Breast Reconstruction

When faced with a possible breast deformity from breast cancer, what are your reconstructive options?

Below we give a broad picture of your options and talk about what to expect at the different surgeries. It is a complex, emotionally challenging topic for many. We are here to support you.

If you would like to learn more, please book a consultation with Dr. Gill at Pulsar Health.

At Pulsar Health, we are honored to support our clients through their breast reconstruction journey. We take many insurances to make the process as easy as possible for you to get the care you deserve.

The most common reason we see clients for breast reconstruction is due to a diagnosis of breast cancer, but we also see people who have had large non-cancerous lumpectomies, breast distortion due to other reasons such as radiation, or congenital breast abnormalities (from birth / development) such as tuberous breasts or asymmetry of breasts greater than two cup sizes difference. Whether breast surgery is a covered benefit will depend on your insurance. Since the Women's Health and Cancer Rights Act was signed into federal law in October 1998, insurances must cover reconstructive surgery for breast cancer, surgeries for symmetry on the other side, any external breast prostheses (that fit in your bra) before or during reconstruction, and any physical complications of mastectomy including lymphedema. There may however be a yearly deductible and some out-of-pocket costs.

Focusing on breast cancer surgery, a conversation regarding reconstruction is best done before the cancer surgery, so that you can have more information to decide what route you want to take. A simple lumpectomy may not require any intervention, depending on where in the breast the mass is and its' size relative to the size of your breast. Sometimes the breast cancer surgeon will move the tissue around to fill in the defect from the lumpectomy. If you do develop a distortion of your breast from lumpectomy, a plastic surgeon can fill in the defect via rearranging the breast tissue or using fat grafting. Sometimes a plastic surgeon is involved at the time of the breast cancer surgery to lift the breast and reduce the other side, called an oncoplastic reduction and symmetrizing surgery. However, the other side surgery is often done at a later date, once you have healed from the cancer surgery, to get a closer "match" to the healed side.

Fat grafting is taking fat from elsewhere on your body, such as your abdomen or thighs, and putting it into the breast area or anywhere else we need to "fill out". About half the fat goes away and the other half "takes", or gets its own blood supply to live on, so fat grafting is usually repeated until we get the result we are looking for as long as you have enough fat to work with. It is also useful for smoothing out irregularities after other forms of breast reconstruction. There is a risk of some of it hardening / not surviving, called fat necrosis, so we try to minimize this risk by only injecting a relatively small amount that isn't under a lot of pressure, to maximize the chances of survival of the fat. If fat necrosis does occur, it can be excised if necessary. Fat grafting is also very helpful for treating irradiated skin, as it helps improve the blood flow in that area, and softens the overlying skin where radiation can make it very firm and inelastic.

When all the breast tissue is being removed by the breast cancer surgeon, called a mastectomy, options for reconstruction fall into a few different categories. 

1. No reconstruction. This is always an option, and insurance covers post-mastectomy bras and prosthetics. Even if you choose no reconstruction initially (most reconstructions are termed "immediate reconstruction" as it starts on the day of removal of the diseased breast tissue), you can have a "delayed reconstruction" if you change your mind later.
2. Tissue based reconstruction. This is where your fat / muscle / skin from elsewhere is moved into the breast area. If the breasts are very large, the skin of the breast itself can be folded into a breast shape, called a Goldilocks breast reconstruction. Rotation of the latissimus dorsi muscle of your back (with or without a skin "paddle"), or of the rectus muscle of your abdomen, can bring in tissue to the breast area for volume. A "free flap" takes tissue from a distant location, such as the lower abdomen or thigh, and brings it to the breast area. This is typically skin and the underlying fat whilst sparing as much muscle as possible. The blood vessels in that tissue are sewn into the blood vessels in the breast area (usually mammary artery and vein) under a microscope in the operating room. This procedure is only done in specialist centers because it requires careful monitoring afterwards. If there are problems with the blood supply, you will need to return to the operating room within hours to have it addressed, in order to maximize your chances of a healthy flap reconstruction.
3. Implant based reconstruction is the most common option picked by those having breast reconstruction. Here implants are used to replace the breast volume lost from the mastectomy. The breast surgeon may do a skin-sparing mastectomy where you keep most of the skin that surrounded the breast tissue, or even a nipple-sparing mastectomy where the nipple areolar complex (NAC or nipple and surrounding darker colored skin) are kept. Whether these are feasible options depends on the breast cancer location and extent. The skin and NAC are reliant on their blood supply coming in from the sides once the mastectomy is done, so parts of them may not survive. This can be addressed if it happens by removal of that portion and further reconstruction. 

As implant-based reconstruction is the most common reconstruction option, we will go into a little more depth about it here, using some questions and answers.

Q: Can I get just one reconstruction surgery with a breast implant, or do I need to do a few surgeries?

A: "Direct to implant" reconstruction can be done by placing breast implants at the time of mastectomy. This is a good option for those with smaller breasts who want to stay the same size and don't require any skin tightening or adjustments. This is ideally performed immediately at the time of a nipple-sparing mastectomy. There are some risks which can be discussed at your visit, but its strength is that it is just one surgery if no revisions are required.

Most commonly, an "expander-based reconstruction" is done, where a temporary balloon-type device called a breast tissue expander is placed in the breast area immediately following mastectomy, to replace the removed breast volume. This temporary device is expanded over the course of a few months and then exchanged for a soft breast implant. The exchange surgery (placing implant to replace expander) is a "safer" time to adjust the skin, such as doing a breast lift to make it all look pretty. A third or more surgeries may be needed for rebuilding the nipple, to do surgery on the other breast for symmetry, or for filling out indented areas, such as where the top of the implant meets the chest wall, using fat grafting.

Q: Why use a breast expander?

A: There are several benefits to using a breast expander. One of the most important benefits of an expander is that it minimizes tension on the mastectomy skin flaps. The skin initially got its blood from the underlying breast tissue as well as the sides, but following mastectomy, it relies on blood from the sides to keep it alive. A deflated expander minimizes stretch or pull on these skin flaps until their blood supply becomes more robust over time. If the skin "dies" due to lack of enough blood supply, it will need to be removed. Skin may also be removed as part of removing the breast cancer. Use of an expander allows us to stretch out the remaining skin so that the implant can look like a normal breast shape. We can also adjust the expander to the desired size over time. We do need a ball-park size that you want in order to choose which expander to place. Radiation and healing can affect the breast aesthetics, and using a breast tissue expander gives us more flexibility than going direct to implant.

Q: What happens during the first surgery?

A: Following the breast tissue removal and possibly lymph node dissection by the breast cancer surgeons, plastic surgeons place the expander and sometimes a mesh at that surgery (unless you are going "direct to implant" in which case just replace "expander" with "implant" in the rest of this paragraph). Dr. Gill prefers to place the expander under the pectoralis muscle to provide a softer fuller upper edge to the final reconstruction as well as reduce chances of infection. The lower portion of the expander can be covered with more muscle, but, more typically, we use a "mesh" to fashion a sling for this lower portion. This is more comfortable in recovery than full muscular coverage, but can be associated with more residual fluid around it (called a seroma or fluid collection). The mesh we are using most commonly at Pulsar Health is Flex-HD, which is derived from human tissue and is relatively resistant to infection. It does get incorporated into the body over time as your own cells grow into the matrix provided by the mesh. The breast tissue expander can be filled with fluid or air at the time of surgery. We only partially fill the expander at the time of the mastectomy, being careful avoid to tension on the mastectomy skin flap. One or more drains will also be placed to reduce fluid build up in the area after surgery.

Q: What should I expect during recovery from the first surgery?

A: The mastectomy and immediate reconstruction are usually the most "intense" of the reconstructive surgeries, and you should expect to be tired for a couple of weeks. Use of antibiotics following surgery is important to prevent infection of the expander / mesh / implant, especially when the drain is still in. Pain is handled using oral opiate pain medication initially and transitioning to simple Tylenol. We do use other medications for pain, such as muscle relaxants or agents for nerve type pain, if needed during recovery. Walking is encouraged but avoid more exertional exercise for about a month. We recommend doing some range of motion exercises with your shoulder but avoid excessive movements of the breast area because that can encourage fluid build up there, called a seroma. The surgical drain is in place to avoid a seroma, and is removed when the drain output is consistently less than 30cc/day. Your caregiver will be shown how to measure what comes out. The expander is filled gradually when you come for your outpatient visits after the surgery, and continued until you are happy with the size. The skin will not "fit" well typically until the subsequent exchange surgery where we switch out the expander for an implant. The expander is a place holder while you get other treatments such as radiation / start chemotherapy.

Q: What happens at the expander exchange surgery?

A: Once you are ready to have the expander switched out for an implant, we estimate what size and shape implant would give you your ideal breast aesthetic, and select a few sizes from which we make the final determination in the operating room. Most breast implants are silicone implants (silicone shell and silicone gel interior) whilst about 10% of clients choose saline implants (silicone shell but saline interior). If a saline implant deflates, you will know immediately, whilst if a silicone gel implant ruptures, you may need an MRI to be able to tell that has happened. Please see the Pulsar Health website section on "Breast Resizing: Going Bigger" for more information on breast implants, monitoring and possible complications. At the time of the implant placement, we can adjust the skin and sometimes do fat grafting. Symmetry of the other breast can be done now or after the implant-based reconstruction has healed, so that we can match the size and shape more accurately. Nipple areolar reconstruction may need to be addressed if the mastectomy removed the nipple or there was loss afterwards. Alternatively, tattoos can be done here if surgery is not desired.

Q: What happens if radiation is needed?

A:  Radiation is important to reduce the chances of breast cancer recurrence, and this is a discussion to be had with your oncology team. Typically, radiation is best given within a couple of months of the surgery to remove the cancer. The irradiated side will remain in a higher position over time whilst the non-irradiated breast ages more naturally, so you may want further surgery later on for symmetry. Also consider fat grafting for the radiated side. Finally, implants may need to be switched out. Please see the section on "Breast Resizing: Going Bigger" for more information on breast implants.

Reconstruction of breasts for reasons other than breast cancer can occur due to other disease or injury to the breast area, or due to a challenge in development. In these more complex situations, we apply the same principles that have been described in the sections on Breast Resizing, Breast Reshaping and above in the Breast Reconstruction section to work towards a healthy beautiful breast shape and size. It is important that all nicotine exposure including smoking and vaping should be avoided for three months before and as long as possible (but at least three months) after your last surgery.