Breast Reconstruction
Breast reconstruction involves making a new breast either at the same time, or sometime after, a mastectomy. There are several different ways of doing a breast reconstruction and many things to consider before deciding to have one. Many women decide not to have a breast reconstruction and have a simple mastectomy and wear an external prosthesis in the bra. All women who need a mastectomy should however, have the option of breast reconstruction. Even if you are fairly sure that you don't want one it is, perhaps, good to know a little bit about what can be done. In this way you make the decision that is best for you being fully aware of the options.
Issues to Consider
One of the first issues to consider is "Do I want a breast reconstruction or not?" To answer this question you need to know what is involved with a breast reconstruction and what options there are. Once you know this, as a guiding basic principle, if you are not convinced about this then the best thing to do is not to have one. Another important issue, on which you will be strongly guided, is whether or not a breast reconstruction performed during the same operation as a mastectomy (immediate breast reconstruction) is a good option for you. For some women the extent of the breast cancer is such that surgery should be kept as simple as possible and reconstruction would be much better performed once all the breast cancer treatment is finished (delayed breast reconstruction). All breast reconstruction involves additional surgery and additional risk of complications. It therefore involves more time in hospital (in the ward or clinic) than if the simplest surgical procedure was performed. If you are advised that a breast reconstruction is an option for you then this advice is based upon the fact that a breast reconstruction will not adversely affect your treatment in any way.
Types of Breast Reconstruction
In general terms, a breast is either reconstructed from artificial means (silicone implants) or from your own tissue (flap reconstruction). Sometimes a combination of the two is used. Not every woman is suitable for every option. Some women may have two or three options for breast reconstruction available, others have only one and just occasionally there are no good options. Having more than one option is good but this can also mean that you have more information about pros and cons of different types of reconstruction to consider. Where possible, if you have more than one option for breast reconstruction you will be advised about which is the one you are most ideally suited for.
Immediate Breast Reconstruction (at the same time as a mastectomy)
Pros
Everything is done at one operation. You never have to have a flat chest. A lot of your own skin overlying the breast can be preserved and used as part of the reconstruction, which then looks more natural and has minimal scarring.
Cons
See "Complications - What can go wrong?" Delayed breast reconstruction refers to a breast reconstruction performed sometime after having a simple mastectomy.
Delayed Breast Reconstruction (at some time after a mastectomy)
Pros
If you are not convinced about a breast reconstruction it gives you time to think. It keeps the surgery as simple a possible at the time of your cancer treatment. You may decide that you don't want a breast reconstruction and are comfortable living without one.
Cons
A second operation is required with its associated time in hospital and recovery time. There will usually be more scarring as part of the reconstruction. Also see "Complications - What can go wrong?"
Nipple Reconstruction
This can often be performed at the same time as an LD flap of DIEP/TRAM flap reconstruction. If not it can be performed (under local anaesthetic) once breast reconstruction is complete. The area around the nipple can be tattooed. Most reconstructed nipples tend to flatten with time. Some women choose not to have a nipple reconstruction. They have the option of having a mould made from the other nipple that can be worn as required. See separate page on Nipple Reconstruction and Tattooing.
Admission and Aftercare
You are generally admitted on the day of surgery, occasionally the day before. You will be re-examined and the site of the scar / scars drawn on your body. The length of the operation will vary depending on the extent of surgery required as outlined above. Dissolvable stitches are used and a waterproof dressing consisting of a special type of glue is applied. Sometimes a support dressing is used for 24 hrs and you may be advised to wear a supportive bra or specialist garment day and night for a couple of weeks.
Complications - What can go wrong?
Any operation can be associated with infection or bleeding. Wound healing can be particularly affected by infection and smoking. If you are a smoker you will be strongly advised to stop smoking before having a breast reconstruction. Any operation can be associated with anaesthetic problems (nausea in particular), venous thrombosis (although precautions are taken routinely) and allergic reaction to drugs or dressings. Any breast reconstruction will feel quite numb. It is probably fair to say that you are less aware of this with time.
Having little sensation can mean that a reconstructed breast is a little more prone to injury such as sunburn or rubbing from a poor fitting or under-wired bra. Other complications are listed under the "cons" for various methods of breast reconstruction above. Some are worth a more detailed mention:
Capsule formation: This refers to the scar tissue that forms around silicone implants. It is the body's way of walling off the implant. The amount of capsule that develops is largely unpredictable. Some women form very soft capsule that causes no problems and some women form a dense capsule that distorts the breast shape, compresses the implant and is painful and tender. Capsule formation is inevitable after radiotherapy, which is why the combination of an implant reconstruction and radiotherapy is best avoided if possible. In the absence of radiotherapy, only a small minority of women have troublesome capsule formation. However over the long-term revision of an implant reconstruction because of capsule formation is reasonably common.
Flap failure: This refers to the situation where the blood supply fails to the tissue that is being transferred. It is extremely rare for LD flaps, but occurs in about 1 in 40 cases for a DIEP or TRAM flap. If this problem did occur you would have a big scar on your tummy and you would have gone through a big operation but there would be no breast reconstruction to show for it. Sometimes a second option for breast reconstruction can be used, sometimes a skin graft is necessary.
Weakness after LD flap: The muscle used for a LD flap is a "climbing muscle". Most women have some shoulder stiffness in the first few weeks after surgery. In the long term it is difficult to demonstrate any difference in ability to do all normal activities including average sporting activities. If you are a competitive sportswomen then it is possible that some effect would be noticeable depending upon your sport.
How do I decide?
You may need more than one consultation to fully appreciate all the options and pros / cons. The breast care nurse will help guide you and direct you to other sources of information. Once you are focused on one or maybe two options, you should ideally have a chat with someone who has undergone that operation. This will give you the best insight into what it is like and a realistic impression of what can (and can't) be achieved. Again, if you are not convinced about undergoing a breast reconstruction then the best thing to do is not to have one.
Finding a "Positive" out of a "Negative"
Some women would ideally wish to have larger breasts, or smaller breasts or breasts that are a different shape. If a new breast is being reconstructed by whatever means, it is worth considering whether you wish the normal breast to be adjusted so that you have a different overall breast size or shape. This is particularly the case if you require a bilateral (double) mastectomy.
FAQ's
Q. Are implants safe?
Answer - Yes. They are not without problems as detailed above but they are not in themselves harmful or toxic.
Q. Could having a breast reconstruction delay my cancer treatment?
Answer - Sometimes. The need for more operating time or two surgeons to be available means that your operation may be scheduled for a couple of weeks later than if you were having a simple mastectomy with no reconstruction. In practice this is more common with the DIEP or TRAM flap reconstruction when surgery needs to be coordinated with the availablity of the microsurgeon. As stated, all breast reconstruction involves additional surgery and additional risk of complications. In theory therefore, you could have a complication that delayed additional treatment such as radiotherapy or chemotherapy. In practice this happens very rarely and any complications that do occur are dealt with early to avoid this scenario.
Q. Will a breast reconstruction affect the effectiveness of my breast cancer treatment?
Answer - No. If that were thought to be a risk, you would be advised against having a breast reconstruction.
Q. If I have a breast reconstruction will it be more difficult to detect a recurrence of my breast cancer if I were unlucky enough to get one?
Answer - No. If you did develop a recurrence in the breast reconstruction area, it would be superficial to the reconstruction. The reconstruction would not make it more difficult to feel.
Q. If I have my other (normal) breast adjusted, will it mean that it will be more difficult to detect a cancer in that breast should it occur?
Answer - Firstly it should be stated that most women are very unlikely to develop a second breast cancer in the other breast and breast cancer does not spread from one breast to the other. If you have the other breast augmented (made bigger with an implant), this usually reduces the sensitivity of mammography. This may be a bigger problem for some women than others. If the other breast is adjusted without the need for an implant, this will not affect our ability to detect a problem in that breast should it occur.
Q. What is the recovery time for breast reconstruction?
Answer - This obviously varies depending on various factors (additional treatments, your general fitness etc) but as a rough guide most women will be back doing all the regular activities you were doing before surgery: 6 weeks after implant reconstruction 3 months after LD flap reconstruction 3-6 months after DIEP/TRAM flap reconstruction