Every woman seeking breast reconstruction is unique. Most of the time, breast reconstruction is needed after the removal of the breast gland to treat an existing breast cancer. In other women who have a strong family history of breast cancer or who carry the BRCA gene, reconstruction follows a prophylactic mastectomy designed not to treat, but to reduce the future risk of developing breast cancer. In yet others, reconstruction may be needed to address a defect following lumpectomy or a congenital problem.
Advances in breast reconstruction have made it possible for most women to wake up following mastectomy surgery with much of the breast recreated in one step. One’s own tissue may be transferred to the breast area or, more commonly, an implant is used to recreate the breast shape. While an implant is not an exact replacement for the breast, technical modifications over the past decade permit a close approximation of the shape and feel of the natural breast.
The goal of surgery is to create a beautiful, proportionate breast with the simplest recovery and least amount of risk possible.
Note: Please keep in mind that breast reconstruction is a highly individualized process that is best discussed in person. The website is designed to provide a background for those curious to have general information beforehand, or as a reference after the consultation to help process the information.
Implant reconstruction usually takes place in a few steps. The first step most often occurs at the time of mastectomy (‘immediate’) or can be performed months or years after the mastectomy (‘delayed’). Immediate reconstruction has several advantages, perhaps the most important being able to wake from surgery without ever experiencing the flat chest associated with a mastectomy. The psychological benefit of waking with a reasonable (albeit imperfect) breast shape is immeasurable. Performing the reconstruction at the time of mastectomy also allows the preservation of your breast skin, which serves as an envelope for the implant and helps minimize the scar and maintain the aesthetics of the breast. Occasionally, discussing reconstruction at the time of breast cancer diagnosis and treatment is too much to contemplate, or other medical conditions may make the combined procedure too risky. In these cases, reconstruction can be deferred to a later date.
Mastectomy refers to the removal of the breast tissue and often (but not always) the nipple and areolar tissue. When done in conjunction with reconstruction, it is critical that your plastic surgeon works closely with your general surgeon to plan the approach to the mastectomy. In most cases, removal of the breast tissue is accomplished via a “skin-sparing” mastectomy in which the skin of your breast is preserved to provide an envelope or template for reconstruction. In other cases, a “nipple/areola-sparing” mastectomy is feasible in which your own nipple and areola are preserved. Deciding which approach to use depends on a number of factors that you will discuss with your general surgeon, as well as aesthetic considerations that we will review at your consultation.
Implant reconstruction involves a series of steps that occurs over 3 to 9 months. The major variable in the equation is the need for chemotherapy after the mastectomy. If chemotherapy is required (frequently a four-month course), we do not proceed with the second step of reconstruction until approximately one month after chemotherapy is completed. If chemotherapy is not required, we can move along faster. In either case, the only inpatient surgery is the first stage of the reconstruction (when the mastectomy is also performed). Subsequent procedures are performed in an outpatient setting (you can go home the same day), and require minimal recovery.
The mastectomy and the first step in reconstruction are performed in the same setting. As soon as the mastectomy is complete, a temporary implant called a tissue expander is placed. The purpose of the expander is to create a space for the permanent implant that will be placed at a later date. The upper portion of expander is placed beneath the pectoralis muscle of the chest in a natural plane where the muscle glides over the ribs. The lower portion of the expander is covered with Alloderm or a similar material which helps to maintain the position of the expander and to recreate the fold beneath the breast. During surgery, the expander is filled with saline as much as possible without putting undo tension on the skin. A drain is placed that exits at the armpit area and the skin incision is closed. Typically, you are able to go home on the second postoperative day. A follow up visit is arranged approximately 5 days later when the drain is usually removed.
The expander has an incorporated self-sealing valve that easily allows additional filling to be performed in the office. Once we are certain the skin is healing well, usually two weeks after surgery, expander fills are started and continue on a weekly basis. Usually 1 to 3 fills are required, but this varies a bit depending on how much fluid was added to the expander during surgery and on your desired breast size.
Once the expander is filled to the appropriate size, we wait at least 6 weeks for the skin and muscle to relax at which point the second step is scheduled. If chemotherapy is required, we need to wait until 1 month after the chemotherapy is completed to allow time for your immune system to strengthen.
Using a portion of the scar from the previous surgery, the tissue expander is removed and a silicone gel implant is placed. Sometimes an adjustment is required during this step to improve the shape or positioning of the implant. If we are reconstructing only one side, this is also a convenient time to improve symmetry by altering the opposite breast if necessary. No drain is required. You are able to go home a few hours after surgery with a follow up appointment in 1 to 2 days. We wait 2 months to reconstruct the nipple and areola.
Once the breast shape is established, the final steps are to recreate the nipple and areola. No matter how beautiful the breast shape, the aesthetic is incomplete without the presence of the nipple and areola. While there are many creative and unusual ways to form a new nipple and areola, the simplest and most consistent is to use the skin on the breast to form the three-dimensional nipple and to pigment the surrounding areola with a tattoo. The former is performed under local anesthetic with light sedation as an outpatient procedure, the latter is done in the office 2 months later.
The following section explains in more detail what you can expect before and after breast reconstruction with implants.
The purpose of the first visit is to provide as much information as possible. Dr. Attkiss meets with you for an hour or more to obtain a thorough medical history, performs a physical exam, takes measurements and photographs, discusses the different options for reconstruction, and tailors a plan to suit your particular needs. It is often helpful to bring a written list of questions that you would like answered. Sometimes the amount of information presented can feel overwhelming. If necessary, a follow up appointment for further discussion is easily arranged. If you like, we can arrange for you to speak to other patients of Dr. Attkiss who have been through the process and can give their perspective.
A preoperative meeting is scheduled 1 to 2 weeks before surgery. Instructions are given regarding when and where to arrive at the hospital, routine blood testing is arranged, a detailed written consent booklet is reviewed, and any additional questions you might have are answered.
You arrive as scheduled at the Greenwich Hospital Surgery Center and are assigned a private room where a nurse greets you, obtains a general medical history, places elastic stockings on the legs, and an intravenous line is placed. You meet the anesthesiologist who also reviews your medical history and discusses anesthesia, as well as methods to minimize postoperative pain and nausea. If desired, a mild sedative is given to relax you. Dr. Attkiss sees you to address any concerns and also to mark the breast skin.
The surgery to perform the mastectomy and place the tissue expander lasts approximately 2 to 3 hours for one side, and 4 to 5 hours when both breasts are being reconstructed. During the procedure, family members are welcome to sit in the Atrium waiting area. After surgery, you are taken to a recovery area until you are awake enough to be moved to your room on the Surgical floor. Your breast surgeon speaks to your family when she is done with her part of the surgery, and Dr. Attkiss does the same when his portion is finished. Your family can see you as soon as you get to your room.
You may rest much of the first day after surgery. Food and drink is permitted as soon as your appetite returns. Pain is controlled initially with intravenous medication and then oral pain medication, as needed.
You are encouraged to be out of bed and walking by the morning after your surgery. Usually you are able to be discharged home after two days. You receive instructions on the care of the drain. You also receive prescriptions for pain medication and an oral antibiotic that you take until the drain is removed. You will see Dr. Attkiss for a follow-up appointment 5-7 days after surgery and will also arrange an appointment with your breast surgeon.
It is preferable to keep the breast area dry until two days after the drain is removed. During this time, a half-filled bath or limited shower is best. The drain is emptied and the amount of drainage is recorded as instructed. Infection or bleeding occurs occasionally. Call Dr. Attkiss if you have a fever, increasing redness or swelling of the breast. Slight bruising or redness of the breast skin is normal.
Most women experience minimal pain, but soreness across the chest or under the breasts is typical, accompanied by a sense of numbness. Oral pain medication is used for the first few days, as needed. Call Dr. Attkiss if you feel the pain is excessive. You can use your arms to eat and care for yourself, but you should avoid reaching or straining. Loose fitting clothes that button in front are easier than pulling a shirt over the head. Any activity that does not elevate your heart rate is encouraged. Walking around is better than sitting on the couch, and sitting is better than being in bed. Usually you are driven to your first postoperative appointment, but driving yourself is fine as long as you not taking narcotic pain medication and can move about freely.
By two weeks after surgery, you usually feel quite good, but are by no means fully recovered. There may still be intermittent discomfort, but often Tylenol or ibuprofen is sufficient. The skin of the breast still feels numb and the expander feels relatively rigid and immovable. At this point, you may resume light aerobic activities and gradually regain the range of motion of the arms and shoulders via simple exercises. If needed, a consult with a therapist can be arranged.
Once the skin is healed, approximately 2-3 weeks after surgery, the expander is filled on a weekly basis. Because the skin is numb, placing a needle through the skin into the expander is virtually painless. The fill itself may create a sense of increased tightness that lasts for a day or two and then relaxes. The filling process is usually complete at the end of this month, at which point you can resume any activity that feels comfortable. Some women play golf or tennis with the expander in place, others limit their activities to light lifting.
While most women become relatively comfortable with the expander in place, it is nonetheless a relief to remove it and place the permanent implant. This procedure requires a brief period of general anesthesia after which you can go home. A narcotic pain medication is prescribed for a day or two, but generally Tylenol is sufficient as there is little discomfort. If a procedure is also being performed to adjust the opposite breast, recovery may be somewhat longer. A drain is rarely required and you may shower after your first office visit, usually within in a day or two. A supportive bra is worn day and night for a few weeks, if desired.
Nipple reconstruction is performed 2 months later under local anesthesia with light sedation. Care is taken to protect the area for 2 weeks after surgery. Finally, the nipple and areola are tattooed in the office. Aftercare involves keeping the area lubricated for one week with aquaphor or a similar ointment.
An appointment to check the tattoo is scheduled in one month, and then routine follow up visits are continued yearly. Presently, MRI screening of gel implants is recommended by the FDA at 3 years following surgery and every other year after that. Usually, yearly follow up with your breast surgeon and/or oncologist is advised as well.
WILL I HAVE SCARS?
Yes, a scar is necessary to perform the mastectomy and reconstruction. It is designed to be as short as possible and to avoid visibility in low-cut clothing. Initially the scar is pink, but fades to a thin, pale line over 6 to 12 months. Reconstructing the nipple and areola also significantly helps to visually ‘push’ the scar into the background (see photos). If the nipple and areola are able to be preserved during the mastectomy, the scar may be placed around the edge of the areola with an extension to the side, or in the fold beneath the breast.
WHAT ARE THE DIFFERENT TYPES OF IMPLANTS?
Breast implants are filled with saline or silicone gel. Silicone gel feels more natural to the touch than saline, particularly following a mastectomy where no breast tissue remains to cover the implant, and therefore is used most commonly. Most implants are manufactured by Allergan or Mentor Corporation in the United States. Silicone gel implants have been used in breast reconstruction since the early 1960’s, but did not gain FDA approval until 2006. Most recently, the FDA approved the use of form stable (‘gummy bear’) gel implants that are shaped to closely match the contours of the natural breast.
ARE SILICONE GEL IMPLANTS SAFE?
The FDA rigorously reviewed the data on silicone gel implants concluding in 2006 that implants are safe to use for reconstruction or cosmetic breast augmentation (FDA site). Silicone gel implants do not pose any known risks to your general health. The review also concluded that breast implants should not be considered lifetime devices since re-operation at some point may be required (see below).
WHAT ARE THE RISKS OF SURGERY?
Every effort is made to keep risk to an absolute minimum. Fortunately, serious risks rarely occur, and minor problems are usually easily addressed. Still, it is important for you to understand the potential risks which can be divided into risks of surgery in general and risks related to the implant itself.
With any surgery, there is a risk of bleeding or infection. Bleeding rarely occurs following implant surgery, but when it does, it may require a return to the operating room to identify and control the bleeding point. Infection is very rare, tending to occur when risk factors such as smoking, diabetes or obesity are present. If an infection occurs around the implant, the implant may need to be removed. Occasionally, the breast skin does not heal primarily and may require revision and re-closure to prevent an infection from developing.
As mentioned, implants are not considered lifetime devices. Additional surgery may be required to replace a ruptured implant, to address excessive scar tissue (capsular contracture), or to adjust the position of an implant. The implant is not a perfect replacement for the natural breast. As such, the implant may not blend at the chest as well as the natural breast, transitions may be more abrupt, or visible rippling or waviness may occur. Minor aesthetic imperfections are usually acceptable and do not require intervention.
WHAT IS ALLOGRAFT?
Probably the most significant technical advance over the past decade in implant reconstruction is the use of Alloderm or other dermal grafts. Alloderm is processed human skin devoid of cells leaving a sheet of material that can provide structural support. The Alloderm serves as a scaffolding that becomes repopulated over time by one’s own cells. Though originally developed in 1994 to treat burn injuries, it has numerous diverse applications all over the body. With respect to breast reconstruction, its use is to provide hammock-like support to the tissue expander or implant until the implant pocket develops. The material is secured to the chest to precisely define the shape of the lower and outer breast, and it is secured above to the pectoralis muscle which covers the upper portion of the implant. Before the use of Alloderm, very little fluid could be added to the expander at the time of mastectomy because of the tightness of the muscle. Now, most of the expansion is completed immediately with much less discomfort and much better aesthetics.
WHEN IS IT NECESSARY TO ADJUST THE OPPOSITE BREAST?
The shape of the breast reconstructed with an implant is usually perkier than the natural breast, meaning there is less fullness hanging below the breast crease and more fullness at the upper portion of the breast. When the reconstruction is performed on one side, this shape may not match the opposite natural breast. If the opposite breast is too large, a breast reduction or lift may be indicated to improve symmetry. If the opposite breast is too small, an implant may be required. If the opposite breast is small but sagging, a lift with an implant may be appropriate. If required, the procedure on the opposite breast is usually performed at the second step of the reconstruction when the expander is replaced with the permanent implant.
SHOULD I HAVE BOTH BREASTS RECONSTRUCTED?
Not infrequently, a woman will choose to have a mastectomy of one or both breasts to reduce the risk of developing breast cancer in the future. This may be the case if you carry the BRCA gene, have a strong family history of breast cancer, have breasts that are difficult to image, and/or have ongoing anxiety about lifetime screening, among other factors. This decision is made in consultation with your breast surgeon who can help weigh the relative risks and benefits. From a reconstructive standpoint, symmetry is easier to obtain when both breasts are reconstructed, since the same procedure is being performed on each side. This may not be reason-enough to have a mastectomy of the opposite breast, but it might factor into your decision if you are uncertain.
CAN RECONSTRUCTION BE PERFORMED IN ONE STEP?
In some women, the breast anatomy permits the placement of the permanent implant at the time of mastectomy, eliminating the need for a second procedure. While there are a few strong advocates to this one-step approach, it can introduce additional risk, particularly with respect to healing of the skin. The skin following mastectomy has compromised blood supply by virtue of the fact that the blood vessels that nourish the skin from underneath are necessarily disrupted to remove the breast tissue. If the permanent implant is placed at this time, pressure from the full weight of the implant can further compromise the blood supply and impair skin healing. By contrast, the two-step method uses an adjustable expander at the first step that is initially under-filled to allow skin healing under minimal tension. If the skin fails to heal in this setting, the adjustable expander provides a ‘safe out’ since the expander can be further deflated and skin revised in the office. The second step also provides an opportunity to adjust the implant pocket and modify the opposite breast when indicated. Planning a second step also gives you opportunity to provide input about your desired breast size since you can see what the new breast shape will look like. The second step does require anesthesia, but you may go home the same day and recovery is relatively minimal.
WHAT IS A MASTECTOMY?
Mastectomy refers to removal of the breast tissue from beneath the skin. If no reconstruction is planned, your breast surgeon will also remove any redundant skin to produce a smooth contour. In contrast, when immediate reconstruction is planned, a ‘skin-sparing’ mastectomy is performed in which the breast skin envelope is preserved to facilitate the reconstruction and help maintain the breast aesthetic. Sometimes it is feasible to perform a ‘nipple-sparing’ mastectomy in which the aesthetics of the nipple and areola are preserved. ‘Prophylactic’ mastectomy refers to the removal of breast tissue to reduce the future risk of developing breast cancer.