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The Breast Reconstruction Process

Author: Dr. Tom Gallaher

Breast reconstruction has become a common and routine procedure, which affords patients facing a mastectomy or even a partial mastectomy the ability to restore their physical appearance.

There are multiple techniques that have evolved over the last several decades that are utilized in this process, but the majority of breast reconstructions in the United States are done with a series of operations. This series begins with the placement of a tissue expander beneath the muscle and skin area of the mastectomy site, either at the same time or at a later time following the mastectomy.  This device is inflated at intervals over several weeks to provide a pocket of space.  The second operation in this series is to remove this device and place a permanent prosthesis, which is made of silicone, the device either being filled with saline (salt water) or gelatinous silicone (silicone gel).  There is typically a third operation a few weeks after the second operation to finish the reconstruction, removing excess tissue from areas of need, as well as adding tissue to areas of need as indicated.  Also at that operation, a nipple-areolar complex reconstruction is typically done.  The last step in the reconstructive process is to provide tattooing, or coloration, of the nipple-areolar complex.

In most recent years, there has been a trend toward prophylactic mastectomies, either in patients being treated on one side for cancer or also for people with strong family histories of breast cancer and/or genetic mutations, placing them at high risk for developing breast cancer.  As techniques have improved and data has been gathered, nipple-sparing mastectomies have also become an option for some patients.  Utilization of the patient’s own tissue, meaning skin, fatty tissue, and sometimes muscle, is utilized in certain circumstances.  The most common form of this type of reconstruction is the use of tissue from the back area (latissimus dorsi myocutaneous flap) and from the lower abdomen (transverse rectus abdominus myocutaneous flap).  These procedures are much less common than implant-alone based reconstruction, but in cases where radiation is part of the patient’s treatment protocol, they are relatively common and necessary to replace the tissue that has been damaged by radiation.

Like any surgical procedure, a great deal of planning is involved to provide the patient with options and information, and to guide them through the reconstructive process, which typically takes around one year to complete depending on which additional treatments may be necessary for the patient from a cancer standpoint.  It is also very important from the reconstruction outcome perspective to have a well-trained breast oncologic surgeon.  This markedly simplifies the process and improves outcomes as the tissues removed require expertise in how they are removed and the remaining tissues preserved to aid in the reconstructive effort.

Reconstruction for congenital deformities of the breast, asymmetries of the breast, and even for changes in shape and volume related to partial mastectomy with or without radiation therapy is also available to restore appearance as best it can be following a wide spectrum of treatments which may be benign or malignant.  In 1998, the federal government passed a law stating the insurance is required to cover breast reconstruction following treatment for cancer and that within this treatment they also are required to provide symmetry operations.  In other words, if the noncancerous breast is preserved, it should be allowed to be made to match the reconstructed breast.  Also, nipple-areolar complex reconstruction is protected under federal law as being “necessary.”

Obviously, the details and extent of all of the different options and procedures are beyond the scope of this article.  Suffice it to say that if you are facing treatment for benign or malignant disease of the breast you should be allowed to consult with a plastic surgeon regarding the potential for reconstruction, and a team of physicians including your breast oncology surgeon should work together to provide you the best treatment options and the best potential outcome.