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Breast Reconstruction After Mastectomy: Options

A woman makes her own journey back to health and wholeness, and no two experiences are exactly the same. For many women, undergoing breast reconstruction is an important part of embracing their health and moving into the future with confidence.

There are various ways to reconstruct the breast; a lot depends on a woman’s individual anatomy and preferences. Your surgeon will work with you to get a full understanding of all of the details that will guide the planning of your reconstructive surgery procedure — such as your health, the shape and size of your breasts, your remaining skin and tissue, and your desires and lifestyle.

The timing of reconstructive surgery

Whichever method of reconstruction is used, it may involve various steps before the final result is achieved. Chemotherapy or radiotherapy might also have an influence on the timing of certain surgical procedures and should be taken into consideration.

Immediate reconstruction

Breast reconstruction may be carried out in the same operation as the breast cancer surgery (it is then said to be immediate). One advantage of this method is that when you wake up from the anaesthetic, you will already have moved partway down the reconstruction path. While this may mean a slightly longer operation initially, it allows you to avoid the experience of having only one breast, or none if a mastectomy* was performed on both breasts.

Delayed reconstruction

If the decision is to opt for reconstruction at a later stage, often called ‘delayed reconstruction’, you will have the advantage of more time to make a decision. In fact, you can work on your recovery in two phases. You can begin by concentrating entirely on any follow-up treatment that may be required, such as radiotherapy, chemotherapy, or both. You will also need time to cope with the whole course of the disease, a process that may require a great deal of energy. On the other hand, delayed reconstruction means that you will have to wait for the restoration/return of your bodily contours for weeks or even months.

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RECONSTRUCTION OPTIONS

There are various ways to reconstruct the breast. Your surgeon will help you choose the best option based on your specific needs. Breast reconstruction can be carried out with the aid of a breast implant, by using your own tissue, or by a combination of the two.

Reconstruction with a breast implant

With this method, a breast implant is placed under the chest muscles to create a cover for the implant. In many cases, stretching the skin on your chest with an inflatable expander is necessary before placement of the final implant in order to recreate a natural-looking breast.

Breast reconstruction with your own tissue

With this method the surgeon may use your own fat, skin, and muscle tissue, most frequently from your back or abdomen. In a few cases, tissue can also be taken from your buttocks, your thigh, or even other distant regions of your body.

Breast reconstruction with your own tissue and a breast implant

In some cases, a combination of both techniques may be used, for example if you are very slim and have a large breast, the reconstruction may require both an implant and your own tissue to obtain satisfactory results.

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TISSUE EXPANDERS

For women with less breast tissue, the first stage of breast reconstruction surgery is inserting a tissue expander to help stretch out the skin and tissue to accommodate the breast implant. An expander is an inflatable silicone balloon-type device that is gradually filled with a saline (salt-water) solution, thereby stretching the skin, similar to what occurs naturally to your abdominal skin during pregnancy. This creates the room needed for the permanent implant to be inserted. Some months later, the expander is surgically replaced by the breast implant itself.

Stage 1. Insertion of the Tissue Expander

The expander is usually inserted behind the greater pectoralis muscle and is then regularly filled with a saline solution through a valve called a ‘port’. This port is an integral part of the expander itself. Filling is done with a fine needle, directly through the skin and is usually painless. Some patients may experience a slight feeling of tightness in the breast, but usually this quickly passes. With the aid of this procedure, the skin is gradually stretched.

Stage 2. Insertion of Implant

Approximately 3 to 6 months after the first operation, when optimum skin expansion has been achieved, the tissue expander can be replaced by the permanent implant. Depending on your overall breast health and treatment plan, the time between the first and second surgery may be prolonged by follow-up therapy. The surgeon will help you to choose the permanent implant to match your desires and remaining breast. In addition, you may be offered surgical adjustment to your remaining healthy breast to achieve the best outcome.

The procedure to insert the new breast implant involves creating a pocket for the implant. After the pocket is created, the breast implant is placed either partially under the pectoralis major muscle (submuscular) or on top of the muscle and under the glands (subglandular). Once the implant is placed, the incision is closed with stitches. In addition to stitches, it may also be taped.

For some women, the option of an expandable breast implant, which combines the functions of both the expander and the breast implant, is also available, and requires only one operation. This implant is composed of two parts: one part is filled with a saline solution, the other with silicone gel. This implant will act as both the expander and the permanent implant: In this case the port is located under the skin and is attached to the expandable implant via a length of tubing. When the right breast size has been achieved (by the addition of the saline solution), the implant does not need to be removed.

Stage 3. Nipple and Areola Reconstruction

In a mastectomy, the nipple is removed if there is any possibility that it may contain cancer cells. Once your initial reconstruction procedure is complete, the reconstruction of the nipple and areola of your breast may be performed as a separate surgery.

The nipple can be reconstructed in any of the following ways:

  • by raising the skin of the reconstructed breast, to create a little ‘button’
  • with the aid of skin from the nipple on the other breast, provided that it is big enough 
  • by using a section of skin from the thigh, ear, or toe
  • by inserting a piece of cartilage from the ear or rib under asmall skin flap.

The areola (the darker skin around the nipple) can usually be reconstructed by:

  • tattooing, 
  • with the aid of a section of skin from the groin or labia, since the skin is somewhat darker in these areas and resembles that of the areola.

In each case, the operation involved is minor and relatively painless. Operations to reconstruct the nipple and areola are carried out only when breast reconstruction has been completed. An important point to note is that reconstructed nipples usually have no sensation.

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