Understanding your options for breast reconstruction

In 1985, October officially became breast cancer awareness month to support and promote widespread use of mammography for breast cancer screening. Now, more than thirty years later, with advances in technology and pharmaceuticals, we have seen dramatic improvements in breast cancer detection and survival. Breast reconstruction after breast cancer treatment, in turn, has evolved in concert with increasing breast conservation, and advances in microsurgical techniques have allowed plastic surgeons the ability to offer a myriad of different reconstructive options for optimal results.

Just as breast cancer treatment has become more individualized, options for reconstruction acknowledge that goals for reconstruction for one patient may not be the optimal reconstruction for another. For optimal care, education and access are priorities and cannot be taken for granted. Even with the widespread use of internet searches and online communities, which serve as invaluable sources of knowledge and shared experiences, it's more common than not for patients to present with little to no knowledge of their reconstructive options or the timing of reconstruction as it relates to therapy and recovery.

When we talk about breast reconstruction, we are often referring to reconstruction after mastectomy for breast cancer. In 1995, breast reconstruction rates were reportedly as low as 8%. We have seen that national average rise to somewhere around 60%, with benefits of reconstruction including improved body image, self-esteem, sexuality and quality of life. We have attempted to briefly outline some of the most common reconstructive options and address common questions and misconceptions below.

Implant-based reconstruction

Most patients choose to have implant-based reconstruction. In 2002, implants surpassed autologous tissue as the more common reconstructive approach. In our hands, with new generation silicone implants, aesthetic results are excellent. This approach usually, but not exclusively, starts with a tissue expander placed partially or fully under the chest muscle and occurs in stages.

Options for well-selected patients can include immediate placement of the final implant or placement of the expander above the muscle (prepectoral) in conjunction with acelluar dermal matrix. In general, the expansion occurs in the office over a period of weeks to months, followed by a second stage with removal of the expanders and replacement with implants. This is often combined with fat grafting, a method where liposuction is used to harvest fat for transplant to the breast for improved symmetry and tissue coverage.

Nipple reconstruction can also be undertaken, techniques of which include the options of skin grafting for areolar reconstruction, surgical reconstruction of the nipple mound and/or 3D tattooing, all of which can give realistic and aesthetically pleasing results.

Autologous tissue-based reconstruction

The other option for total mastectomy reconstruction is autologous tissue-based reconstruction. In other words, this technique is using one's own tissue for breast reconstruction. This traditionally meant taking the back muscle (latissimus) or the abdominal muscle (TRAM) and rotating it with skin and fat onto the chest to recreate the breast mound. With improvements in microsurgical technique, tissue from nearly every part of the body can now be used for autologous reconstruction.

The principle behind all microsurgical breast reconstruction is similar; the tissue to be used for breast reconstruction is isolated on its blood supply, and with the assistance of a microscope, reconnected to blood vessels in the chest. The most common donor site is the abdomen, referred to as DIEP (deep inferior epigastric perforator) breast reconstruction. This technique can be useful in obtaining a more natural look, especially in scenarios where the breast is larger or the nipple is lower hanging (ptotic). This technique often obviates the need to use an implant at all, and patients often refer to it as a "natural" reconstruction, in both feel and appearance. Sometimes, we even reconnect nerves to give sensation to the reconstructed breast with this method. It is also the preferred modality in the setting of radiation, although the majority of patients that undergo reconstruction with an implant have a good result.

The need for a donor site means there is another scar, the operation itself is longer and more involved, and recovery involves a hospital stay of at least 2-3 days and a recovery period that can last a few months.

Oncoplastic breast surgery

When cancer surgeons talk about surgery to treat breast cancer, often their goal is breast conservation. In fact, 70-80% of all breast cancers are treated with breast conservation therapy (lumpectomy +/- radiation). Although this approach allows for preservation of breast tissue, subsequent lumpectomy defects can be deforming. In cosmetic breast surgery, we have a multitude of different techniques to reconfigure the breast into an ideal shape and position. This can include volume reduction, lifting and tightening procedures.

Using these skills and principles to plan cancer excision is often referred to as oncoplastic breast surgery and can allow for resection of the cancer and reshaping of the breast at the same time. Volume-replacement techniques with tissue rearrangement can restore symmetry, while volume displacement techniques in conjunction with contralateral breast lifts can restore ideal shape and nipple position.

In each clinic we ask ourselves, what will it take to make our patients feel whole again? The answer is that it takes something different for every patient, and board-certified plastic surgeons are trained to offer this individualized care that patients deserve. The landscape of breast reconstruction is changing. Options are increasing, and while this can increase the complexity of the decision-making process, it also allows us to personalize the reconstructive plan based on the goals and wishes of the patient. This patient-centered, multidisciplinary approach to breast cancer care, with cure of disease and restoration of self, is the ultimate goal.