Breast Reconstruction

One out of eight women in the United States develop breast cancer.   Breast cancer may also run in families; a woman may be genetically susceptible to developing cancer.   Removal of one or both breasts may be recommended for a woman with breast cancer or a strong family history of it.   Reconstructing the breast(s) is often an appealing option.  Breasts may be reconstructed using implants, a woman’s own tissues, or a combination of both.  Breast reconstruction is almost always covered by insurance and can make an enormous difference is a woman’s self-image.

Types of breast reconstruction

There are a number of ways to reconstruct a breast.  The best technique for any one person will depend on a number of factors.  The woman’s desires and expectations are important.   Her overall health, age, and anatomical features play a role.  The type, size, and location of the cancer also factor into the decision.  The potential need for chemotherapy and radiation must also be considered.

breast reconstruction with a tissue expander

Reconstruction with a tissue expander is typically a two-stage process; at least two operations are involved.  At the first procedure a temporary device called a tissue expander is placed in the mastectomy site.  Saline (salt water) is injected into the tissue expander.  Over the next several months saline is gradually added to the tissue expander when the woman visits the office.

Once the desired size of the breast has been reached, the woman undergoes a second operation.  The second procedure usually takes an hour or two and the woman goes home the same day.  The expander is replaced with a breast implant.  Most women choose a silicone implant, but advantages and disadvantages of different implants are thoroughly discussed before she decides what type of implant to use.

direct-to-implant breast reconstruction

It may be possible to skip the tissue expander entirely and just have the final implant placed at the time of the mastectomy.  This is a great option for many women, but some may not be candidates.  For instance, this may not be the best options for a woman who has small breasts.  Direct-to-implant reconstruction creates the opportunity to complete the mastectomy and reconstruction in one operation.  It’s a powerful option.

Oncoplastic breast cancer surgery

This may be a great option for a woman with larger breasts who undergoes a lumpectomy to treat her cancer.  When the breast oncology surgeon removes the tissue containing the cancer, a defect is created.  Dr. Kunkel may be able to re-arrange adjacent tissues to fill the defect.   In most cases this is much like undergoing a breast reduction or breast lift.   Typically the woman’s nipple is elevated to an aesthetically pleasing position and the breast is re-shaped.  Oncoplastic breast cancer surgery may be completed as an outpatient.  Most women who choose this type of cancer care also require radiation.

latissimus flap breast reconstruction

This may be a good option for a woman who has breasts that are a little droopy and who is only going to have one breast removed. Skin, fat, and muscle are transferred from the woman’s back to the mastectomy site. This tissue is draped over a tissue expander or an implant that has been placed in the mastectomy site. Latissimus flap technique allows for more shaping and sculpting of the breast than just using a tissue expander or an implant alone. The skin, muscle, and fat create a more natural look and feel to the breast.

DIEP flap

Skin and fatty tissue in the lower abdomen are removed and re-attached to small blood vessels at the mastectomy site.  This results in breasts that are made from the woman’s own tissues.  This is a modification of an operation called a TRAM flap.  TRAM flap procedures were common in the 1990’s and early 2000’s.  As surgical techniques continue to evolve, DIEP flap surgery has replaced TRAM flap surgery in most cases.  A woman who has had several abdominal operations may not be a candidate for this procedure.  There are other procedures where her own tissues (inner thighs, buttocks) may be used rather than implants.

Recovery after breast reconstruction surgery

Recovery is different for women who undergo implant-based reconstruction (tissue expanders, direct-to-implant) than DIEP flap reconstruction.  Women undergoing reconstruction with a tissue expander or an implant typically spend one night in the hospital.  It is possible to do the entire procedure as an out-patient; she may go home the same day.  Most patients are surprised at how good they feel and have little discomfort.  Dr. Kunkel urges patients to go out and see a movie within 5 to 7 days of their mastectomy surgery.  Some women are able to go back to work after two or three weeks.  Patients should not do strenuous activity for about 6 weeks.

DIEP flap patients may spend 4 or 5 nights in the hospital.  In addition to their breast incision sites there are also abdominal incision sites and additional drain tubes.  Women may walk bent over for several days.  They may need additional help with dressing changes and physical activity compared to implant-based reconstruction.

Nipple reconstruction

It is possible to reconstruct a nipple, and there are a few options.   Dr. Kunkel likes to wait to do nipple reconstruction until the patient is happy with the size, shape, and symmetry of her reconstructed breasts.

There are two major ways to reconstruct a nipple.  For a woman who wants some projection of the nipple (front-to-back dimension), a small 20 minute procedure is required.  A small incision is made at the desired site for the nipple.  Fatty tissue beneath the skin is pulled forward in that location.  Small additional incisions are made to allow surrounding skin to be wrapped around the fat.  This creates a small mound that looks like a nipple.  About 6 weeks later color is added to the nipple and around the nipple to complete the reconstruction.

A different option is to skip the surgery and just have a tattoo.  The patient decides where she thinks a nipple will look best on her reconstructed breast.  She chooses color for the tattoo.   The tattoo procedure is often done by a nurse in Dr. Kunkel’s office.  It is possible to have this done by other tattoo artists as well, but most patients have it done in the office.  These nipples can look very good, but there is no projection; they are flat like any other tattoo.    The color may fade over time.



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