What you need to know about breast reconstruction

Breast reconstruction helps people who have undergone a mastectomy or had breast tissue removed due to cancer or other medical conditions restore a sense of wholeness and self-confidence. However, while breast reconstruction is a valid option for many people, it's equally important for individuals to know it’s OK to choose not to undergo reconstruction.

Everyone has their unique preferences and should feel empowered to make a decision that is right for them, says Erin Carroll, a physician assistant in plastic and reconstructive surgery affiliated with Sharp Memorial Hospital and Sharp Mary Birch Hospital for Women & Newborns.

Here, she provides answers to your top questions about breast reconstruction:

What is breast reconstruction?

Breast reconstruction aims to recreate a breast after a lumpectomy or mastectomy. A lumpectomy involves the removal of a portion of the breast tissue, while a mastectomy removes all of the breast tissue.

During a mastectomy, the surgeon may or may not remove your nipple, depending on your preference and the surgeon's recommendation. If your nipple is removed, nipple reconstruction can be performed as part of your breast reconstruction.

What are my breast reconstruction options?

There are two options available for breast reconstruction: reconstruction with implants and reconstruction using your own tissue, which is known as autologous reconstruction. Many people choose implant-based reconstruction using either saline or silicone implants because it’s a faster and less invasive way to recover compared to reconstruction with their own tissue. However, it’s essential to note that implants have a lifespan of approximately 10 to 12 years and will need to be replaced.

If you have undergone radiation therapy in the past, implant reconstruction may not be the best choice, as prior radiation therapy increases the risk of infection, delayed wound healing and contracture of the implant, which is when scar tissue forms around the implant. These complications can cause distortion or pain in the affected area.

Autologous reconstruction uses tissue from your abdomen to rebuild the breast, avoiding the risks and complications associated with implants. However, it requires a more extended surgery and recovery time. What's more, it’s only an option if you have enough tissue in the abdominal region and no prior tummy tuck — also known as abdominoplasty — or clotting disorders.

What happens during breast reconstruction surgery with implants?

The process of breast reconstruction with implants usually involves multiple stages. The first is the insertion of tissue expanders that make room for the eventual breast reconstruction.

In the second stage, the expander is removed and replaced with a permanent implant. The timing of the second stage will depend on whether you require chemotherapy or radiation therapy and the completion of the tissue expansion. If no chemotherapy or radiation is required, your surgeon can proceed with the exchange surgery about two to three months after the expansions are finished.

Although there is an option for a one-stage implant reconstruction, which involves placing the final implant during the mastectomy surgery, this approach is not as common as the two-stage approach.

In cases where someone has undergone a one-sided mastectomy, it can be challenging to match the exact shape and size of the natural breast. However, some procedures, including breast reduction and lift, and implant placement, can improve symmetry. Breast reduction and lift can raise the natural breast and make it smaller, while implant placement can increase breast volume when the natural breast is smaller than the reconstructed breast.

What are the differences between saline and silicone implants?

Plastic surgeons use either saline or silicone implants for implant-based breast reconstruction. Saline implants are made of a silicone shell filled with salt water during the surgery to reach your desired breast size before being placed inside the breast pocket.

These implants are then monitored for any leakage or rupture. If either occurs, the silicone shell remains in the breast pocket while your body naturally absorbs the saline solution. It is then recommended to have the implant removed and replaced.

On the other hand, silicone implants are made of a silicone shell and silicone interior. To monitor these implants, you’re advised to undergo an MRI of the breasts five years after the placement of the implants and then every three years thereafter to ensure your implants remain intact. If a silicone implant ruptures, removal and replacement is suggested.

What are my options for nipple reconstruction?

If you have a mastectomy and your nipple is removed, you can choose to have nipple reconstruction after the second-stage surgery. Nipple reconstruction is typically done three to six months after your implant reconstruction is complete and no further procedures are planned. There are two options for nipple reconstruction: the "flap" technique using your own tissue, or 3D nipple areolar tattooing by a tattoo artist.

The "flap" technique involves using your skin to create a nipple that protrudes outward. A small piece of mesh is used to maintain the projection. This procedure is performed in an operating room, and a nipple guard is placed over the reconstructed nipple to protect it. Once your nipple has healed and you have been given the OK by your plastic surgeon, you can opt for areola tattooing around your nipple to improve its appearance.

If you cannot safely undergo nipple reconstruction, due to having thin skin, or do not want additional surgeries, 3D nipple and areola tattooing is an option. A local tattoo artist performs the tattooing after you receive a referral from your doctor. The tattoo artist uses different shading and color techniques to create a nipple and areola. However, the tattoo will remain flat and have no projection.

What are the risks of breast reconstruction?

Like any surgical procedure, there are potential risks and complications in breast reconstruction, including:

• Pain

• Bleeding

• Infection

• Delayed wound healing

• Fluid accumulation

• Unevenness

• Partial or complete loss of the nipple and areola

• Loss of sensation

• Possibility of discovering additional breast cancer during the operation

Risks associated with implants include:

• Capsular contracture

• Animation deformity, when the shape of the reconstructed breast changes during muscle contraction

• Implant leak

• Implant rupture

• Rippling

• Need for further revision surgery

"If a patient is considering breast reconstruction, it is important to consult with their health care provider to get more information on the risks, benefits and alternatives involved," Carroll says. "Ultimately, the decision on whether to undergo breast reconstruction should be based on the patient's preference. It’s important to understand that going flat is also an option."

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