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 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.
There are two main types of breast reconstruction. The most common type uses some type of breast implant. The second type uses a person’s own tissues to create a breast. This is called a “flap”, and there are several options. Sometimes a breast may require a combination of an implant and a person’s own tissues. This can be a little confusing, and that’s why a visit with Dr. Kunkel is so important.
Breast reconstruction with implants
In 2016, 80% of women who underwent breast reconstruction had their breasts reconstructed with an implant of some type. Reconstruction with tissue expanders is the most common type of breast reconstruction in the U.S. However, there is a trend toward skipping use of a tissue expander and going directly to the final implant. Both are described below.
breast reconstruction with a tissue expander
Since the 1990’s this has been the most common type of reconstruction. Breast reconstruction with a tissue expander technique 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 plastic surgeon’s office. As saline is added to the expander the tissue stretches, or expands, creating a new breast shape.
Once the desired size of the breast has been reached, the woman undergoes a second operation. The second procedure usually takes place 3 to 6 months after the mastectomy surgery. The operation takes an hour or two and the woman goes home the same day. The tissue expander is replaced with a more long-term breast implant. Most women choose a silicone implant, but saline implants are also an option. This second operation also allows additional adjustments to be made. Sometimes an implant may require a little re-positioning. If a little more shape is desired at the top of the breast it may be possible to do liposuction of the abdomen and place that fat in that part of the reconstructed breast. Insurance pays for all of these things.
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 referred to as direct-to-implant reconstruction. It is a powerful option. Direct-to-implant technique creates the opportunity to complete the mastectomy and reconstruction in one operation. In some instances it even may be completed as an outpatient. The woman can undergo her mastectomy and reconstruction and sleep in her own bed that night! Most women, however, spend one night in the hospital. This is also referred to as “breast in a day” reconstruction.
Direct-to-implant reconstruction is a great option for many women, but some may not be candidates. For instance, sometimes the size and location of the cancer requires removal of a lot of breast skin. In cases like these, a tissue expander or use of a woman’s own tissues may be a better option.
Breast reconstruction using a person’s own tissues: flap surgery
An alternative to using implants is to use a person’s own tissues. This may be a good option for someone who is otherwise in good health, near their ideal body weight, and has not had a lot of surgery on their abdomen or back.
In DIEP flap surgery, breasts are made using a woman’s own abdominal 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 situations. Skin and fatty tissue in the lower abdomen are removed and re-attached to small blood vessels at the mastectomy site. A woman who has had several abdominal operations may not be a candidate for this procedure. For a woman who has had multiple abdominal operations but wants to use her own tissues rather than an implant, there are alternatives. Sometimes tissue from the inner thighs or buttocks may be used, for instance.
latissimus flap breast reconstruction
In latissimus flap surgery, 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 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. 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. The skin, muscle, and fat create a more natural look and feel to the breast.
In the past a mastectomy almost always required removal of the nipples. Advances in understanding of breast cancer and advances in surgical technique now allow many women to keep their nipples. Most women who have positive genetic tests for breast cancer are candidates for this type of reconstruction. A woman who has a small cancer located an inch or more away from the nipple may be a candidate. Dr. Kunkel works closely with breast oncology surgeons and medical oncologists to help identify the best candidates for this procedure.
Oncoplastic breast cancer surgery
Many women with breast cancer choose to undergo a lumpectomy rather than a complete mastectomy. The advantage of a lumpectomy is that a woman gets to keep her breasts. No implants and no major flap surgery are involved.
In a lumpectomy procedure, when the breast oncology surgeon removes the tissue containing the cancer a defect is created. When an oncoplastic operation is chosen, Dr. Kunkel then steps in and re-arranges 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. This surgery is often completed as an outpatient. The woman goes home and can sleep in her own bed that night. Most women who choose this type of cancer care also require radiation.
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.
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 brief 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.