Breast reconstruction following breast cancer: Options and recovery

It's common to find someone whose life has been affected by breast cancer — a friend, sister or mother has likely received the difficult news that they have breast cancer. It's more common than you might think. One in nine women will be diagnosed with breast cancer at some point in their lives. For the vast majority, this is difficult, frightening and overwhelming. In addition to digesting the information provided about cancer, there's also the option for breast reconstruction to consider.

What is breast reconstruction?

Breast reconstruction is a series of optional procedures designed to restore the appearance of natural breasts following mastectomy (the surgical removal of all tissue in one or both breasts). Many options exist after receiving a breast cancer, including:

• Mastectomy only (no reconstruction)
• Mastectomy with immediate reconstruction, using either one's own tissue (autologous) or implants
• Mastectomy with delayed reconstruction, using either one's own tissue or implants
• Preventative mastectomy with or without reconstruction

Reconstruction often involves, at minimum, one surgery, but more often two to five surgeries.

What are the differences in reconstructive options?

Mastectomy with immediate reconstruction is reconstruction that occurs in conjunction with the mastectomy. Immediate reconstruction can be done with either your own tissue (autologous) or with implants. In an implant-based immediate reconstruction, a tissue expander will be placed under the skin where the breast tissue had been. Most often, a general surgeon will perform the mastectomy and a plastic surgeon will then perform the reconstruction during the same surgery. The tissue expander is similar to an implant but has a port embedded within it so that it can be injected with saline at intervals during the healing process in order to restore your breast size to your pre-operative state. After healing and completing cancer therapy, a second surgery is required to remove the tissue expander and replace it with a permanent breast implant. Sometimes, a permanent implant may be placed during the initial surgery.

In an immediate reconstruction with your own tissue, skin, fat and/or muscle is moved from one area of the body (donor site) to the breast. The donor site is most often the abdomen but can also come from the back or other areas.

Mastectomy with delayed reconstruction is another option. This is sometimes chosen because other therapies, i.e. radiation, may interfere with the reconstructive process. The delayed reconstruction techniques are the same as for immediate reconstruction, but they may require a longer timetable for processes like tissue expansion to accommodate an implant, if that is the chosen method of reconstruction.

Both the implant-based and autologous techniques have their own set of drawbacks and advantages.  And since both use your own tissue versus using an implant, multiple surgeries are often required to recreate an aesthetically pleasing breast shape.

If I decide to have reconstruction, what is the recovery like?

It depends. Autologous reconstruction is a more technically difficult surgery, often lasting many hours. The hospital stay following autologous reconstruction is several days, as the relocation of tissue from one area to another requires close surveillance. Follow up in the next few weeks includes assuring the blood flow to the newly relocated tissue is adequate, removing postoperative drains from both the breasts and donor site and assessing healing. Recovery time is generally four to six weeks, with the most common limiting factor being the donor site healing.

The hospital stay following an implant-based reconstruction is generally one day. Follow up the next few weeks entails assessing healing, expanding the tissue expander with saline and removing post-operative drains. Women often return to their daily activities within a few weeks.

For both procedures, a series of surgeries can be required. For the autologous reconstruction, further procedures address contour issues, perhaps removing or lifting excess tissue or with fat grafting. Fat grafting involves liposuctioning from the abdomen, flank or thighs and injecting it into the breasts. For implant-based reconstruction, subsequent surgeries, when necessary, include exchanging the tissue expander for a permanent implant and contouring with fat grafting. Many surgeons prefer waiting two to three months or longer between each of the surgical procedures.

These subsequent procedures are done after the breast cancer therapy (radiation, chemotherapy) has been completed.

What about nipple reconstruction?

Nipple reconstruction, like breast reconstruction, is completely optional. There are several options:

• Surgical nipple reconstruction
• Nipple and areolar tattooing
• A combination of surgical nipple reconstruction and nipple and areolar tattooing

Surgical nipple reconstruction consists of taking skin from the front of the breast and rearranging and folding it in such a way that it projects from the breast. This does not, however, recreate the coloration of the nipple and areola. Coloration may be done with tattooing, with or without the surgical nipple reconstruction. The tattooing is done with surgical grade ink and generally requires touch-ups every five to 10 years. Nipple reconstruction and tattooing is submitted to insurance, just like all aspects of the reconstructive process.

What is involved in long-term follow up?

The breast reconstruction process can vary from approximately six months to one-and-a-half years. This includes initial reconstruction, through the procedures to address contouring and/ or surgery to exchange a tissue expander to a permanent implant, to the nipple reconstruction and nipple areolar tattooing. After that, you should receive yearly checkups. If the reconstruction is silicone-implant-based, the Food and Drug Administration (FDA) recommends MRIs of the breasts every two to three years to assure the implants are intact. Both silicone and saline breast implants may require replacement in about 10-15 years. Oncologists will continue to monitor your breasts from a cancer perspective.

Breast reconstruction is an option that can help you feel whole again after the arduous experience of breast cancer. Every surgeon has her or his own set of guidelines, recommendations and areas of expertise, so asking your surgeon these questions — and more — can help you make the difficult decisions that accompany overcoming breast cancer.

By Mayo Clinic Health System staff