Mastectomy for treating breast cancer is the most common reason that women have breast reconstruction. In fact, the number of women undergoing this reconstructive surgery has increased dramatically over the past 30 years, and the trend for immediate breast reconstruction after mastectomy has grown from 10% in the 1980s to about 90% today.
At Stony Brook Medicine, our breast surgeons perform the following different kinds of mastectomy:
- Total Skin-Sparing Mastectomy
- Total Skin-Sparing/Nipple-Sparing Mastectomy
Our plastic surgeons have special expertise in reconstructive breast surgery. They use state-of-the-art reconstructive techniques, providing patients with a range of different options for breast reconstruction.
Breast reconstruction is an operation carried out to restore breast shape and replace breast tissue lost during a mastectomy or, occasionally, a lumpectomy. The operative goal is to match the opposite breast as closely as possible. Or, in some cases, to create a pair of breasts that are symmetrical and natural-looking and that, if possible, resemble the patient’s original breasts.
Our plastic surgeons can create a breast that closely approximates the form, feel, and appearance of a normal breast.
There are many benefits to breast reconstruction. These include restoration of a woman’s feeling of being whole again, as well as her self-confidence and feelings of femininity. In clothes, the appearance of the reconstructed breast will be similar to the appearance prior to the mastectomy. Without clothes, the breast mound will restore the natural shape of the breast.
On a practical side, breast reconstruction eliminates the need for external artificial breasts (prostheses), which can be uncomfortable and awkward to wear.
It is important to note that reconstructive breast surgery does not interfere with future treatments such as radiotherapy, chemotherapy, or detection of breast cancer recurrence. Breast reconstruction does not increase the risk of breast cancer recurrence.
Although breast reconstruction aims to match a woman’s previous breast(s) as closely as possible, patients must bear in mind that this surgery will not precisely restore the original appearance and shape. The reconstructed breast will not have the same sensation, and lactation is not possible in the reconstructed breast.
The trend at major breast cancer centers has been to offer immediate reconstructive surgery for patients who have a mastectomy. In fact, New York State law now requires that all patients having mastectomy should be offered immediate reconstruction. However, there are still some high-risk scenarios where breast reconstruction should be delayed or even avoided altogether.
New York law requires that every woman undergoing a mastectomy be offered reconstructive breast surgery, and be told about her options.
Some women are uncomfortable weighing all of the reconstructive options while they are struggling to cope with the diagnosis of breast cancer. Breast reconstruction can certainly be performed at a later date. However, the advantages of immediate breast reconstruction are that not only is the patient spared a second major operation and hospitalization, but that after the mastectomy, she wakes up with some breast shape, and is spared the some of the psychological impact of mastectomy.
For most patients, breast reconstruction will require from one to three surgical procedures to achieve the desired result. The first procedure is the most lengthy and complex, while the other procedures tend to be done on an outpatient basis, and are more focused on perfecting form.
The first procedure involves creation of the breast mound or breast shape. There are many ways this can be achieved.
Tissue Expander Plus Implant Reconstruction
The most common way to reconstruct a breast is to use a combination of a tissue expander and an implant. A tissue expander is a small “balloon” that is placed beneath the chest muscle (pectoralis muscle) at the time of the mastectomy. The muscle covers the upper portion of the tissue expander, and the lower portion is covered with what is called acellular dermal matrix. This bio-material, derived from human donor skin, has been washed to remove all cells. It acts as a sling or scaffolding that holds the expander and, eventually, the implant in place.
Over the ensuing weeks, the balloon is then filled with saline (sterile salt solution) through a small porthole using a syringe and needle. This process allows for the creation and stretching of skin, much like what happens to a woman’s belly during pregnancy.
This remodeling of the skin requires about six weeks. After sufficient skin has been created, a second operation, in which the tissue expander is removed and a permanent breast implant placed, is performed several months later. The current breast implants are filled with either silicone gel or saline solution.
Every effort is made to achieve the best possible result from the reconstruction. The results, however, can vary a great deal. Although it is impossible to achieve a perfect match, it is generally possible to achieve a close match that, even in a bathing suit or low-cut dress, looks similar to the opposite breast.
Most women are very satisfied with the final result of reconstructive breast surgery, and feel a significant improvement in their appearance and quality of life.
Tissue-Transfer Reconstruction
The type of breast reconstruction to be chosen depends on the desires of the individual patient, as well as the surgical factors that determine the reconstructive possibilities in each case.
The transverse rectus abdominus muscle (TRAM) flap reconstruction is—from the surgeon’s viewpoint—perhaps one of the most rewarding ways to reconstruct a breast. From the patient’s viewpoint, the TRAM reconstruction is especially attractive because the outcome is very natural, from materials to appearance.
This operation involves using entirely the patient’s own tissue to build the new breast(s). A section of tissue—generally, from the belly area, in which a section of skin/fat is removed with a standard “tummy tuck” procedure; or, from the back—is brought to the mastectomy site, and then shaped into a new breast closely matching the opposite breast.
The TRAM operation is lengthier than other reconstructive options and requires more time for recovery, but it yields the most natural-looking breast. Occasionally, skin and muscle from the back is used to reconstruct the missing breast; this is called a latissimus dorsi flap. However, with this latter technique, an implant is usually required if a larger breast needs to be made.
Our plastic surgeons at Stony Brook also have specialized training in microscopic techniques, which can be used to enhance outcome in some patients who are having flap reconstruction. These procedures are called DIEP (deep inferior epigastric perforator) flap and SGAP (superior gluteal artery perforator) flap.
Creating the nipple areola complex is the final step in completing a breast reconstruction. Some patients are comfortable without having a nipple, and do not wish further surgery. Others choose the non-surgical method of tattooing without reconstruction. This allows coloring to simulate the nipple areola complex without the contours of the actual nipple.
The other approach is to create a nipple mound from skin taken as a local flap on the reconstructed breast. The areola can then be tattooed, or reconstructed with a skin graft taken from elsewhere on the body. Common donor sites include abdominal scar from a flap reconstruction, the inner thigh, or buttocks crease.
Nipple areola complex reconstruction is done in the plastic surgeon’s office.
“Lumpectomy” and “partial mastectomy” are terms used interchangeably. They both refer to the same procedure. Both share the common goal to remove the cancer with a clear margin. The amount of tissue removed is the same. The term “partial mastectomy” is frequently used in place of “lumpectomy” for billing and coding purposes only, since it is a relatively more specific term.
The primary goal of partial mastectomy is to obtain microscopically clear margins, while obtaining an acceptable cosmetic result. The scar generally heals nicely. After partial mastectomy, it is reasonable to expect some change in breast size and shape.
Generally, the cosmetic results are acceptable, and studies have shown that most women are satisfied with the results.
Partial mastectomy is almost always followed by radiation treatments. For some women, the cosmetic appearance after partial mastectomy is poor. These patients are encouraged to consult with our plastic surgery team to discuss options for reconstruction. Generally, these procedures are performed 6–12 months after completion of the initial surgery and radiation.
Our breast surgeons and plastic surgeons are highly experienced and specially trained to offer a range of surgical options and techniques. We will do our very best to treat your cancer and also to optimize the cosmetic outcome. While we are extremely confident in the care that we provide, the decisions about breast reconstruction are yours to make. They are important for you.
For this reason, we tell all patients they should feel free to get other opinions from other healthcare professionals, in order to help them make the best decisions regarding breast reconstruction. Such opinions may be helpful to you in deciding whether reconstruction is what you want, and if it is, then what kind of reconstruction you would prefer.
Our breast specialists and support staff, of course, are available to talk about this with you and your family, to answer your questions, and to provide you with the best possible care.
The following website is recommended as a good source for additional information regarding breast reconstruction: www.plasticsurgery.org.
Please see our brochure, "Breast Reconstruction: What You Should Know." For more information about breast reconstruction performed by our plastic surgeons, please call 631-444-9287.
