- Should I have a reconstruction?
- Types of reconstruction
- How will the operation affect me?
- Can a breast reconstruction hide a cancer?
- Sexuality and breast reconstruction
- Pregnancy and breast reconstruction
- Financial issues
- Information checklist
Breast reconstruction is the surgical rebuilding of a breast. It can be done at the time of, or at any time after, a mastectomy (breast removal).
After having a complete mastectomy, there are various choices available. Reactions to the loss of a breast or breasts vary from woman to woman and only you can choose what feels best for you. You might feel quite comfortable wearing an external prosthesis; an artificial breast worn inside your bra. A good prosthesis not only helps with your appearance but also helps you to maintain your posture and balance. Many women choose this option. Others choose not to wear prostheses at all and still others choose to have a reconstruction.
Some women feel less confident and less feminine after a mastectomy and can become depressed. Some women find that wearing a prosthesis is both uncomfortable and a nuisance. These problems are often short-lived but sometimes they persist. Breast reconstruction can overcome some of these difficulties.
A breast reconstruction will require more surgery, extra time in hospital and extra time at home for your recovery. It may also involve additional costs. As with all operations problems may occur and there is no guarantee of a good result. In making your decision about reconstruction, you must weigh up the advantages and disadvantages for yourself.
There are different opinions about the best time for reconstruction. It can be done at the time of the mastectomy, some months afterwards or even years later.
The timing may depend upon the type of breast cancer you had, whether you need further treatment (for example, chemotherapy), how you feel about the loss of your breast or breasts, your general health and other concerns, such as the cost. Talk over these issues with your breast surgeon and plastic surgeon until you understand their advice. Ask for a second opinion if you would like one.
Breast reconstruction is a specialised form of surgery and you should talk it over with your breast surgeon first. Although most women are able to have a reconstruction, your surgeon may advise against it. This might be because of the type of breast cancer you had, because you need extra therapy, because of your general health, or because of the type of treatment you have undergone.
If a reconstruction is possible, your own breast surgeon may have the expertise to do this or they may refer you to a plastic surgeon. Ask to be referred to a plastic surgeon who is an expert in breast reconstruction. Make sure that he or she is a Fellow of the Royal Australasian College of Surgeons and a member of the Australian Society of Plastic Surgeons. Sometimes it is helpful to get a second opinion from another breast surgeon or plastic surgeon. They may suggest another method of reconstruction for you. Ask your surgeon or GP about a second opinion if you want to. Don’t feel awkward about it, it is your right to ask for one. In the end it is very important that you feel comfortable with, and have trust in, your surgeon.
You may also find it helpful to talk with a woman who has already had a breast reconstruction. Cancer Council SA can put you in touch with a woman who has undergone a breast reconstruction or you can ask your surgeon. A breast care nurse or counsellor at your hospital or local community health centre may also help you think through the issues.
Other people may offer you advice. Family and friends may be helpful, but some might try to discourage you from having a reconstruction because they think you have been through enough already. Others could pressure you to have a reconstruction when you are not yet ready. It is important for you to make your decision in your own time. There is never any urgency to make a decision concerning reconstruction.
In implant reconstruction, an implant is placed under the skin to recreate the shape of the breast. In flap reconstruction, skin, fat and muscle are taken from elsewhere on the body to make the new breast.
Each type can be achieved by several different methods, some more difficult – both surgically and for the woman to undergo – than others. Some reconstructions involve two or more operations several weeks or months apart. Flap reconstruction is a larger operation with higher risk of complications.
Your plastic surgeon will discuss the different methods with you and recommend the one that is best for you. This will depend upon:
- the amount of tissue that has already been removed
- scars from previous operations or radiotherapy
- the quality of the remaining skin
- factors such as your general health and the build of your body
- whether you smoke: this affects the type of flap that can be done
- the preference of the surgeon
- your preference.
Make sure that you understand why your surgeon is recommending a particular method and ask to see photographs of women who have had a reconstruction using this method.
Specialists and other health professionals who care for women undergoing a breast reconstruction include:
- breast surgeons—specialise in performing surgery on the breast, including mastectomies and reconstructions
- plastic surgeons—reconstruct or restore to near-normal, appearances and functions in people who have been injured, disfigured or scarred
- anaesthetists—administer an anaesthetic before an operation.
- breast care nurses—advise patients about all aspects of caring for their breasts, including pre- and post-reconstruction counselling
- occupational therapists, physiotherapists and social workers—advise you on support services and help you get back to normal activities.
Breast implants are made from a silicone (plastic) envelope and filled with either silicone or saline gel. They are used not only for women who have had mastectomy but also for cosmetic breast enlargement.
There are advantages and disadvantages in using implants in breast reconstruction. There are also some specific problems related to each type of implant.
The main advantage in using an implant in reconstruction is simplicity, both surgically and for the woman. An implant reconstruction takes less time and is less complicated than other types of reconstructions. The implant can be used to create the shape of the new breast without having to bring tissue (muscle, skin or fat) from elsewhere in the body. There is a shorter recovery time and the woman is left with only one scar.
Implants come in a range of sizes and shapes. Pear-shaped implants that are designed to best match the remaining breast are now available. The main disadvantage of an implant is that it involves placing ‘foreign’ material within the body and the body will respond to this by creating a ‘capsule’ of scar tissue around the implant.
In making your decision about whether to have an implant, it will help to weigh up the advantages and disadvantages of the different types of operations. Your decision may also depend on the way you feel about having something foreign in your body. Some women are comfortable with this idea, while others will prefer not to have one, even if it means having a more complicated breast reconstruction.
You will need to discuss the use of an implant and possible problems with your plastic surgeon or GP. You may also find it helpful to talk with someone who has had a breast reconstruction using an implant.
Silicone breast implants are a silicone envelope containing silicone gel. Silicone gel is a soft jelly-like substance and these types of implants tend to be softer and have a more ‘natural’ feel to them than saline implants.
There has been some controversy surrounding the use of silicone implants. They were withdrawn from the US market (not from the Australian market) for a period of time because of concerns about the effects of silicone if it was to leak outside the ‘capsule’ that the body has created around the implant. Modern implants are made of a cohesive gel that holds its shape if the shell breaks. Discuss any concerns you have about silicone implants with your plastic surgeon.
Saline breast implants are used for some forms of breast reconstruction. These implants have a solid silicone envelope containing salty water. If they break, the saline released into the body is not harmful. However the long-term safety of saline implants is still being evaluated.
Although they can give a good breast shape and feel, they are not quite as lifelike as silicone gel implants. Problems such as wrinkling of the skin around the new breast and ‘sloshing’ may also occur. A saline implant may deflate without warning or it may wear out. In both circumstances it will need to be replaced.
How is implant reconstruction done?
- After the mastectomy.
- With a tissue expander to stretch the skin.
- After a permanent implant has been inserted.
If you have healthy chest muscle and enough skin to cover an implant, a breast implant can be inserted under the chest muscle. The implants come in various shapes and sizes. The plastic surgeon will choose one that best matches your own breast.
With this method of reconstruction, the mastectomy scar is usually
re-opened to allow the implant to be put in.
Inflatable tissue expander
If you don’t have enough skin to cover an implant, an inflatable tissue expander can be used to stretch it.
The expander, a balloon-like bag, is placed under the skin, either at the time of the mastectomy or during a small operation, under anaesthetic, some time later. Once the skin has healed the balloon is gradually filled by injecting it with saline. These injections are given every couple of weeks until the new breast is about the same size as the other breast. Another small operation is then performed to remove the filling tube and injection point. If a temporary expander is used, it will be replaced with a permanent implant.
This method results in less scarring than the more complex flap reconstruction methods but the regular saline injections can cause discomfort for a few days afterwards. Check with medical staff about suitable pain relievers.
The texture and feel of a breast reconstructed using tissue expansion methods is unlikely to be normal; it may be firmer than your other breast or it may not ‘fall’ naturally.
If you have larger breasts or do not have enough skin to cover an implant, one of several flap methods may be used. They are named after the various muscles used in the reconstruction.
These methods use muscle and skin from other parts of the body to build a new breast, which avoids some of the problems that can occur with implants. Once the reconstruction has successfully healed, it is permanent. However the surgery takes a longer amount of time, there is greater risk of infection, there is greater recovery time and you will be left with more than one scar. After reconstruction there is a loss of feeling; discuss this with your surgeon.
Latissimus dorsi reconstruction
The latissimus dorsi is a broad, flat muscle on the back below the shoulder blade. With this method, the latissimus dorsi muscle and some skin are surgically moved to the chest. An implant may be required under the flap to make your breast large enough to match the remaining breast but there is no need in this situation for a tissue expander, and the reconstruction, apart from the nipple, can be completed in one operation.
After surgery, you will have an oval-shaped scar on your new breast and a straight scar on your back. The scar on the back may be covered by a bra.
- After a mastectomy.
- The muscle flap from the back brought around to make a new breast. Nipple made from the nipple on the other breast.
- Five years later the skin from the back has faded.
- Five years later and the scar on the back has faded.
- Wearing clothes it is hard to see the difference between the two breasts.
Rectus abdominis reconstruction (TRAM flap)
One of the pair of long, flat stomach muscles, called the rectus abdominis, is used for this reconstruction method. The plastic surgeon moves the muscle, along with some of the local skin and fat, to the chest area where it is shaped into the form of a breast.
About two weeks before the main operation, a smaller operation may be advised, particularly for women with larger breasts. The aim of the smaller operation is to improve the blood supply to the tissue that will be made into the new breast.
There are two ways in which a TRAM flap reconstruction can be done.
- Pedicle TRAM flap method – in this method the muscle is left attached to its blood supply and ‘tunnelled’ under your upper tummy skin to the breast. Maintaining these blood vessel connections is called a ‘pedicle’. A reconstruction done in this way takes approximately three to four hours and usually requires three to four days in hospital.
- Free TRAM flap method – in this method the plastic surgeon uses microsurgery to completely divide the muscle and the blood vessels and re-attach them to the vessels in the chest or under the arm. This method can be better at recreating a larger breast and makes it easier for the plastic surgeon to shape the breast, giving a more accurate final result but it is a more complicated and longer operation requiring special facilities.
A free TRAM flap operation takes approximately five to seven hours and requires up to one week in hospital.
The removal of the abdominal muscle in a free TRAM flap operation can weaken the abdominal wall, which can result in a hernia. To reduce the risk of problems of this kind occurring in the future, the surgeon will insert a special mesh into the abdomen to replace the muscle. Complications following a microsurgical free TRAM flap can also include blood clotting and loss of circulation to the flap. For this reason it is strongly advised that women quit smoking before undergoing this operation.
With both methods of TRAM flap reconstruction, heavy lifting – including lifting small children – should be avoided for about six weeks. Both methods will cause a tightening of the abdomen similar to a ‘tummy tuck’ operation.
TRAM flap reconstructions leave a long scar across the hip area below the waist. There will also be a scar on the new breast, and no feeling in the skin transferred to the new breast. Before undergoing a flap reconstruction the plastic surgeon may take some blood in case you require a blood transfusion during surgery.
Secondary procedures are usually required to get the flap in the correct position.
- After the mastectomy.
- After reconstruction using the TRAM flap.
- Three years later the breast has begun to droop.
- The reconstructed breast after a 'tuck' to make it a bit firmer. The abdominal scar has faded.
- The final result.
After having a breast reconstruction, some women choose to have their nipple rebuilt as well. This includes rebuilding the nipple itself and the surrounding area called the areola.
Nipple reconstruction is usually a small operation and can be done in a number of ways. Tissue for a new nipple can be taken from the remaining nipple or a new nipple can be tattooed to match the colour of the opposite one.
Instead of having a nipple reconstruction, some women prefer to use special ‘stick-on’ nipples. These stick on to the skin and will stay in place for several days. Because the new breast may sag slightly in the weeks following surgery, nipple reconstructions are generally not performed until at least three months after a breast reconstruction.
For many women, the small differences between their remaining breast and the reconstructed breast are not noticeable when they are wearing a bra. For others, particularly large-breasted women, the difference in size may be quite noticeable. Some women decide to have the remaining breast made smaller through surgical breast reduction. This can improve balance and posture.
Because of their particular type of breast cancer, some women may also be advised to have a subcutaneous mastectomy on their other breast. Some breast surgeons favour this procedure - which involves the removal of the majority of the breast tissue, leaving the skin and a thin layer of tissue for reconstruction - believing it will prevent cancer occurring in the remaining breast. Other surgeons are opposed to the procedure, believing there is not sufficient clinical evidence to support removing a healthy breast. Discuss this issue with your doctor and seek a second opinion if you have any concerns about the advice you receive.
The effects of the operation depend a lot on the type of reconstruction. Two or three operations are usually necessary. Some women find they are back to normal very quickly while others find it takes several weeks to recover at home.
Most operations carry some risk of blood loss, infection, pain and/or blood clot formation in the leg. Transfer flap surgery carries a higher risk of these complications than implant surgery, as well as a risk that the flap may not survive the procedure.
The main operation for a breast reconstruction usually requires you to spend two to ten days in hospital. A general anaesthetic will be used and you will feel some discomfort afterwards. If you have had a flap reconstruction, you will also be sore in the area from where the muscle was taken as well as in the breast area. You can take pain relievers to control any discomfort. You will probably have a small tube inserted into the operation site to allow fluid to drain away. This will be removed after a few days.
Sometimes it is necessary to be careful when moving around immediately after the operation, to help the healing process. Ask your plastic surgeon about this.
As with all operations, recovery will take longer if problems occur. These might be related to the anaesthetic, to infection or with healing. You should be aware of possible problems and discuss them with your plastic surgeon or breast care nurse before the operation, so that you can make the necessary arrangements for your work, home-help or child care.
Your plastic surgeon will continue to care for you until your body has healed properly. Then your usual check-ups with your breast surgeon will continue. Once healed your reconstructed breast will not need any special care or attention.
Differences between your breasts
Most women are very pleased with the results of their reconstruction. Remember however that it is not possible to make an exact copy of your remaining breast. Sometimes there will be differences in the size, shape or position of the two breasts.
If your weight changes, you may find that one of your breasts changes in size while the other one stays the same.
You may also find differences in the feeling of your breasts. Your reconstructed breast may feel either numb or extremely sensitive. You may also suffer some loss of feeling if you have had surgery to your remaining breast (for example a breast reduction).
Excess scar tissue
If a breast implant has been used, a ‘capsule’ of scar tissue will form around it. If this becomes thick over time it may make the reconstructed breast feel firm. This condition is called a capsular contracture. It can be uncomfortable and may change the shape of the implant. For some women this may be very painful. Further surgery may be needed and sometimes the implant has to be removed.
Occasionally there may be healing problems within the first week or so after surgery for a breast reconstruction. These can be caused by infection or problems with an implant. Any infection must be treated and, if an implant has been used, it might have to be taken out. It may be possible to insert a new implant later on.
Sometimes shortly after the operation, extra blood collects around the wound. This is called a haematoma. It causes swelling and pain and may need to be surgically removed.
Most women who have a flap method reconstruction are able to carry on their usual activities without difficulty once they have recovered from the operation. Occasionally a breast reconstruction can result in muscle weakness. For example, women who have had a TRAM flap reconstruction may notice some weakness when bending at the middle, perhaps when getting up from a low chair.
As implants are made of a type of plastic they will not last forever. At some stage they may develop a leak or ‘rupture’. This may be due to unusual pressure on the implant, for example, an accidental blow to the breast.
With saline implants the implant will immediately collapse after a rupture but replacement with a new implant is possible, usually involving day surgery or perhaps an overnight stay. With silicone implants the silicone gel is often contained within the body’s capsule of scar tissue and it may not be possible even to tell if the implant is ruptured. If the silicone leaks outside the capsule it tends to cause a lump which may be painful. Usually if the implant is known to have ruptured, it is surgically replaced. The average time after which an implant will rupture is thought to be around fifteen years but can vary considerably. Many women have had implants in place for 25 years without sign of rupture. Cohesive gel implants address some of these issues.
All people heal differently and the final appearance of a scar will vary from person to person, even if the surgery is the same. Most scars have a thickened, red appearance early that peaks at around three months and resolves slowly over time.
Sometimes the scar will stay thick for a long time and can become itchy and uncomfortable. Treatments are available to help with this. Scars may be surgically improved later on.
Many women are concerned about the possibility of a reconstruction hiding a recurrence of cancer.
This is very unlikely because most recurrences of the cancer occur in the skin or in the tissue just under the skin. If a flap method of reconstruction is used, any recurrence would usually only occur in the skin that belonged to the original breast. This would not be hidden by the flap used to make the new breast.
If a breast implant is used it is placed beneath the chest muscle. Again it should not be difficult to detect a recurrence.
Having a reconstruction after a mastectomy for cancer does not affect your chances of a long-term cure. After reconstruction it is a good idea to examine both your breasts every month. Your GP will also check you regularly and will advise you about how often you need to have a mammogram. Special techniques may be required so the mammogram will be at a hospital breast clinic or radiological practice rather than at BreastScreen.
The removal of a breast due to breast cancer may affect how you feel about yourself and your relationships. Some women may feel they are less sexually attractive to their partner. Having a breast reconstruction, for some women, can be a way of helping to retain their sense of being a woman after a mastectomy. Share your feelings with your partner. If you do not have a partner or are worried about forming new relationships, it can help to talk about how you feel with a breast care nurse. Call Cancer Council Helpline 13 11 20 for information and support.
Breast reconstruction should not interfere with a woman’s normal sexual activity, however sensitivity in the reconstructed breast will not be the same as it is in the remaining breast. It may be some time until you feel you are ready for sex. It will help if your partner can provide reassurance. You may need to build up your confidence gradually. Talking about your needs together is important to help you feel more confident and to reduce any fears.
If you find that you are having difficulty resuming your sexual relationship, you may need specialist help and advice. You may want to talk with your general practitioner about this or ask for advice on where you can get help.
Whether or not to become pregnant after breast cancer, and if so when, is an issue for many women. Always discuss this with your oncologist.
Pregnancy after a breast reconstruction is possible with little or no physical limitations, regardless of the type of reconstruction undergone. An implant reconstruction does not affect the abdominal wall muscles, therefore pregnancy can proceed as usual. Pregnancy after a flap reconstruction is still possible with few physical limitations, despite it being a more complicated operation. Mesh implanted into the abdominal wall during a TRAM flap operation is designed to support the abdominal wall muscles and will help to decrease the risk of developing a hernia as a result of pregnancy. Always discuss the issue of pregnancy after breast reconstruction with your plastic surgeon.
Breastfeeding is not possible with the reconstructed breast. Most women can successfully breastfeed with their other breast. A breast care nurse can advise you about any concerns you have about breastfeeding after a reconstruction.
Make sure you know how much it will cost you to have a breast reconstruction. Check with your surgeon, your hospital, Medicare and your private health fund before deciding to go ahead.
Reconstruction after a mastectomy is regarded as a medical procedure, not a cosmetic one. This means that, through Medicare, the cost may be covered completely for a public patient in a public hospital. However there may be some extra charges if an implant is used. There may be some other charges for private patients in a public hospital. Because of the demand for public hospital beds, you may have to wait for your operation. Check this with your GP.
If you don’t want to wait so long and want to choose your own plastic surgeon, then you will need to be covered by private health insurance or be prepared to pay the extra costs yourself. If you already have private health insurance, check what you are covered for before deciding to go ahead with the surgery. Your insurance may not cover the total cost.
If you don’t already belong to a private health fund but decide to join one before your operation, remember that the reconstruction is the result of a ‘pre-existing illness’. You will need to wait the full qualifying period before you can make a claim. Sometimes this is as long as a year. Check this with the various funds before deciding which one to join.
Whether or not you have insurance, check what costs are involved. In a private hospital Medicare will cover some of the surgeon’s and anaesthetist’s fees and you will be able to claim an extra benefit for these through your private health fund. Part or all of the cost of the tissue expander and any permanent implant should also be covered by your private health insurance.
Each hospital has its own charges and you must check these too. The rebate you get depends on which private fund you belong to and which level of cover you have paid for. Financial assistance may be available. Contact the social worker at your hospital or call Cancer Council Helpline 13 11 20 to find out more about financial assistance.
Having a breast reconstruction is a matter of personal choice that can involve a great deal of thought and discussion. Take time to get a good understanding of what a reconstruction involves and make sure that you have realistic expectations of the end result.
Use this information checklist to help you think through the questions you need answered. Talk to your GP, plastic surgeon and breast care nurse until you are sure you know what is going to happen and how it will happen.
If you are unsure about something, feel confident enough to ask for a second opinion. If you have carefully thought about the issues involved and sought answers to all your questions, then you are in the best possible position to make your own decision.
You may find the following checklist helpful when thinking about the questions you want to ask your doctor about breast reconstruction.
- Do you think I can have a reconstruction?
- When would you advise me to have the reconstruction?
- What type of reconstruction do you advise for me and why?
- What are the possible problems with this type of reconstruction?
- How long will I be in hospital and how long will it take me to recover at home?
- How much will it cost? Am I covered by Medicare? Am I covered by my private health fund?
- What will the new breast look and feel like?
- May I see photos of other women who have had this type of reconstruction?
- I’d like to talk with another woman who has had a similar operation. Do you know anyone I can talk to?
- Will the operation hide any new problems that may arise?
- How can I get a second opinion?
- Do I need to have a mammogram on the reconstructed breast?
If there are answers you do not understand, feel comfortable to say ‘can you explain that again’ or ‘I am not sure what you mean by...’
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