A Guide to Breast Reconstruction

Breast cancer and its subsequent breast reconstruction procedures are very emotionally overwhelming and physically trying. Patients experience intense feelings of fear, shame, sadness and embarrassment; not to mention uncertainty about how the surgery will affect their future and their lifestyle.

But however difficult the process is to endure, doctors and breast cancer survivors agree that lumpectomies and/or mastectomies, followed by breast reconstruction surgery, is the best way to preserve patients' lives and their health. Just ask actress and breast cancer survivor Christina Applegate, People Magazine's new cover girl for their annual "100 Most Beautiful People" issue.

Christina Applegate was named one of the "most beautiful people" for more than just her bubbly, blonde good looks— in the fall of '08, Applegate endured a courageous and public battle against breast cancer. She chose to have a double mastectomy to eradicate any future risk of the cancer. Rather than succumb to grief over her circumstances, Applegate projected a message of hope and resolution. As a result, she fueled new interest and awareness for breast reconstruction from breast cancer patients and others around the country.

For those currently dealing with breast cancer and considering their breast reconstruction options, and for those seeking breast reconstruction for cosmetic purposes, we've created this guide to help outline the process and its variables.

What Exactly is Breast Reconstruction Surgery?

Breast reconstruction surgery is sometimes lumped into the breast augmentation category alongside breast implants, breast lifts, breast reduction and even breast liposculpture procedures. In actuality, breast reconstruction is its own category of breast surgery. Breast reconstruction procedures focus on different surgical methods and techniques for reconstructing or repairing breast tissue, for both medical and aesthetic reasons.

Generally, breast reconstruction surgery is performed to reconstruct breast tissue that was removed during mastectomy and/or lumpectomy breast cancer surgery, or to repair malformed or asymmetrical breast tissue caused by birth defects, burns or severe injuries. Breast cancer patients' options in reconstructive breast surgery will depend on the severity and location of their cancer, their medical history and health complications, their natural breast size and shape, and their individual preferences.

The First Step: Breast Cancer Surgery and Treatment

Before breast cancer patients can undergo reconstruction surgery, they first must have surgery to remove the tumor or cancerous breast cells. Common breast cancer surgical procedures include:

Biopsy: the most minor of breast cancer surgeries is the biopsy. Mostly a method of screening for the presence of cancer, biopsies are performed when a doctor removes tissue samples from a breast lump for cancer testing.
Lumpectomy: also known as a partial mastectomy, lumpectomy is the process of removing a cancerous tumor (the lump) from the breast tissue to prevent the cancer from spreading. The amount of breast tissue removed with a lumpectomy will depend on the size of the lump or the amount of cancerous cells present. For larger tumors, patients may require a quadrandectomy, which is a lumpectomy that removes roughly a fourth of the breast.
Mastectomy: mastectomy surgery will also vary with the degree of cancer that's present. A partial mastectomy can be the removal of a portion of breast tissue, like with a quadrandectomy. A simple mastectomy, or total mastectomy, is when the entirety of the breast is removed. A double mastectomy involves the removal of the majority of breast tissue from both the right and left breast. Even within this procedure there are specific techniques that focus on preserving areas like extra skin tissue, the nipples, pectoral muscles, or the areola.

Sometimes patients choose to have a preventative mastectomy, or prophylactic mastectomy, to greatly reduce their breast cancer risk. This can be a smart choice for patients who've undergone gene testing and are found to have mutations of the BRCA genes. These BRCA gene mutations are shown to be highly predictive of a future bout of breast cancer, particularly in patients with a family history of the disease.

Once it's understood that a patient will require a mastectomy or other breast cancer surgery, it's time to explore breast reconstruction surgery options. There are many decisions and specific details that must be determined with breast reconstruction surgery, such as whether to have immediate or delayed breast reconstruction, and what kind of breast reconstruction procedure to have: tissue flap breast reconstruction, breast reconstruction with implants, or a combination of the two.

Before making any decisions in terms of your breast reconstruction surgery, you will want to extensively research all of the procedure options, and meet with an experienced breast reconstruction surgeon to thoroughly discuss your individual possibilities.

The Second Step: Breast Reconstruction Surgery

Determining the many variables of breast reconstruction surgery can be daunting. A patient's possible options in breast reconstruction will be narrowed down by their physical circumstances after breast cancer treatment, and by their candidacy for different procedures. A patient's candidacy for a certain type of breast reconstruction will depend on their overall health, breast size and shape, and their surgical goals. The two most common forms of breast reconstruction patients receive are breast implant reconstruction and tissue flap breast reconstruction. There is also the matter of determining whether the patient will undergo immediate or delayed reconstructive surgery.

Breast Implant Reconstruction

Breast implant reconstruction can be performed immediately or through the delayed reconstruction method (see below). Sometimes it can be difficult to insert implants directly following a mastectomy; this is because breast tissue as well as skin is removed during mastectomy surgery, and the remaining skin is typically very tight and hard to manipulate. To accommodate the implant, a tissue expander is inserted post-mastectomy, which will gradually enable implants to fit into the new chest tissue. If, however, a patient has had a partial mastectomy and there is still a good amount of chest tissue left, the implant might be inserted immediately.

Tissue expanders are inflatable rubber devices that are inserted underneath the chest skin after mastectomy surgery. Over the course of four to six months, the expander is filled with a saline solution via injections, causing the expander to grow and the chest tissue to gently expand with it. After the skin has created an appropriately sized pocket to fit the implant, the patient will have the expander removed and the implant inserted.

Tissue Flap Breast Reconstruction

Tissue flap breast reconstruction can be performed with or without breast implants. In both circumstances, the "tissue flap" is literally a flap of skin removed from another area such as the abdomen, upper back, buttocks or upper hips. The flap is then attached to the chest area and is used to cover up the implant, or simply to replace the loss of removed or damaged breast tissue.

Tissue flap surgery is an in-depth surgical procedure that has strict requirements for candidacy. Poor health, a smoking habit, an absence of healthy body fat or conversely a high level of obesity, and even circulatory problems can disqualify a patient for tissue flap surgery. Patients who are candidates for tissue flap breast surgery sometimes prefer it implants because:

Flap reconstruction utilizes the patient's own natural skin
Tissue flap reconstruction can replace natural skin tissue lost with the mastectomy
Flap reconstruction makes implant reconstruction an option for patients left with minimal chest tissue post mastectomy

Because implant reconstruction of one breast usually requires the other, healthy breast, to be augmented as well to achieve symmetry, tissue flap procedures are sometimes preferred for partial mastectomy patients. With tissue flap surgery, the healthy breast may not need to be augmented.

Types of Tissue Flap Reconstruction

The two most common forms of tissue flap breast reconstruction are the TRAM flap reconstruction and Latissimus Dorsi flap reconstruction. TRAM (transverse rectus abdominus musculocutaneous) flap reconstruction removes skin from the abdomen and attaches it to the chest. TRAM flap surgery is often performed in one of two ways, pedicled or free.

Latissimus Dorsi (LD) flap breast reconstruction takes tissue from the sides of the upper back and attaches them to the chest area where the breast was removed. This surgery may create temporary or even permanent muscle weakness in the back where the tissue was removed. Latissimus flap reconstruction may be more appropriate for the reconstruction of smaller breasts, since skin on the upper back is thinner than abdominal skin.

Both TRAM flap breast surgery and the LD flap breast surgery are known to leave scars along the lower abdomen and upper back, and usually on the newly constructed breast as well. However, these incisions can often be made along the bra line, so patients can conceal them for the most part.

There are a few other alternate tissue flap breast reconstruction options, such as the GAP tissue flap procedure. GAP flap surgery uses skin tissue from the buttocks to reconstruct the damaged breast(s). This type of flap surgery is considered very technically difficult, and the buttock tissue can be more difficult to mold into a breast shape.

Immediate Breast Reconstruction vs. Delayed Breast Reconstruction

The choice of either delayed or immediate breast reconstruction surgery will be closely tied to the patient's choice of reconstruction procedure, and on their individual needs.

Immediate Breast Reconstruction

Just like it sounds, immediate breast reconstruction surgery is performed immediately following the mastectomy procedure. Choosing immediate breast reconstruction surgery is more comforting and preferable for some women, as it can help them complete their breast reconstruction as quickly as possible. It can also be more convenient, since combining the mastectomy with the reconstruction procedure means less total time spent in recovery.

Immediate breast reconstruction can be completed in one or two stages. One-stage immediate breast reconstruction is performed when the surgeon immediately inserts the breast implant after removing the necessary tumor and most of the breast tissue. Two-stage immediate breast reconstruction is performed when the surgeon first inserts a tissue expander following the mastectomy, and then the implant is inserted at a later date.

One-stage immediate breast reconstruction typically can't be performed for women with minimal tissue left post-mastectomy.

Delayed Breast Reconstruction

Delayed breast reconstruction is a good idea if you're still weighing your options in terms of implants, or you want a chance to recover emotionally from the loss of the natural breast tissue before proceeding with silicone or saline implants. Delayed reconstruction surgery may also be recommended by your plastic surgeon in the event that complications or healing problems are foreseen after surgery.

Delayed breast reconstruction more heavily relies on the use of tissue expanders being inserted underneath the chest tissue post-mastectomy; this encourages the tissue to stretch and develop around the expander in order to prepare for the future implant. Delayed breast reconstruction surgery is also the recommended method for undergoing tissue flap procedures, since reattaching the tissue flaps are often a difficult procedure in of themselves.

The Final Step: Secondary Breast Reconstruction Surgery

Secondary breast reconstruction procedures are the final touches in the breast reconstruction process. A patient may require several secondary procedures or none, depending on their personal circumstances and their reconstruction results.

Common secondary breast reconstruction procedures include nipple reconstruction, nipple/areola tattoos, flap revisions, or expander to implant transitions. Secondary breast surgery may also mean augmenting the opposite breast to match the newly reconstructed one.

Last but not least, it's important that patients take some time and come to terms with their new breasts. By meeting a final time with their plastic surgeon or doctor, patients can confirm that their breast reconstruction was successful and their recovery is progressing. This also gives breast reconstruction patients a chance to discuss future options in cosmetic breast enhancement if they still feel unsatisfied with their results.