The decision to undergo breast reconstruction after a mastectomy is a personal one. Not all women are candidates for breast reconstructive surgery, and some choose not to pursue this option. For many women, however, restoring the appearance of one or both breasts may help improve their physical, emotional and social well-being. While treating the cancer remains our primary focus, the reconstructive surgeons at Cancer Treatment Centers of America® (CTCA) recognize that treating breast cancer patients involves more than removing the tumor.
It is important to recognize that breast reconstructive surgery is an elective process tailored to each patient’s needs and goals. While breast reconstruction in a single operation is possible for some women, the majority of women will require more than one procedure, typically over several months.
We offer many options, and each technique has a unique set of considerations. Recommendations are based on many factors, including the patient’s overall health status, breast size and shape (both natural and desired), as well as the specifics of her cancer, such as its type, size and location within the breast. At CTCA®, our reconstructive surgeons evaluate each patient to understand her expectations and goals, then discuss the options available to meet those goals. It is important to begin this conversation well before the mastectomy.
In most cases, the reconstructive process may begin at the time of mastectomy—a technique known as immediate reconstruction. However, the surgeon may not recommend immediate construction for a number of reasons, such as when the patient is using nicotine products, has an advanced tumor or is morbidly. In these cases, or for any woman who has already had a mastectomy without reconstruction, delayed breast reconstruction is often a viable option. Also, if the patient is not satisfied with the outcome of her reconstruction, our surgeons are experienced at revising reconstructed breasts to help improve outcomes and achieve patients’ goals.
Overview of breast reconstruction
The process of total breast reconstruction depends heavily on the type of mastectomy performed, as well as the additional therapies used to treat the cancer, such as chemotherapy and/or radiation. The process may be different for women who choose to remove both breasts (bilateral mastectomy), compared to those who have just the affected breast removed (unilateral mastectomy).
During reconstruction, the surgeon creates a mound and a skin envelope to resemble a natural breast. This may require a staged approach involving two or three procedures. In most cases, the skin required for reconstruction is preserved at the time of mastectomy, and in many cases, the nipple and areola may also be preserved. Both the breast surgeon and reconstructive surgeon will evaluate and discuss each patient’s options.
Breast reconstruction is divided into two general categories: implant-based reconstruction and autologous reconstruction, which uses using the patient’s own tissue.
This technique uses a silicone gel implant to create the breast mound. Saline implants may be an option, but they are not typically recommended, mostly because the newer generation of silicone gel implants offers a more natural look and feel. Multiple implant options are available to provide volume, shape and projection, allowing each patient to choose an option tailored specifically to her.
In some cases, the surgeon may place the silicone gel implant at the time of the mastectomy in a process called one-step or direct-to-implant reconstruction. In most cases, however, the process is completed in two operations, known as two-stage implant-based reconstruction. In the first stage, the surgeon places a temporary tissue expander after the breast tissue is removed, then gradually fills the expander over time to stretch or shape the skin envelope. In the second stage, the surgeon removes the tissue expander and inserts the more natural silicone gel implant into the skin envelope.
Traditional implant-based reconstruction involved placing the devices completely or partially beneath the chest muscle, in a process known as subpectoral reconstruction. In the majority of today’s cases, this is no longer necessary. Instead, a prepectoral reconstruction technique is used, leaving the muscles attached to the chest wall and placing the implant above them, similar to a natural breast. This procedure often reduces post-operative pain and recovery time, in addition to providing better aesthetic results.
Surgeons do not typically recommend implant-based reconstruction for women who have had, or who will require, radiation as part of their therapy. Implant-based reconstruction operations do not take as long as autologous procedures, and recovery often takes two to three weeks. Implants come with a unique set of considerations and possible risks, and our reconstructive surgeons discuss these with each patient. Our surgeons also discuss how acellular dermal matrix, a biologic mesh often used to hold or support the implants, may play a role in the reconstruction.
Compared to implant-based reconstruction, autologous procedures typically require more time and a longer recovery period. However, because they take advantage of the patient’s own tissue, these techniques may yield more natural and longer-lasting results.
In these procedures, fat and skin may be transplanted from various areas of the patient’s body to create the reconstructed breast, with the area and method chosen depending on the amount and quality of tissue available. The tissue (called a flap) may be removed from the lower abdomen, back, buttock or inner thigh—areas generally referred to as donor sites.
Reconstructive microsurgical techniques are often used to improve the outcomes of autologous reconstruction procedures, creating natural-looking breasts while reducing damage to donor sites. Specially trained microsurgeons use these techniques to remove skin and fat, along with their blood supply (called a free flap), from the donor site. The surgeon then transplants the tissue to the chest, where it is connected to nearby blood vessels and shaped into a breast. This free flap process allows the surgeon flexibility in shaping the breast, and using the primary blood supply aids in the healing process. The procedure is also designed to decrease recovery time compared to other techniques that may cause more damage to the donor site.
CTCA offers a wide array of autologous breast reconstruction procedures to specific patients, depending on their needs and other factors. These procedures include:
Deep inferior epigastric artery perforator (DIEP) flap: This reconstructive microsurgical procedure uses skin and fat of the lower abdomen, with its primary blood supply carefully removed from the muscle beneath. Skin and fat may be taken from both sides of the lower abdomen to create two breasts if necessary or desired. The DIEP flap procedure has become the standard of care for autologous breast reconstruction using abdominal tissue, compared to the outdated TRAM flap procedure, which involves completely removing a muscle from the abdomen and inserting mesh. Some muscle weakness may result from DIEP flap reconstruction, but this side effect is uncommon.
“Stacked” DIEP flap reconstruction: In this procedure, reconstructive microsurgery techniques are used to transfer both sides of the lower abdomen to create a single breast, allowing women with limited donor tissue to take advantage of autologous reconstruction.
Superficial inferior epigastric artery (SIEA) flap: In this procedure, a free flap of skin and fat is harvested from the lower abdomen, but a different blood supply is used. This blood vessel is completely above the muscle and does not require manipulation of the muscle. Not all women have this blood supply; in many other cases, the blood supply is not sufficient. Because of the anatomy of this blood supply, many women who undergo reconstruction with a SIEA flap experience less post-operative pain than with a DIEP flap, without any risk of muscle weakness.
Medial thigh-based flaps (TUG, VUG, DUG, PAP): These procedures use the skin and fat from the inner thigh, along with blood vessels that may be removed from the muscles. In some cases, a small muscle from the inner thigh (the gracilis) may be removed with little to no impact on the leg’s muscle function. These procedures may be beneficial for women who are not candidates for the DIEP or SIEA flap.
Buttock-based flaps (SGAP and IGAP): These procedures use the skin and fat from either the upper or lower portion of the buttock, along with blood vessels that may be removed from the gluteal muscles. These techniques may also benefit women who are not candidates for the DIEP or SIEA flap.
Thoracosdorsal artery perforator (TAP) flap: This procedure uses skin and fat from the upper back and a small portion of the latissimus dorsi muscle. The technique is not a free flap procedure and is usually used to reconstruct defects caused by a partial mastectomy. It also may be used in combination with an implant for total breast reconstruction, particularly for women who may not be candidates for any of the above-mentioned flaps.
The final stages of reconstruction
Our doctors may also recommend that some patients undergo additional techniques and procedures to complete the breast reconstruction process, including:
Symmetry procedures on the unaffected breast: Breast reconstruction is designed to create a breast with a more lifted, rejuvenated appearance. For women who undergo a unilateral mastectomy and reconstruction, standard procedures may be performed on the unaffected breast to improve symmetry. These may include a breast reduction, breast lift or breast augmentation. Our surgeons discuss available options with each patient during the initial consultation.
Autologous fat grafting: This technique uses liposuction to carefully remove fat from one area of the body, then transfers it to the reconstructed breast, allowing the surgeon to fine-tune the breast’s volume and shape. Fat is a rich source of stem cells, which are critical to healing. In addition to improving breast shape and volume, transferring fat may help stimulate the formation of new blood vessels, improve skin texture and, in some cases, restore some lost sensation.
Nipple reconstruction: For women who are not candidates for a nipple-preserving mastectomy, traditional nipple reconstruction may be performed using the skin of the reconstructed breast to create small flaps, which are shaped to resemble a nipple that projects from the breast. Once the nipple heals, tattooing may be used to create a more natural pigmentation.
3-D nipple tattoo: Instead of using tissue to build a nipple that projects from the reconstructed breast, some women choose to have a more detailed tattoo applied, using shading to create the illusion of a three-dimension structure. The reconstructive team at our Illinois hospital has specially trained providers in this technique.
Surgery for breast cancer-related lymphedema
Some patients are at risk for lymphedema, a buildup of fluid that often results from lymph node damage or removal during breast cancer treatment. Our clinicians provide proactive lymphedema management, including physical therapy and early education, to help prevent this condition. However, if you experience symptoms of lymphedema after trying non-surgical therapeutic approaches, you may be a candidate for surgery.
The reconstructive surgeons at our Illinois hospital offer two surgical options to treat lymphedema:
- Vascularized lymph node transfer (VLNT) surgery: This is an advanced microsurgical procedure used to treat patients with advanced lymphedema affecting the arm and/or hand. Functional lymph nodes from another part of the body, typically the upper groin or lower abdomen, are removed with their blood supply as a free flap. The flap is then transferred and connected to blood vessels in the axilla, where previous lymph nodes were removed. In many instances, the lymph nodes may be included in the creation of a DIEP flap, as part of a procedure called a total breast autologous reconstruction (TBAR), which uses reverse lymphatic mapping to reduce the risk of lymphedema developing near the donor site.
- Lymphaticovenular anastomosis (LVA) or bypass surgery: In this surgery, an intricate super-microsurgical procedure used to treat patients with mild to moderate lymphedema, the dilated lymphatics in the affected arm are identified and sewn into nearby venules (tiny veins), creating a shunt, or bypass, of lymphatic fluid into the circulatory system to reduce pressure and swelling.