Breast reconstruction has become increasingly popular among mastectomy patients in recent years, including women who have adjusted well to using a breast prosthesis. Although a reconstructed breast does not look exactly like the natural one, improved plastic surgery techniques, using silicone implants and, if needed, muscle, skin, or fatty tissue taken from other parts of the body, can achieve remarkable results. Even an areola and nipple can be made from other body tissue.
Successful breast reconstruction was first used for women whose breasts were damaged by burns or other injuries. The early procedure was a complex and costly series of operations, which involved taking tissue from elsewhere on the body and moving it, step by step to preserve its blood supply, to the mastectomy site. The development of silicone implants greatly simplified the procedure
The consistency is not exactly like that of the other breast, and the old mastectomy scar remains, although it fades considerably with time. However, the reconstructed breast looks like a natural breast under clothes even low-cut dresses and bathing suits. Almost any woman who has had a mastectomy can have breast reconstruction. This includes women whose skin has been damaged by radiation and those who have had a radical mastectomy, in which the pectoral muscles are removed in addition to the breast. The reconstruction may be more difficult in these instances, but it is not impossible.
Increasingly reconstruction is being done at the same time as the mastectomy, especially if radiation treatments are not being planned. After the breast is removed, a silicone prosthesis is inserted, the incision is closed and drainage tubes inserted. In some women there may be an inadequate amount of skin or too marginal a blood supply to do a complete immediate reconstruction. In these instances a balloon like device called an expander is inserted instead of the prosthesis. After the incision is healed, a saline solution is injected through the skin to “inflate” the expander. After the tissues have stretched enough to accommodate the silicone prosthesis, the expander is removed and the permanent implant is inserted.
An immediate reconstruction has several advantages: It avoids a second major operation, an additional scar, and increased expense. It also provides the psychological advantage of awakening from surgery and finding a near-normal contour where the natural breast had been. Most patients who can plan a reconstruction with their surgeon and plastic surgeon before a mastectomy do not seem to experience the same sense of loss as women who undergo a mastectomy without such planning.
In most post mastectomy reconstructions, the original mastectomy line is followed and there is no new scar. There may be an additional scar elsewhere on the body if donor tissue is needed from another site, usually the abdomen, side or back. Even the deformity created by a radical mastectomy can be corrected and an almost normal contour restored. Breast reconstruction has been performed as long as ten to twenty years after a mastectomy.
Although women who have undergone a mastectomy but have metastases elsewhere in the body are generally not considered candidates for reconstruction, the option is available to them and should be considered if the patient and her doctor feel it will enhance the quality of her life. Regardless of the stage of her disease, then, any woman who has had a mastectomy is a potential candidate for reconstruction unless her physical or emotional state indicates that she could not tolerate surgery and the recuperative period after surgery.
Reconstruction usually takes about one and a half hours, sometimes longer. It requires the use of an implant or the woman’s own tissue. Implants are generally made of plastic filled with silicone gel or saline and come in many shapes and sizes, to match the remaining breast. Often it is necessary to reduce or tighten the other breast if there is great size discrepancy. If a woman’s own tissue is used, it will be taken from the lower abdomen (rectus abdominus muscle tissue), leaving a scar just above the pubic hairline, or from the back (latissimus dorsi muscle and tissue), leaving a horizontal incision along the skin lines of the back.
After reconstruction, patients are usually able to get out of bed the next day, if not sooner, and to return to work within a week. Arm mobility begins to return within a few days and should be back to normal in two weeks or so. The two most common complications are loss of the skin over the implant due to an impaired blood supply, and the formation of a capsule—hard, fibrous scar tissue around it. The latter is less common if the prosthesis is placed under the muscle. Also, regular breast massage can help avoid this problem and keep the breast soft and supple.
A few months after the initial reconstructive surgery, women who choose to do so can have a nipple and areola added to their new breast. This is almost always done in a second operation to allow time for the reconstructed breast to stabilize in shape and position so that the new nipple is symmetrical in location, size, and projection with the remaining one.
The areola is fashioned from pigmented skin found elsewhere on the body. For a woman whose areola is pink, skin from behind the ear is generally used to match the color. If her areola is brown, the graft can be taken from the upper inner thigh. In either case, the scar heals quickly and is barely visible. If the areola of the normal breast is very large and the breast is being lifted or reduced, part of this areola may be used for the reconstruction.
The nipple itself can be created in one of three ways.
Unless the remaining nipple is very small, the lower portion of it can be used without any noticeable loss of size. If it is too small to use, a new nipple can be fashioned with skin from the earlobe or upper inner thigh, although this new nipple may not project as much as the original. Finally, a nipple can be formed by gathering up a thick layer of skin in the center of the breast where it is usually removed in preparation for the areola implant and using that as the nipple. If it is too light in color, pigmented skin from elsewhere can be grafted over it.
Whichever method is used, the results are generally satisfactory and provide the finishing touch for many women, making them feel that they now have a breast that is a reasonable facsimile of the one they have lost.
Social and Emotional Factors
In recent years, women have become more knowledgeable about factors that increase their risk of developing breast cancer. For example, in a Gallup survey conducted for the American Cancer Society, 62 percent of the women polled knew that having sisters or a mother with breast cancer increased the likelihood of their having it too. More than half realized that previous breast cancer increased their chances of developing it again.
Although women may be more knowledgeable, they are not necessarily more diligent about things like regular breast examinations. In the Gallup survey for the ACS, 80 percent of the women surveyed said that they examined their breasts for lumps, but only 27 percent said that they had done it twelve or more times during the previous year. When asked why they did not practice breast self-examination, a third said they relied upon their doctors to do this, 17 percent felt there was no need for them to do so, and 16 percent felt they did not know how to do it properly. Three out of four women knew about mammography, but only 41 percent of those over the age of forty had had breast X rays, and 15 percent of the women over the age of fifty who were polled had yearly mammography. Only 45 percent of women over the age of forty had their breasts examined yearly by a physician.
Other surveys have confirmed that women are taking a more active role in treatment decisions, particularly regarding breast cancer. In its National Survey on Breast Cancer, the National Cancer Institute found that only three out of ten women in 1980 said they would let their doctors alone decide whether or not a breast should be removed. In contrast, 70 percent said they wanted to discuss the decision first with a spouse or someone close to them, and 90 percent said they would want a second opinion.
Contrary to popular belief, the NCI survey found that fear of disfigurement was not one of the major concerns. Only 12 percent cited this as a worry; more important were concerns that the surgery would not cure the cancer or that the effects of radiation therapy or chemotherapy would be debilitating.