What is breast reconstruction after Mastectomy?

Those who have a mastectomy, the surgical removal of one or both breasts, may choose to have the removed breast reconstructed. Some women decide against having a breast reconstructed and may elect to have the mastectomy site closed flatly.

Breasts can be reconstructed using implants or the patient's own tissue, or a combination of both.

Reconstruction surgery can be performed (or continued) at the time of the initial mastectomy, termed immediate reconstruction, or it can be postponed until months or even years later, a process referred to as delayed reconstruction.

The final step in any breast reconstruction is to recreate the nipple and areola, if they were not saved during the mastectomy.

Sometimes the other breast is also reconstructed to a similar size and shape so that both breasts are matched.

How do surgeons perform implants to reconstruct a woman's breast?

An implant is placed beneath the skin or chest muscles as part of a two-step procedure. In the first step, a tissue expander (a pocket formed by placing a balloon-like device under the skin and/or chest muscles) is placed under the skin left after the mastectomy or under the chest muscles. At routine clinic appointments, the tissue expander is progressively inflated with air or saline solution until it achieves the required size.

In the second step, the expander is removed and replaced with a permanent implant. The tissue surrounding the expander needs to be stretched to accommodate the implant; this usually takes two to six months after the expander is placed.

The placement of an implant can sometimes be done at the time of the removal of a breast, if no tissue expander is placed.

It is becoming more common for surgeons to use a cellular dermal matrix to "tension" tissue expanders and implants during breast reconstruction surgeries. This matrix is a type of mesh usually derived from human or animal skin, purified to remove cells that might cause rejection or infection.

How do surgeons perform breast reconstruction using a patient's own tissue?

Using tissue from a woman's own body to reconstruct her breast, also known as autologous tissue reconstruction, allows surgeons to replace the skin, fat, and blood vessels taken out during a mastectomy with skin, fat, and blood vessels from another part of the body. These are termed flaps because they consist of tissue moved from one area to another.

Tissue can be removed from many parts of the body, but most often comes from the abdomen or back. Sometimes, it is taken from the thigh or buttocks. Flaps can be either pedicled or free.

Pedicled flaps have blood vessels that allow blood to continue to flow to the moved tissue. In contrast, free flaps, also known as transferred flaps, have their blood supply cut off and then reconnected to blood vessels in another part of the body through a specialized surgical technique called microsurgery. There are several variations of free flaps, while pedicled flaps are generally attached to muscles.

Several different autologous tissue breast reconstruction methods are currently available. These methods differ in the location and type of tissue removed from the donor site.

These methods include:

• DIEP flap: The tissue comes from the abdomen, including skin, blood vessels, and fat, but not muscle. This is a free flap.
• Latissimus dorsi (LD) flap: The tissue comes from the middle and lower part of the back. This flap can be used as a pedicled flap for breast reconstruction (as well as reconstruction in other parts of the body, including the abdomen and head and neck); it can also be used as a free flap.
• SIEA flap (also called SIEP flap): Similar to a DIEP flap, the abdominal tissue does not require the removal of any muscle and has a distinct set of blood vessels; it is a free flap. Because of the challenges associated with this flap, it is rarely used for breast reconstruction.
• TRAM flap: The tissue comes from the lower abdomen, similar to a DIEP flap, but with the addition of muscle. This flap can be used as a pedicled or a free flap.

The tissues for reconstruction are taken from other areas, including the thighs and/or buttocks for patients who do not have enough abdominal tissue available or have had abdominal surgeries in the past that make autologous tissue reconstruction from that area unfeasible. Flaps from the thighs and buttocks are generally free flaps.

• IGAP flap: The tissue includes skin, blood vessels, and fat that is derived from the buttocks.
• PAP flap: Muscle-free tissue is taken from the upper part of the inner thigh.
• SGAP flap: Just like the IGAP flap, except the blood vessels are different and the tissue is from the buttocks.
• TUG flap: The upper inner thigh provides the muscle and tissue.

Sometimes, an implant and a flap are used together. For example, when a flap is taken from the thigh or buttocks, an implant is often used as well, given the volume required to reconstruct a breast adequately. In other circumstances, reconstruction with a flap may be utilized to provide coverage for an implant when there is insufficient tissue available after a mastectomy to allow for expansion and implant placement.

How do surgeons reconstruct the areola and nipple?

Once the chest has healed from reconstruction surgery and the reconstructed breast mound has settled within the chest, the nipple and areola can be reconstructed using either surgical means or tattooing.

For surgical reconstruction of the nipple, small sections of skin from the reconstructed breast are cut out and rearranged to form a new nipple. Several months later, the areola can be surgically recreated using tattoo ink.

Another option for surgical areola reconstruction is to take skin grafts from the groin or abdomen and graft them to the reconstructed breast at the same time as the nipple surgery (1).

Alternatively, some women may want to consider having a tattoo artist with special training in 3-D nipple tattooing create a new areola/nipple complex. The tattoos can look very natural, but the reconstructed nipple would not be functional.

Some women may elect to have their existing nipples and areolae saved, a procedure called nipple-sparing mastectomy. This is an option for women who are candidates for it based on their tumor type and location and the overall shape and size of their breasts.

What factors determine eligibility for immediate vs. delayed breast reconstruction?

One of the most common reasons women consider delayed reconstruction is the potential need for radiation therapy after their mastectomy. Radiation therapy can cause complications for reconstructed breasts, including delayed wound healing and/or infections. As such, some women may defer breast reconstruction until after any radiation treatments have been completed.

However, with advances in surgical and radiation treatment techniques, immediate reconstruction using implants is now considered a viable option for women who require radiation therapy. Breast reconstruction using the woman's own tissue is generally scheduled after radiation therapy is completed, so that the radiation-injured tissue in the chest wall is replaceable with healthy tissue.

Even if a woman is eligible for immediate reconstruction, she may choose to have delayed reconstruction, for a variety of reasons. Some women may wish to wait until after their mastectomy and any additional treatment has been completed before making any decisions about breast reconstruction. Women considering delayed reconstruction (or forgoing reconstruction entirely) can consider using external breast prostheses, also called breast forms, to simulate the appearance of normal breasts.

How do you choose the right type of breast reconstruction procedure?

Various factors can influence a woman's decision about which type of reconstruction to pursue. Among the various considerations are the size and shape of the reconstructed breast, a woman's age and/or medical history, any prior surgeries, and/or risk factors for complications following surgery (e.g., history of smoking and obesity). In addition, a woman's eligibility for reconstruction using her own tissue can also play a role in influencing her decision.

Other considerations that can play a role in determining which type of reconstruction a woman chooses include the location of her tumor(s) and the extent of her breast cancer. Women who have undergone prior abdominal surgeries may not be eligible for abdominal flap reconstruction.

Each woman has to weigh various considerations when deciding which type of breast reconstruction is best for her. Below is a summary of the most common considerations for each type of reconstruction.

Considerations for Reconstruction Using Implants

Surgery & Recovery

• Enough skin and muscle must be present after the mastectomy for the implant to be covered.
• Surgery is less invasive than flap surgery, with little blood loss during recovery.
• Shorter surgical procedure than with flap reconstruction.
• Shorter length of hospital stay than with flap reconstruction.
• Fewer complications than with flap reconstruction.

Possible Complications

• Infections.
• Swelling due to fluid buildup resulting in the formation of masses (seroma) within the reconstructed breast.
• Accumulation of blood resulting in the formation of masses (hematoma) within the reconstructed breast.
• Blood clots.
• Implants "extruding".
• •Implant leakage (implant leakage with fluid/silicone from inside the implant).
• Contractures (formation of tough scar tissue around the implant).
• Being obese, having diabetes, and smoking predispose to the development of complications.
• Very rare complication of breast implant-associated anaplastic large cell lymphoma, usually occurring in textured implants.

The following very rare complications have been reported with implants:

• Development of squamous cell carcinomas and lymphomas in the scar tissue around the implants.

Other Considerations

• May not be an option for patients who have received radiation to the chest wall.
• May not be suitable for patients with big breasts.
• Will not last a lifetime; implants will have to be either replaced or removed after some years.
• Saline implants don't feel as natural as silicone implants.
• FDA recommends periodic MRIs for women with silicone implants to check for silent ruptures.

Considerations for Reconstruction Using a Woman's Own Tissue

Surgery & Recovery

• Surgery is longer than that for implants.
• Surgery is generally outpatient; however, recovery may be longer than with implants.
• Pedicled flap reconstruction is usually a shorter surgery than free flap reconstruction, and generally requires a shorter length of hospitalization.
• Free flap reconstruction is a complex surgery that requires a surgeon trained in microsurgery to reconnect blood vessels.

Possible Complications

• Necrosis (tissue death) of the flap.
• Increased risk of bleeding and blood clots compared to implant reconstruction.
• High risk of complications in patients with obesity, diabetes, and tobacco use.
• Pain and functional limitation at the donor site.

Other considerations

• Natural appearance and feel.
• Softness and natural appearance/feel.
• Scar at the donor site.
• Can be used in patients treated with radiation therapy (due to superior tissue quality).

Those who undergo mastectomy for breast cancer will experience some degree of loss of sensation in their chest/nipple area due to the disruption of sensory nerves during the mastectomy. However, they generally experience partial restoration of sensation over time due to nerve regeneration. Advances in surgical technique will also contribute to improved sensory recovery for women undergoing breast reconstruction.

Any reconstruction surgery for the breast is associated with an increased risk of complications, including the failure of the implant or flap. If an implant fails, it is generally removed and replaced with another reconstruction method.

Will my health insurance cover breast reconstruction?

A federal statute known as the ‘Women's Health & Cancer Rights Act (WHCRA) of 1998 requires insurers and group health plans that provide coverage for mastectomy to also pay for reconstructive surgery after the procedure. This includes all stages of reconstruction and surgery to create symmetry between the breasts, breast prostheses, and treatment of any complications associated with the mastectomy, including lymphedema. Some non-profit insurers, particularly those affiliated with religious organizations, and government employers may be exempt from this law. Additionally, the WHCRA does not apply to Medicare or Medicaid; however, Medicare may cover breast reconstruction surgery and breast prostheses following a medically necessary mastectomy. Women should contact their local Medicaid office for more information about their state's Medicaid program and whether breast reconstruction is covered.

Women who are considering breast reconstruction surgery should have a thorough discussion with their doctor and health insurer about their options. Some insurers may ask for a second opinion before approving the procedure.

What post-surgical care and physical rehabilitation will I need?

Any reconstruction increases the likelihood of many of the side effects that come with a mastectomy. Your team of medical experts will monitor you closely for any complications that may arise, including those that may occur several months or years after surgery.

Women who undergo breast reconstruction surgery may get the advantage of physical therapy to restore range of motion and functionality of the shoulder, or to rehabilitate the donor site following autologous tissue reconstruction. A physical therapist can work with you to find safe ways to exercise, help you adapt to any limitations you may experience, and recommend the most appropriate way to perform certain activities.

Does having breast reconstruction affect future breast cancer screening?

Women who undergo breast reconstruction surgery generally do not undergo screening mammography of the reconstructed breast; rather, they undergo clinical examination to evaluate the breasts for recurrence of cancer. However, women who have undergone mastectomy of one breast will still undergo regular screening mammography of the other breast.

What is flat closure?

Flat closure, also called aesthetic flat closure, is a procedure that reconstructs the chest wall by removing excess skin, fat, and other tissues from the breast area. This procedure is also an option for those who wish to remove their breast implants via surgery.

As part of this procedure, the surgeon removes excess fat, skin, and unwanted tissues from the breast area. The remaining tissue is then pulled together and adjusted to shape the desired contour of the chest wall. Simple removal of the breast implants during the mastectomy follow-up surgery will not result in a flat closure.

What are the latest advances in breast reconstruction and fat grafting?

Oncoplastic surgery:

In general, patients who undergo lumpectomy or partial mastectomy to treat early-stage breast cancer are not offered reconstruction, as they have a reasonable likelihood of achieving excellent cosmetic results with their remaining breast tissue. However, for patients with large tumors in relation to their breast size, or for whom lumpectomy would cause unacceptable cosmetic deformity, breast reconstruction using oncoplastic surgery techniques may be considered.

This type of breast-conserving surgery employs techniques used in plastic surgery to achieve optimal cosmetics while removing the cancerous tissue. The techniques used can range from rearranging the existing breast tissue to reduce breast size to reconstructing the breast with tissue from another part of the body (a flap). The long-term cosmetic and functional outcomes of this type of surgery are similar to those of standard breast-conserving surgery.

Autologous fat grafting:

A promising new technique uses fat tissue harvested from other parts of the body, including the thighs, abdomen, and/or buttocks. It injects it into the breast to recreate a natural contour in breast reconstruction surgery. Fat tissue is obtained via liposuction, then processed and liquefied before being reinjected into the breast. Fat grafting can be used to reconstruct the entire breast, or to correct contour deformities and/or asymmetry following breast reconstruction surgery. While long-term data on this technique have not been well studied, it is generally considered to be a safe option.

Why choose Tender Palm Super-Speciality Hospital for Breast Reconstruction after Mastectomy in Lucknow, India?

Tender Palm Super-Speciality Hospital offers advanced Breast Reconstruction after Mastectomy in Lucknow, India, with experienced breast surgeons, reconstructive specialists, and a multidisciplinary oncology team. Our specialists carefully assess the patient's breast cancer diagnosis, type of mastectomy, overall health, previous or planned cancer treatments, and individual preferences to develop a personalized reconstruction plan. Depending on the patient's condition, reconstruction may be performed using implants or the patient's own tissue and may be planned immediately during mastectomy or as a delayed procedure. We focus on safe surgical techniques, modern facilities, careful post-operative monitoring, and coordinated follow-up care. With comprehensive cancer services and affordable treatment options in Lucknow, India.

To seek an Expert Consultation for Breast Reconstruction after Mastectomy in Lucknow, India:

Call us at +91-9076972161
Email at care@tenderpalm.com

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