Since writing my last my last post I have had a number of questions posed to me about reconstruction options after breast cancer surgery from both mastectomy patients and non-mastectomy patients.
And while I am always happy to share (and often, over-share) my story, I am NOT a medical professional (if by nothing else but by my sad looking bank balance!). Please understand that this process has been my personal journey and my personal reality and it certainly may not be the journey and reality of another breast cancer patient. Chemo brain and elective memory failure have also taken their toll, so I may not have always remembered every (important) detail explained to me.
But, what I have been encouraged by is the fact that women are asking these sometimes very hard questions and that they are going into these often very scary procedures armed with vital knowledge.
The information on the internet is often overwhelming and for most part you need to have a medical degree to actually understand it. Add this to that fact that you need to be wary of believing everything you read on the web and you have a very definite risk of being totally overwhelmed and just sticking your head in the sand!
I have found that the following articles seem to be legit and a little easier for us common folk to understand, and also pretty much what I remember being explained to me. But if you find any articles which you think would be suitable, please feel free to post them below under comments.
Obviously this is not meant to replace, and is still a VERY poor substitute, for sitting down with your plastic surgeon and discussing your individual options with them in detail. However, it just may help you prepare for those meetings and get you to ask the questions which may make a huge difference in your life post cancer.
MOST IMPORTANTLY – please also remember, some options may not be available to everyone due to their particular oncology treatment plan, and no plastic or reconstructive surgery is ever worth risking your life over.
Types of breast reconstruction
Several types of operations can be done to reconstruct the shape of your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of both. (A tissue flap is a section of your own skin, fat, and in some cases muscle which is moved from another area of your body to your chest.)
Types of implants
Implants have a silicone shell filled with either silicone gel or salt water (saline).
Silicone gel-filled implants are one option for breast reconstruction. Most of the recent studies show that silicone implants do not increase the risk of immune system problems, and the FDA (Food and Drug Administration) has approved silicone implants since 2006.
Some newer types use thicker silicone gel, called cohesive gel. The thickest ones are sometimes called “gummy bear” implants and are made of highly cohesive silicone. They are more accurately called form-stable implants, meaning that they keep their shape even if the cover is cut or broken. Although it was first thought they wouldn’t leak even if they did break, there have been reports of ruptures with leakage. Form-stable implants were approved in early 2013 in the United States.
Types of implant surgery
One-stage immediate breast reconstruction is also called direct-to-implant reconstruction. For this, the final implant is put in at the same time as the mastectomy is done. After the surgeon removes the breast tissue, a plastic surgeon places a breast implant. The implant is usually put beneath the muscle on your chest. A special type of graft or an absorbable mesh is used to hold the implant in place, much like a hammock or sling. (See the section “New methods of tissue support.”).
Two-stage reconstruction means that a short-term tissue expander is put in after the mastectomy. The expander is a balloon-like sac that’s slowly expanded to the desired size to allow the skin flaps to stretch. It’s used when the surgeon believes that the mastectomy skin flaps are not healthy enough to support a full-sized implant right away. Through a tiny valve under the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over a period of about 2 to 3 months. After the skin over the breast area has stretched enough, a second surgery will remove the expander and put in the permanent implant. Some expanders are left in place as the final implant.
The two-stage reconstruction is sometimes called delayed-immediate reconstruction because it allows time for other treatment options. If radiation therapy is needed, the final placement of the implant is put off until radiation treatment is complete. If radiation is not needed, the surgeon can start right away with the tissue expander.
Considerations about implants
Keep these important factors in mind if you are thinking about having implants to reconstruct the breast and/or to make the other breast match the reconstructed one:
- You may need more surgery to remove and/or replace your implant later. In fact, up to half of implants used for breast reconstruction have to be removed, modified, or replaced in the first 10 years.
- You can have problems with breast implants. They can break (rupture) or cause infection or pain. Scar tissue may form around the implant (called capsular contracture), which can make the breast harden or change shape, so that it no longer looks or feels like it did just after surgery. Most of these problems can be fixed with surgery, but others might not be reversible.
- MRIs may be needed every few years to make sure silicone gel implants have not broken. Your health insurance may not cover this.
- Routine mammograms to check your remaining breast for cancer will be more difficult if you have a breast implant there – you’ll need more x-rays of the breast, and the compression may be more uncomfortable.
- An implant in the remaining breast could affect your ability to breastfeed, either by reducing the amount of milk or stopping your body from making milk.
Tissue flap procedures
These procedures use tissue from your tummy, back, thighs, or buttocks to rebuild the breast shape. The most common types of tissue flap procedures are from the lower abdomen (called TRAM [transverse rectus abdominismuscle] flap or DIEP [deep inferior epigastric perforator flap]), and the latissimus dorsi flap, which uses tissue from the upper back. Other tissue flap surgeries described below are more specialized, and may not be done everywhere.
These operations leave 2 surgical sites and scars – one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but never go away. There can be donor site problems such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue’s blood supply, flap procedures can cause more problems in smokers, and in women who have uncontrolled diabetes, vascular disease (poor circulation), or connective tissue diseases.
In general, flaps require more surgery and a longer recovery. But when they work well, they look more natural and behave more like the rest of your body. For instance, they may enlarge or shrink as you gain or lose weight. There’s also no worry about implant replacement or rupture.
Abdominal flaps: TRAM and DIEP
The TRAM (transverse rectus abdominis muscle) flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). Some women, have enough tissue in this area to shape the breast, so an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower belly, or a “tummy tuck.”
There are different types of TRAM flaps:
- A pedicle TRAM flap leaves the flap attached to its original blood supply and tunnels it under the skin to the chest. It usually requires removing most if not all of the rectus muscle on that side, which means an increased risk of bulging and/or hernia on one side of the abdomen.
- A free TRAM moves tissue from the same part of the lower abdomen but doesn’t take very much muscle. The flap is completely disconnected and moved up to the chest. The blood vessels (arteries and veins) must then be reattached. This requires the use of a microscope (microsurgery) to connect the tiny vessels and the surgery takes longer than a pedicle TRAM flap. The blood supply to the flap is usually better than with pedicle flaps and the donor site (abdomen) often looks better. The main risk is that sometimes the blood vessels get clogged and the flap doesn’t work.
The DIEP (deep inferior epigastric perforator) flap uses fat and skin from the same area as the TRAM flap but does not use the muscle to form the breast shape. This results in less skin and fat in the lower belly (abdomen), or a “tummy tuck.” This method uses a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest. As in the free TRAM surgery, a microscope is needed to connect the tiny blood vessels. There’s less risk of a bulge or hernia because no muscle is taken.
TRAM flap incisions The tissue used to rebuild the breast shape
Donor tissue site for DIEP flap After DIEP flap
Latissimus dorsi flap
The latissimus dorsi flap tunnels muscle, fat, skin, and blood vessels from your upper back, under the skin to the front of the chest. This provides added coverage over an implant and makes a more natural-looking breast than just an implant alone. It can sometimes be used without an implant. It’s a very reliable flap and can even be used in women who smoke (smoking can delay healing). Though it’s not common, some women have weakness in their back, shoulder, or arm after this surgery.
Latissimus dorsi flap
Gluteal free flap
The gluteal free flap orGAP (gluteal artery perforator) flap is newer type of reconstruction surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It might be an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons, but it’s not offered in many areas of the country. The method is much like the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest. Like all of the free flaps, a microscope (microsurgery) is needed to connect the tiny vessels.
Inner thigh or TUG flap
A newer option for those who can’t or don’t want to use TRAM or DIEP flaps is a surgery that uses muscle and fatty tissue from along the bottom fold of the buttock extending to the inner thigh. This is called the transverse upper gracilis flap or TUG flap, and it’s only available in some centers. Because the skin, muscle, and blood vessels are cut out and moved to the chest, a microscope is used to connect the tiny blood vessels to their new blood supply. Women with thin thighs don’t have much tissue here, so the best candidates for this type of surgery are women whose inner thighs touch and who need a smaller or medium-sized breast. Sometimes there are healing problems due to the location of the donor site but they tend to be minor and easily treated.
Questions for Your Plastic Surgeon
- What types of breast reconstruction surgery can I have?
- Which type is best for me and why?
- When is the best time for me to have breast reconstruction — at the time of the mastectomy or later? Is there a time limit for having reconstruction done?
- How many procedures are involved in the type of reconstruction I am having?
- If I need to have radiation therapy after my mastectomy, how will that affect my reconstruction choices and cosmetic outcomes?
- How many of these procedures have you performed?
- Would you please show me photos of both your best and your more typical results?
- What are the chances of infection and failure with my reconstructive surgery? Are there any other risks or side effects to consider?
- What are the short- and long-term results with implant versus natural tissue reconstruction?
- Will I have a surgical drain in place when I go home? If so, how will I care for it? When will it be removed?
- Is there much pain after surgery?
- Will I have any numbness after the surgery?
- What side effects might I expect after surgery? What problems should I report to you right away?
- Where will the surgical scar(s) be?
- What body changes should I expect after surgery? How many hospital stays are needed? How long will each hospital stay be?
- How can I expect the reconstructed breast to look and feel? How will it look compared to my healthy breast?
- Will I be able to detect a possible return of cancer after reconstructive surgery?
- What breast cancer screening is recommended for me?
Using an implant to rebuild the breast requires less surgery than flap reconstruction, since it only involves the chest area (and not a tissue donor site). Still, it may require more than one procedure. It also may require additional surgery in the future, as implants can wear out and develop other issues, such as tightness of scar tissue around the implant.
The implant can be filled with:
- saline (salt water)
- silicone gel
- a combination of the two — silicone or vegetable oil in the outside chamber and saline on the inside
The implant is placed under the pectoral chest muscle. For implant reconstruction, the length of the surgery and your time of recovery are usually shorter than for flap reconstruction.
Implant reconstruction is also a good option if:
- You’d like to avoid incisions in other parts of the body (donor sites) or sacrificing the muscle structure in donor sites. Also keep in mind that the newest flap procedures preserve muscle and may be worth exploring if you’re concerned about this.
- You do not need radiation therapy. There is a high chance of developing problems in an implant reconstruction after radiation.
- You can’t or don’t want to endure a lengthier flap reconstruction operation.
- You are willing to surgically alter your healthy breast to achieve symmetry or balance. It is not always easy to match an implant, which has a fixed shape, to the remaining natural breast.
You may have implant reconstruction at the same time as mastectomy (immediate reconstruction), after mastectomy and other treatments (delayed reconstruction), or you might have the staged approach that involves some reconstructive surgery being done at the same time as mastectomy and some being done after (delayed-immediate reconstruction).
Implant reconstruction after mastectomy may be more difficult since the skin of the breast will have been removed. In this case, tissue expansion, or stretching of the remaining skin, would be attempted by your plastic surgeon. A surgery to insert a balloon-like expander would be performed, and the expander would be gradually filled with saline over the course of weeks to stretch the skin. Expanding skin this way can be difficult and sometimes doesn’t work, particularly after radiation because the skin is tough and resistant to stretch. Once expansion is complete, you have another operation to swap out the expander for the final implant. You and your surgeon can discuss what’s best for your situation.
Implant vs. flap reconstruction: Potential advantages and disadvantages
Advantages over flap
- shorter, less complex surgery
- uses the mastectomy incision for procedure (doesn’t create new scars)
- sometimes can be completed in one step
- easy to find qualified surgeons
Disadvantages vs. flap
- overall reconstruction process can take longer (multiple steps, multiple office visits to receive tissue expander injections)
- less likely to feel, look, or move like a natural breast
- subject to future problems such as rupture, deflation, capsular contracture
- opposite healthy breast often needs surgery to match the implant
- generally not a good option if skin has undergone radiation
- implant won’t last a lifetime
Source: Kathy Steligo, The Breast Reconstruction Guidebook: Issues and Answers from Research to Recovery (Baltimore: Johns Hopkins, 2012)
This is worth looking at for sure!
I think that may be enough quotes for the day, how about you?!