast reconstruction is usually performed in stages that will include i) building a breast mound on the reconstructed side, ii) refining the breast mound to optimize its appearance, iii) performing a matching procedure of the other breast such as a lift, reduction, or augmentation and iv) reconstructing the nipples (bump) and areolas (colored area around the bump). Reconstruction following a lumpectomy may also occur in stages, but in large breasted women can often be performed in conjunction with a breast reduction. In this case, a single operation can be used to remove the breast cancer, match the appearance of the healthy breast, and provide relief of neck pain, back pain, and the skin irritation that women with large breasts often suffer from. The steps required to complete a breast reconstruction, therefore can range from a single operation, to over one year particularly if you require mastectomy, chemotherapy, radiation, and a more complex delayed reconstruction. Your board certified plastic surgeon will work with the rest of your breast cancer treatment team to synthesize the reconstructive treatment plan that works for you.

In addition to sound medical judgement, your plastic surgeon's technical expertise and proficiency enables them to offer you several surgical options for reconstructing your breasts. One important way in which breast reconstruction differs from breast augmentation relates to the fact that unlike breast augmentation, breast tissue and skin are missing following a mastectomy procedure. So, to replace this missing tissue, your surgeon can either replace it with an implant, or with your own tissues. If an implant is chosen, your surgeon must decide if you will have enough skin remaining to cover an implant large enough to provide you with a cosmetically acceptable result. Most frequently, there will not be enough skin available to cover a breast implant at the time of your mastectomy and so an intermediate step know as tissue expansion will be required. A tissue expander is a temporary device that is placed beneath one of the muscles of the chest known as the pectoralis major. To enable the tissue expander to reside in a more natural position, the pectoralis major muscle is usually detached along its lower border. The bottom part of the tissue expander can either be left alone, covered with other muscles, or using a more recently developed technique, is covered by a material known as an acellular dermal matrix which can support the lower part of the tissue expander, effectively functioning like an internal bra. The tissue expander is incrementally inflated with saline (salt water) solution in the operating room, and later on when you visit your plastic surgeon in their office. This tissue expander is removed several months later and replaced with a more permanent saline or silicone breast implant. Breast implants have an average lifespan of 10 to 15 years before replacement is recommended or required. Alternatively, large breasted women that are unlikely to undergo radiation or chemotherapy, that undergo a skin- or nipple-sparing mastectomy, and who will tolerate a potentially significantly smaller breast can undergo a single-stage direct-to-implant breast reconstruction that forgoes the tissue expansion step.

Breast reconstruction with your own tissues (autologous) is an excellent option for women who have undergone radiation therapy for their breast cancer, who do not want breast implants, or have had difficulty with breast implants in the past. Most commonly, tissue can be taken from the lower abdomen (transverse rectus abdominis myocutaneous or TRAM flap), or the back (latissimus dorsi myocutaneous flap), but other options including the inner thigh (transverse upper gracilis or TUG flap) or buttocks (superior gluteal artery perforator or SGAP) may be appropriate in specific circumstances. Breast reconstruction with your own tissues, is a more significant surgical procedure than implant-based reconstruction and is typically associated with longer recovery times since muscle tissue from the abdomen or other body parts must be used to make the breast reconstruction work. However, newer operations in breast reconstruction allow plastic surgeons skilled in microsurgery to remove less (muscle-sparing free TRAM flap) or in some cases no muscle tissue (deep inferior artery perforator flap - DIEP flap, or superificial inferior epigastric perforator flap - SIEA flap). These technically complex operations, typically offered only by board-certified plastic surgeons with experience in microsurgery, can offer reduced recovery times and avoid a breast implant in patients that are appropriate candidates for these operations.

Breast reconstruction is unique to reconstructive surgery since it also demands a strong aesthetic sense. The broad-based training of a board certified plastic surgeon in both reconstructive and cosmetic surgery is ideally suited to getting you the best results. Following your initial reconstruction to build the breast mound, your plastic surgeon will rely on their knowledge of cosmetic surgery to refine the reconstructed breast and match the healthy breast. Covered by insurance, as mandated by the Federal Breast Reconstruction Law of 1998, several procedures are available to match the reconstructed to the healthy breast. Since the reconstructed side is frequently smaller or in a more youthful position than the healthy side, the healthy side can be lifted or reduced to match your reconstruction. In some cases the reconstructed size is larger or more full than the healthy side, and in these cases a breast implant can be placed on the healthy side to help match your breasts. In other instances, more subtle contour discrepancies between the reconstructed and healthy side exist. With increasing frequency, the patient's own fat can be harvested from the abdomen, thighs, or flanks using standard liposuction techniques, processed, and then reinjected to help smoothen ripples or fill contour depressions thus helping to further match the reconstructed and healthy breast. This process is known as fat grafting. Patients who have both breasts removed and reconstructed are also eligible to have procedures performed to help match both breasts since discrepancies between two reconstructed breasts will also exist. Finally, scars related to breast cancer reconstruction or vascular and pigmentation changes related to radiation therapy may also be improved with various laser or intense pulsed light therapies. These laser scar therapies may or may not be covered by your insurance provider.

A breast cancer diagnosis is an unexpected and emotionally challenging event. Patients are presented with a large amount of information related to their breast cancer diagnosis, and then expected to undergo treatment in short succession. Because their lives just suddenly became so much more complex, it is critical that they trust their plastic surgeon to function as their advocate, and to make decisions that will ensure that they remain healthy while restoring their image of self as safely and effectively as possible. By the time their cancer and reconstructive therapies are finished, we are likely to have spent more time with our breast cancer patients than any of their other medical providers. We frequently see them from the time of their diagnosis and before their mastectomy surgery, through all of their cancer therapies, throughout their reconstructive steps and then for annual follow-up. The initial visit is critical - it must be informative but also sensitive to the fact that our patients have a lot more on their minds. Providing the information in writing or on a website so they can digest it on their own time is critical. Being available to answer questions, providing them with photos of reconstructed patients, or setting up meetings with other patients who have been through the same thing is often indispensible. This patient-physician rapport is critical to our patients and the appreciation that our patients show us following their reconstruction, even if there are bumps along the way, makes our jobs as plastic surgeons extremely rewarding.

Article Written By:
Terence M. Myckatyn, BSc(Hon), MD, FACS, FRCSC
West County Plastic Surgeons of Washington University
Associate Professor, Division of Plastic and Reconstructive Surgery
Washington University School of Medicine in St. Louis