Plastic Surgery for Breast Reconstruction

This content has been reviewed and approved by

William J. Gradishar, MD FACP
Director, Breast Medical Oncology, Professor of Medicine
Robert H. Lurie Comprehensive Cancer Center
Northwestern University Feinberg School of Medicine

With advances in breast reconstruction surgery, more than one-third of women undergoing breast removal have their breast(s) rebuilt. Even though medical, surgical, and radiation therapy treatments for breast cancer have increased the number of breast-sparing procedures available, some patients with breast cancer may still require a mastectomy (removal of the breast or breasts). In addition, other women have their breast(s) removed due to other diseases.

What is breast reconstruction surgery?

Breast reconstruction surgery involves creating a breast mound that comes as close as possible to the form and appearance of the natural breast.

The goal of reconstructive surgery is to create a breast mound that matches the opposite breast and to achieve symmetry. If both breasts have been removed, the goal of breast reconstructive surgery is to create both breast mounds approximately the size of the patient's natural breasts.

What are the criteria for breast reconstruction surgery?

In general, all women undergoing a mastectomy are candidates for immediate or delayed breast reconstruction. However, there are criteria for selecting the best candidates for the procedure, including the following:

• The size and location of the cancer, as this helps to determine the amount of skin and tissue to be removed in the mastectomy (a primary factor when making recommendations for reconstruction)
• Whether tissue has been damaged by radiation therapy or aging, and is not sufficiently healthy to withstand surgery
  

Other considerations include the following:

• Potential for complications
• Patient's desires
• The amount of tissue removed from the breast
• The health of the tissue at the planned operation site
• Whether radiation therapy is part of treatment
• The patient's general health and physique
• Past medical history
• Coexisting illnesses
• Other risk factors, such as cardiac disease, diabetes, smoking, and obesity 
  

Who pays for breast reconstruction surgery?

The Women's Health and Cancer Rights Act of 1998 requires all health insurance providers who cover mastectomy procedures to also cover the cost of breast cancer reconstruction. If you are uninsured, consider speaking to your surgeon and the hospital where your mastectomy was performed. Sometimes surgeons will waive the fee and/or the hospital may offer a discount if you're paying cash.

When is breast reconstruction surgery performed?

The patient is usually educated and counseled in breast reconstructive possibilities before the mastectomy, so that she can make the decision for or against reconstruction before going into surgery. Based on the personal medical history of each patient, a recommendation will be made for either of the following:

• Immediate reconstruction - reconstructive surgery performed at the same time as mastectomy.
• Delayed reconstruction - a second operation (to reconstruct missing breast tissue) is performed after recovery from the mastectomy is complete. If chemotherapy is part of the treatment protocol, the surgeon may recommend delayed reconstruction.
  

Possible Complications Associated with Breast Reconstructive Surgery

Possible complications that may be associated with breast reconstruction may include, but are not limited to, the following:

• Bleeding
• Fluid collection
• Infection
• Excessive scar tissue
• Anesthesia problems
  

The most common complication of breast reconstruction surgery is capsular contracture, which occurs if the scar or capsule around the implant begins to tighten. Occasionally, this (and other) complications are severe enough to require a second operation.

What are the different types of breast reconstruction surgery?

The two most effective approaches available for both monolateral (one breast) and bilateral (both breasts) reconstruction are:

• Expander/implant reconstruction - the use of an expander to create a breast mound, followed by the placement of a permanently filled breast implant.
  

Expanders are empty silicone "envelopes" placed under the pectoralis muscle, located between the breast and the chest wall. To enable the skin and soft tissue of the breast to grow, the expander is gradually filled with saline solution over a period of several weeks. The saline is injected into the expander through a valve or port in the expander. Once the expander has been completely filled, it is left in for several more weeks to months, allowing for maximal skin and soft tissue growth.

Implants are envelopes filled with liquid that are implanted into the breast tissue and are used to form the shape of the breast. Implants may be filled with saline or silicone gel. Each type of implant has advantages and disadvantages. Your physician will discuss the types of implants with you and seek your input about the type of implant to be used.

Although there have been questions raised about the safety of silicone gel implants, the Institute of Medicine published a report in 2000 that refuted most of the claims about silicone implant hazards, and in late 2006, the U.S. Food and Drug Administration (FDA) approved the marketing of silicone gel implants from two manufacturers, Allergan Inc. and Mentor. 

• Autologous tissue reconstruction - This is the use of the patient's own tissue to reconstruct a new breast mound. The common technique is the transverse rectus abdominis muscle (TRAM) flap. A TRAM flap involves removing an area of fat, skin, and muscle from the abdomen and stitching it in place to the mastectomy wound. 
  

About the Procedure

Although each procedure varies, generally breast reconstructive surgeries follow this process:

• Location options may include:
  
• Surgeon's office-based surgical facility
• Outpatient surgery center
• Hospital outpatient
• Hospital inpatient
  
  

When performed at the time of a mastectomy, a reconstructive procedure adds about 1 hour or so to the surgery. Drains are put in place, and recovery time is longer due to the additional surgery, but the care afterward is the same as for mastectomy alone.

Delayed reconstruction, as a second surgery, may require more than 1 hour, and drains are not routinely inserted. The recovery is much quicker than it is after immediate reconstruction because the mastectomy wound has already healed.