Breast Reconstruction

Who is a candidate?

Breast reconstruction refers to rebuilding breasts following cancer surgery, such as a mastectomy, or trauma. Even patients who undergo a limited mastectomy such as a segmental resection, or a lumpectomy, may be candidates for breast reconstruction.

Does insurance cover breast reconstruction?

Insurance companies are required to cover breast reconstruction following cancer.

What about the opposite breast?

Insurance companies are also required to cover surgery on the opposite breast in order to achieve symmetry. The opposite breast may require reduction, lift, or augmentation in order to match the reconstructed side, and these procedures are covered.

Immediate versus Delayed Reconstruction

Immediate reconstruction refers to reconstructive surgery done during the same surgery as the cancer resection. In other words, once the surgical oncologist is done with the mastectomy, the plastic surgeon starts the first stage of the breast reconstruction. This allows for one recovery for both procedures.

Different Types of Breast Reconstruction

The three main types of breast reconstruction are implant based reconstruction, autologous tissue flap, or free tissue transfer. The first thing to know about breast reconstruction options is that no matter what type of reconstruction you choose, rebuilding a breast and achieving symmetry with the opposite breast is a process that can take anywhere from 3 months to upwards of a year. The first step is reconstructing the breast(s) that had cancer. This can be a one or 2 surgery process. The next step is a procedure on the opposite breast to make it match the reconstructed side. The third step is either a touch up needed to make sure both breasts now match as closely as possible, or nipple reconstruction for the side without a nipple. The last step is nipple tattooing to restore the color to the nipple and areola.

IMPLANT BASED BREAST RECONSTRUCTION

Implant Based Reconstruction is a good option for women undergoing bilateral (or double) mastectomy, women who already have implants, thin women (with little bulk to possible donor sites for using their own tissue), and women who want to minimize downtime or have the quickest recovery possible. This is not as good of an option for patients who have undergone radiation therapy. The first step in this type of reconstruction is having a temporary device called a tissue expander placed under the pectoralis muscle on the chest. This type of surgery can be done with a one night stay in the hospital, or as an outpatient procedure with one night stay in an aftercare facility. Tissue expanders are inflatable devices that have a magnet and injection site or port. The expander can then be filled at your office visits by using an external magnet on the skin, and injecting sterile saline through the port. The amount injected per visit depends on many factors, including the condition of the skin overlying the expander, the final goal amount, and patient comfort. Expansions are usually performed either once a week or once every two weeks until the goal is reached. Often the goal amount is greater than the size of the implant to be used. This is because the tissue has its own properties that cause some level of contraction once the expander is removed. After the breast is allowed to settle, and the skin/muscle is allowed to relax to accommodate this new volume, a second surgery is performed to remove the expander and replace it with a breast implant. The implant chosen may be round or shaped. If the opposite breast needs to be addressed with a lift, reduction, or augmentation, it may be addressed at this surgery or a separate surgery. Once both breasts are at their final position, the nipple can be reconstructed, often using the skin of the breast. Three months after the nipple is reconstructed, it can be tattooed to match the opposite nipple areola color. If both breasts and nipples are being reconstructed, you can choose your final nipple areola color for both. Since the breast has been removed in a mastectomy, there is little to camoflouge the borders of the implant. In some cases, it helps to perform fat transfer to the breast along the upper border of the implant to provide a smoother contour.

AUTOLOGOUS TISSUE BASED RECONSTRUCTION

Autologous tissue based reconstruction means skin and tissue is taken from one part of the body, and rotated into position to create a new breast. Examples of this type of reconstruction include the pedicled TRAM (transverse rectus abdominus myocutaneous) flap, and the pedicled latissimus dorsi flap. For the TRAM flap, skin, subcutaneous fat, and rectus abdominus (abs) muscle, are taken from one side of the lower abdomen and tunneled below the skin and brought out at the breast to create a new breast mound. The advantage of this surgery is that there is no implant involved, and the tissue tends to hang in a way that resembles the natural breast shape. Another advantage is the flattening effect on the abdomen, since in order to close the donor site the abdomen is closed in a manner similar to a tummy tuck. The latissimus flap involves taking tissue from the back, and the incision is created in a way that the final scar can lay in the bra line. This flap typically gives a smaller volume, and if the goal volume for reconstruction is greater than a B cup, you may need an implant in addition to this flap. The recovery for this type of surgery typically involves 2-3 days in the hospital. In addition to risks at the breast, there are associated risks at the donor site also. In order to be a candidate for this surgery, there needs to be enough tissue at either the abdomen or back to create a breast, and this tissue cannot be previously operated on.

FREE TISSUE TRANSFER (FREE FLAP) BREAST RECONSTRUCTION

Free tissue transfer is different from the above options because it involves complete separation of skin and tissue from one area, including it’s blood vessels, and reattaching these vessels  to blood vessels in the chest under an operating microscope. This procedure takes significantly longer than the other techniques, and involves close postoperative monitoring and care, typically requiring at least one night stay in the intensive care unit. The total hospital stay tends to be around 5-6 days. The most common donor site for tissue is the lower abdomen, and different variations include the free TRAM flap, muscle-sparing TRAM flap, DIEP (deep inferior epigastric perforator) flap, and SIEA (superficial inferior epigastric artery) flap. Other less common donor sites are described, and include for example harvesting tissue from the buttocks. While both the operating room time and recovery time are the longest for this type of reconstruction, it does create natural appearing breasts and can transfer a significant volume of tissue. The reason for the early ICU care is to monitor the flap for problems with the blood supply (the flap turning purple or losing a Doppler signal that monitors arterial flow). If there is any concern for blood supply or drainage that threatens the livelihood of the flap, this requires an immediate return to the operating room for a second surgery to explore the flap and fix any issues that are found. There is a risk that the flap will not survive, and a new reconstruction needs to be performed. This does not happen commonly, but is always a possibility. In the more common scenario of the flap surviving and healing, the next step is any procedure on the opposite breast for symmetry, and/or adjusting or fine-tuning the shape and contour of the flap. At times fat transfer is performed to smooth out defects or add volume to create a smoother shape.

Which option is best for you?

This depends on a number of factors. First, you need to see what types of reconstruction you are a good candidate for. This depends on various factors including the stage of breast cancer, whether or not radiation is planned, how much tissue is removed, the goals of reconstruction, and time from chemotherapy. When it comes to breast reconstruction, patient preference is of utmost importance. Often patients are candidates for more than one type of reconstruction, and the preference on time in the operating room, recovery process and time, length of scars, risks and benefits of each type surgery, and goals with the opposite breast all help in coming up with what procedure is best for each individual. The type of surgery that was best for your friend may not be what is best for you. This is a very personal decision, and should be made after weighing all of the options.