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A Guide to Post-Mastectomy Breast Reconstruction

Kelsey Tyler

An estimated 266,000 new cases of breast cancer are diagnosed in the U.S. each year. Meanwhile, a growing number of women undergo genetic testing for mutations in BRCA, the “breast cancer gene.” As a result, thousands of American women get mastectomies, removing one or both breasts as a means of halting or preventing the spread of cancer.

Mastectomies save lives. As of 1998, with the passage of the Women’s Health and Cancer Rights Act, insurance companies are required to cover the cost of post-mastectomy breast reconstruction. The choice to reconstruct is a highly personal one, although medical complications, access to specialist care and other socioeconomic barriers may influence a woman’s decision. About 35 percent of women have their breasts surgically rebuilt following mastectomies, according to BreastCancer.org.

Fortunately for breast cancer survivors who are able and want to reconstruct their breasts, surgical options have improved and expanded. We spoke with Constance M. Chen, a plastic surgeon specializing in breast reconstruction and an assistant professor of plastic surgery at Weill Cornell Medical College, and put together a guide to post-mastectomy reconstruction options.

Planning ahead

Women might assume they should schedule their mastectomies first and then figure out breast reconstruction later. But the manner in which a mastectomy is performed actually dictates reconstruction options and outcomes. That’s why patients are often encouraged to make decisions about reconstruction beforehand, as well as select a breast surgeon and plastic surgeon who work as a team. “If you can find a breast surgeon who thinks about skin and tissue preservation,” Chen said, “you’ll be in the best place for reconstruction if that’s the road you decide to go down.”

Timeline of reconstruction: A mastectomy and breast reconstruction can be performed during the same surgical session or as separate operations. Medically, there’s nothing wrong with leaving time between the two procedures — some women wait months or even years to rebuild their breasts. But there are some advantages to doing them together.

For one thing, undergoing an additional surgery can be a stressor, both mentally and physically. Additionally, depending on the type of mastectomy and reconstruction performed, undergoing both procedures at once might obviate the need for tissue expanders, which stretch out the skin in order to make room for breast implants or tissue flaps.

Type of mastectomy: When you think of a mastectomy, you might picture a long, horizontal scar stretching across the chest where the breast and nipple used to be. While this “total” or “simple” mastectomy is the most common type, it’s only necessary when the nipple and breast are compromised by cancer. Total mastectomies, Chen says, aren’t the best choice for many women who get them. “Once you throw away some of that tissue with the total mastectomy and you throw away the nipple areola, it changes the breast envelope and flattens the breast,” said Chen. “It makes it more challenging to fix.”

The ultimate goal of every type of mastectomy is to remove cancerous cells. But mastectomy procedures that leave more of the breast intact make it easier for surgeons to reconstruct natural-looking breasts and, in some cases, offer women the possibility of returned nipple sensation. Skin-sparing mastectomies preserve the breast envelope (the skin), while nipple-preserving mastectomies preserve both the skin and nipple.

The nipple can be spared by removing the breast tissue through either an opened areola or a “lollipop scar” tracing the underside of the breast. “If you don’t have nipple discharge or a tumor pushing into your nipple area, you may be a candidate for a nipple-sparing mastectomy,” Chen said. “That removes all the breast tissue, but preserves your entire breast envelope.”

If patients aren’t candidates for a nipple-sparing mastectomy or can’t find a surgeon near them who will perform one, Chen recommends finding a breast surgeon who will design an incision that preserves as much of the breast envelope as possible.

Reconstruction options

There are two options for breast reconstruction: implants and autologous (or flap) surgery. Eighty percent of American women who undergo post-mastectomy reconstruction get implants, and Chen says they’re more popular for a reason: “Implants are the simplest option. Everyone knows how to do them.”

Implants

If you go the implant route, you’ll need to decide which type of implant to get and how to position it (or them).

Type: Most plastic surgeons give patients the choice between silicone and saline breast implants. The natural feel of silicone makes it the more popular choice, but both types carry the same three main risks: infection, rupture and hardening due to the presence of scar tissue.

While some breast implants now come with a “lifetime guarantee” from their manufacturers, many women need to have them replaced within seven to 10 years. Also, with every type of implant, some women report numb, cold breasts and pain during exercise.

Positioning: “Saline or silicone?” isn’t the most important decision to make about implants. Instead, it’s choosing where they’ll go. Implants can either be placed under or over the pectoralis muscle in the chest.

Traditionally, plastic surgeons have stuck them below the muscle in order to prevent the implant from rupturing skin, a complication known as implant erosion. This placement lets the muscle tissue function as an extra barrier between the implant and the outside world.

Today, Chen says, more surgeons are placing the implant above the muscle. Part of the reason for this shift is that the risk of skin “rippling” is lower than previously thought. Also, many women believe above-the-muscle placement looks and feels more natural, given that the implant sits where the breast tissue used to be.

Chen also says above-the-muscle placement is less painful for patients. “Having the implant underneath the muscle is like having a rock in your shoe at all times,” she said. Patients who’ve had radiation are especially likely to experience high levels of discomfort, because the treatment can adversely affect the cells of tissue, muscle and skin. Thus, due to reduced elasticity of skin and tissue after radiation, implants in general can be painful, and under-the-muscle placement may be unbearable. These patients should ask their surgeons about those specific risks before settling on implants.

Autologous or “flap” surgery

This innovative surgery — or surgeries, since there are many subtypes — involves reconstructing the breasts using tissue from other parts of the body, such as the abdomen, thighs, back and buttocks.

If a patient decides to undergo a mastectomy and flap-surgery reconstruction at the same time, their plastic surgeon will start harvesting tissue from the body during the mastectomy. Immediately after breast removal, tissue will be placed into the (spared) breast envelope, right below the nipple. If the breast skin and/or nipple weren’t spared, then a tissue expander, which stretches out the skin, needs to be inserted instead. When expanders enter the equation, reconstruction can’t be performed immediately, as the skin-stretching process takes time.

Next, a plastic surgeon skilled in microsurgery reconnects the arteries, veins and nerves.

Compared to implants, flap surgery requires both more time on the operating table and in recovery — about six weeks, on average. But it does have several advantages:

  • The reconstructed breast will both look and feel more natural. “When you’re putting skin and fat where skin and fat was,” Chen said, “it’s going to look and feel like your regular breast.”
  • Surgeons can restore breast sensation by reconnecting nerves.
  • The harvested live tissue also has blood flow, which helps maintain body temperature and avoid the risk of sepsis that breast implants have.
  • Because tissue is taken from other “fatty” body parts, such as the inner thighs, the procedure doubles as a body lift.

Many plastic surgeons praise flap surgery as the superior option for breast reconstruction. Still, it can be intimidating for patients to digest the long list of different flap surgeries. They’re categorized into types based on 1) which body parts the removed tissue comes from and 2) whether the surgeon takes muscle from that location as well .

Procedures that spare the muscle are called perforator flap surgeries. Here are a few of the most common ones:

  • DIEP flap: Tissue is removed from the lower abdomen in a similar fashion to a “tummy tuck.”
  • PAP flap: Tissue is removed from the inner thighs, often leaving a hidden groin-area scar.  
  • IGAP flap: Tissue is removed from the lower butt cheeks.

Here are three of the more popular procedures that do involve muscle removal:

  • TRAM flap: Muscle, tissue and skin are removed from the abdominal wall.
  • Latissimus dorsi flap: The latissimus dorsi muscle, located underneath the shoulder, is used to build the flap.
  • TUG flap: Skin, tissue and the gracilis muscle are removed from the inner thigh.

Muscle-removal procedures are becoming increasingly outdated, but many plastic surgeons still perform them because they’re faster and easier; moving muscle, skin and tissue together obviates the need to reconnect arteries and veins. Even so, they come with a considerable drawback: Women don’t want to give up muscle mass, and that’s exactly what happens when muscle is moved from the abdomen, back, legs or buttocks into the breast, where it will atrophy and eventually die. Such muscle loss can affect a woman’s strength and physical capabilities, and should be part of any cost-benefit analysis of different reconstruction approaches.

Regardless of body type, flap surgeries work for most women. While many thin women assume they don’t have enough extra bodily tissue from which to reconstruct breasts, Chen says that’s a misconception. As long as they’re not expecting DDDs, flap surgery should work. “I’ve never met anybody who does not have enough tissue,” Chen said. “You can be rail thin — I’ve had multiple patients who are runners. I’ll take tissue from the upper inner thigh. You can make beautiful perky breasts with that.”

It’s your body

For breast cancer survivors who want to undergo surgical reconstruction, there’s no shortage of options. But the key word here is “want.”

What matters most, Chen says, is that women get the information they need to make their own decisions. No one should feel pressured to choose a specific surgical method or even to choose surgery at all. Some women are pursuing nonsurgical alternatives, such as wearing prosthetic breasts underneath their clothing. Others are forgoing any and all corrective measures, opting to “go flat” instead.

“You do have to do a little research and legwork on your own,” Chen said. “But it’s your body. You have agency. You get to decide what to do.”

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