Which Type of Breast Reconstruction Is Right For You?

A woman in Australia faces a 1 in 9 lifetime risk of developing breast cancer. Her 5-year survival rate is nearly 90 per cent. Many women lose one breast or both to the disease. Despite Medicare covering the cost of breast reconstruction in breast cancer patients, the rates of breast reconstruction remain rather low. Lack of information about options could be the key to why most women undergoing a full or partial mastectomy are not having breast reconstruction. Let us explore the different breast reconstruction options suitable for a wide variety of women.  

Australian women face a 1 in 9 lifetime risk of developing breast cancer. The Breast Cancer Network Australia estimates that around 14,610 Australian women are likely to have been diagnosed with breast cancer in 2012. The Cancer Australia government website projects a rise to 17,210 new cases of breast cancer by 2020. The good news is that by 2010, the 5-year survival rate for a woman diagnosed with breast cancer had risen to over 89 per cent. Most breast cancer survivors go on to live long and healthy lives after treatment, although many lose one breast or both to the disease.

A unilateral or bilateral mastectomy or lumpectomy can affect how survivors of breast cancer view themselves and how they relate to their intimate partners. Because most women think of their breasts as symbols of femininity, attractiveness and motherhood, the loss of one or both breasts or even part of one can be a devastating experience.

This article discusses the options and choices faced by women considering breast reconstruction.

What is breast reconstruction?

Breast reconstruction is an attempt to restore the breast’s shape, appearance and size following mastectomy or partial removal. Breast reconstruction requires the use of multiple surgical techniques.

A reconstructed breast is an attractive alternative to a breast prosthesis, and is infinitely better than doing nothing at all. A reconstructed breast can remove the constant reminder of what was lost to cancer and help relieve some of the feelings of loss.

Breast reconstruction in no way interferes with treatment or surveillance of breast cancer.

Stages of breast reconstruction

Three main steps are involved in any breast reconstruction process.

The first step is the creation of the breast mound.

The second stage involves touch-ups or revisions to the reconstructed breast. For people who have had a unilateral mastectomy, it may be desirable to modify the remaining breast for the sake of symmetry. This optional procedure may involve a breast lift, breast reduction or a breast augmentation.

The third and final stage of breast reconstruction is the creation of a nipple and areola. This is also an optional procedure.

Types of breast reconstruction

A breast can be reconstructed in one of three ways:

• Using a silicone gel implant, which acts as the breast mound.
• Building a breast mound with tissue taken from other locations on the body such as the abdomen, back, buttocks or hips (love handles). Surgeons refer to this as autologous reconstruction.
• A combination of borrowed tissue and a silicone gel implant. The implants are placed inside pockets of tissue borrowed from another part of the body.

Which option is best for you depends on multiple factors, including:

• Your own preferences – Some people prefer not to have artificial implants. Others don’t mind.
• Your surgeon’s preferences – Cost, timing and other factors, like your anatomy, make some options more viable than others.
• Timing of the reconstruction – Those who know that they want a breast reconstruction in the future and have worked through the mastectomy with their surgeons generally have more options than those who decide after the surgery to have breast reconstruction.
• Natural skin preserved at mastectomy – Whether the natural skin envelope from your removed breast was preserved during the mastectomy.
• Your individual anatomy – Whether you have enough tissue or muscle to be borrowed for rebuilding a breast is also a factor in the decision.
• Previous cancer treatments – Especially cancer treatments such as radiation therapy may limit your options during breast reconstruction.

Here is a look at each of the breast reconstruction options in detail.

Breast reconstruction with an implant

Breast reconstruction with an implant is the easiest reconstruction method, but is a relatively long process. Its greatest advantage is that, unlike other methods, most women are eligible for this method of reconstruction.

Reconstructing a breast with breast implants can be achieved in two ways. One option is using the natural skin of the removed breast to hold the implant. The alternative method is to reconstruct the breast envelope with tissue borrowed from another part of the body.

For the former, the skin of the removed breast has to be preserved intact at the time of the mastectomy. This option, which uses tissue expanders, is open only to women who know they want breast reconstruction and work with their cancer surgeon to preserve the natural skin envelope from the breast at the time its removed.

Implanting a tissue expander—an expandable temporary breast implant filled with saline—in place of the removed breast mound, preserves the breast skin. If this is not done immediately, and the woman undergoes radiation therapy, the skin will become damaged, making it impossible to use the natural breast skin envelope.

Once the breast tissue expansion process is complete, the surgeon will typically replace the temporary expander with a natural looking, teardrop-shaped silicone breast implant. This usually takes place 12 to 24 weeks after the final expansion.

You can read more about this process in the Costhetics article, Tissue Expanders for Breast Reconstruction.

Autologous breast reconstruction

In this method the breast mound is reconstructed with tissue from another part of the body. Over the years, surgeons have become adept at transferring tissue to fill the breast area. There are multiple techniques for using muscle or other tissue from the abdomen, back, buttocks, hips and thighs for breast reconstruction.

Women who prefer a more natural reconstruction to an implant often opt for the autologous route. This is also true for women who can’t have an implant reconstruction. Women who have had radiation to the chest wall or have had a failed implant reconstruction can have breast reconstruction using their own tissue. These techniques are suitable both for those opting for immediate breast reconstruction and those who prefer or need delayed reconstruction, provided there is tissue to spare in another part of the body. Sometimes, women with an athletic build may not have the extra tissue necessary for this procedure.

An autologous reconstruction can be done in two ways—pedicle flap method or as free flap surgery—using different donor sites.

In the pedicle flap technique, blood vessels feeding the tissue flap are severed and the flap is tunnelled across the body from the donor area to the chest. Some blood vessels and nerves are left intact, reducing the risk of tissue death.

Free flap surgery removes the tissue from its blood supply and reattaches the tissue flap in the chest area. Microsurgery is then used to reattach the blood vessels to the tissue flap now forming the breast mound.

Most flap reconstruction methods are named after the muscles repurposed to serve as the breast mound. All you need to really know is the acronym and where the donation site of the muscle flap is.

Abdominal tissue breast reconstruction

There are multiple techniques using abdominal tissue:

• Abdomen TRAM flap surgery removes tissue from the abdomen using a procedure called transverse rectus abdominal muscle (TRAM) flap. TRAM is one of the four main muscles in the abdomen. For your surgeon to use this method, you need to have sufficient muscle tissue in this area. The TRAM flap transfer can be achieved either with the pedicle or the free flap method. Because this method uses the entire rectus muscle, it can weaken the abdominal wall, occasionally leading to hernia.
• A free TRAM flap or a muscle-sparing free TRAM helps retain abdominal strength.
• Abdomen DIEP flap technique uses the deep inferior epigastric perforator (DIEP) flap. In this procedure, which is similar to the muscle-sparing TRAM flap, only skin and fat tissue are removed, leaving the abdominal muscle intact. DIEP flaps are transferred using the free flap method. Again, you need enough spare fat and skin in the stomach area for this to be possible.
• A SIEA flap or superficial inferior epigastric artery flap is a variation of the DIEP flap, but involves a less invasive form of flap surgery. It is only possible for women with sufficient levels of SIEA blood vessels.

To be eligible for using the abdomen as a donor site, the patient must have enough abdominal wall tissue to create one or both breasts as needed. These methods are not suitable for those who have had previous abdominal surgery.

Using tissue from the upper back

The latissimus dorsi flap method uses skin, fat and muscle tissue from the upper back to build the breast mound. The flap is tunnelled beneath the skin to the chest area. The size of the breast mound is limited to small or medium when using this technique, because only moderate amounts of tissue can be transferred in this manner.

This technique can lead to muscle weakness in the arms, shoulders and back after surgery.

Buttocks, love handles and thighs

It is not just the tissue from the abdomen and back that are used as donor sites in breast reconstruction. Tissue from the buttocks, hips and thighs can also be used for this purpose.

• SGAP flap technique uses the superior gluteal artery perforato as a free flap from the buttocks. It is typically used on women who do not have a sufficient level of tissue to spare in their abdomens and backs. However, removing the SGAP flap deforms or flattens the appearance of the buttocks because a large chunk of tissue gets removed. Often follow-up surgery is necessary to reshape the buttocks. Surgeons also say that the blood vessel length of the SGAP flap can make it difficult to connect to the blood supply in the chest.
• LSGAP—so named because it uses lateral septocutaneous perforating branches of the superior gluteal artery—can be considered a new version of the SGAP. The technique, developed by Johns Hopkins surgeons, uses tissue from ‘love handles’ below the waist. It makes autologous breast reconstruction possible even in slim, athletic cancer patients who lack adequate fat sources elsewhere. Patients love this method because they lose stubborn love handles and avoid deformity in the buttocks at the same time—a double bonus. Surgically, SGAP appears to be less complicated than other options.
• TMG flap, named after the Transverse Myocutaneous Gracilis muscle, is taken from the inner thigh region, just as would occur during a cosmetic inner thigh lift. As only a part of the gracilis muscle is taken to ensure blood supply to this flap, there are no contour abnormalities in the thighs. This method is used to create relatively small breasts.

Because all these techniques limit the amount of skin available for the reconstruction, they are mostly used in immediate reconstructions—those, which take place immediately following a mastectomy. The risk of microsurgery failure is higher in these techniques than in the TRAM/DIEP flap techniques because the procedures are technically much more complicated. Only a few surgeons perform these operations.

In addition to the usual surgical risks, the downside of flap surgery is the risk of partial or complete loss of the flap. If the flap fails to flourish in the breast area, you have lost its use from the donor area as well. It is also possible to lose sensation both at the donor site and in the reconstructed breast.

Autologous tissue and implant combination

When there is limited natural tissue for an autologous breast reconstruction, the next best option is using a small tissue expander followed with a small implant to make up the volume.

This procedure is usually performed using the Latissimus Dorsi Flap, borrowing muscle and skin from the upper back.

Although this technique provides much of what is needed by way of skin, there is insufficient tissue to form the breast mound. This is why it’s necessary to use a tissue expander to stretch the borrowed skin and an implant to make up for the missing volume. This procedure is most commonly performed on women who have had a mastectomy on one breast followed by radiation therapy, making them unsuitable candidates for a TRAM or DIEP flap reconstruction.

You will not be advised to have this procedure if your work involves a lot of strenuous or repetitive overhead activities with your arms.

Beyond the tissue expansion, the key features of this type of reconstruction are how best to match the reconstructed breast with the opposite breast, and the reconstruction of the nipple and areola. Both these are optional procedures that enhance the results obtained with flap-plus-implant surgery.

People with large breasts may opt for a breast reduction in the remaining breast to bring about better symmetry. Those who have small and/or sagging breasts may need a breast lift and breast augmentation with an implant to match the reconstructed breast.

All these procedures are likely to leave scars. You will need to discuss the specifics with your surgeon, because the location of these scars will depend on the specific techniques used to bring about symmetry.

Reconstruction of the nipple and areola should ideally be performed at least three months after the breast is reconstructed, to allow the reconstructed breast to settle.

The new nipple can be created from the fat and tissue of the reconstructed breast. Or, if your remaining natural breast has a sufficiently large nipple, part of it can be used as a graft in a procedure referred to as ‘nipple share’. It is also possible to create a nipple using a wedge from the labial region. People who have excess and redundant labial tissue may prefer this alternative. You can read more about each of these procedures in our articles on breast lift, breast augmentation and breast reduction.

Timing is critical in breast reconstruction

It is possible to reconstruct the breast at the same time as the mastectomy itself. This is referred to as an immediate reconstruction.

Reconstruction can be delayed and performed at a later time as well.

Often this decision is not entirely up to you, because the characteristics and stage of the breast cancer may limit your options. The reconstruction decision and timing will have to be discussed with your oncologist and your breast reconstruction surgeon.

Immediate Reconstruction

In an immediate reconstruction, the breast mound is created at the same time as the mastectomy. Immediate reconstruction reduces the number of general anaesthetics you may need before completing reconstruction. It can also help minimise the blow to body image and self-esteem.

Delayed Reconstruction

Delayed reconstruction can be performed months or years after the mastectomy. Generally the wait is a minimum of six to nine months after the completion of any radiation therapy. This wait allows the skin on your chest to heal.

Limitations of breast reconstruction

A reconstructed breast is not a perfect replacement. It will not produce the same sensations or feel like the natural breast it replaces.

There will most likely be visible incision lines both from the reconstructive surgery and from the mastectomy. If tissue is taken from another location and used for reconstructing the breast, there will be incision lines at the donor site, such as in the back, buttocks or abdomen.

Asymmetry may be an issue in cases where only one breast was affected by cancer and then reconstructed. Your surgeon may recommend a breast lift, breast reduction or breast augmentation to the other breast to improve symmetry and position.

Making the decision

Multiple factors have to be considered in selecting the breast reconstruction option that is right for you.

	Tissue expander followed with Silicone implant	Autologous breast reconstruction (using own tissue)
Surgery	Two separate surgeries of around two hours each	One longer procedure that requires 3 to 4 hours for TRAM or latissimus flap surgery and 6 to 8 hours for microsurgery.
Hospitalisation	Day surgery. Overnight stay in some cases.	1 to 2 days average for pedicle TRAM flap surgery.5 days average for free DIEP flap surgery.
Recovery period	Two weeks following insertion of tissue expander.	6 to 8 weeks
Shape and feel of breast	Remains firm over time. There’s no natural sag.	Natural feel, durable, remains soft over time.
Scars	Mastectomy scar on breast.	Mastectomy scar on breast and a scar at the donor site.
Opposite breast	Changes may be necessary to match the implant.	Fewer changes needed for symmetry with reconstructed breast.
Complications	Breast feels firmer, could harden and may appear less natural with time.Needs to be replaced in 10 years or so.Potential for rupture	There is minimal risk of pedicle TRAM flap failure. Other flaps are more risky.There is a 1-3 percent risk of microsurgical failure that result in flap loss.Weakness of the abdomen, bulging and hernia are other potential complications with TRAM flap surgery.
Costs	Few hours of surgery means less costs	More hours of surgery lead to higher costs

Not many women are having breast reconstruction

Although breast reconstruction is an option available to women undergoing breast removal surgery, not all women go on to have their breasts reconstructed.
Breast reconstruction after breast removal surgery is paid for by Medicare, but there is a large gap—sometimes running to thousands of dollars—between what Medicare reimburses the patient and the actual costs incurred for breast surgery of any sort, including breast reconstruction. Often people find they are unable to afford this gap. But costs are not necessarily the main reason for low rates of breast reconstruction in Australia. Similarly low rates occur in the US and Canada too, both of which pay for breast reconstruction surgery.

Lack of awareness of options could be a key reason

Globally, the awareness of post-mastectomy breast reconstruction options appears to be rather lacking. A 2012 online survey conducted among women 18 years and older who did not have breast cancer, showed that survey participants knew little about breast reconstruction options, their outcomes or the factors that can affect the results of reconstructive surgery. Less than a quarter of the participants (23%) knew about the range of options for breast reconstruction. Even fewer (22%) were familiar with the expected outcomes of breast reconstruction. Less than one in five (19%) knew that the timing of breast cancer therapy and reconstructive surgery could limit their options and affect results. But 89% of respondents wanted to know in advance what to expect from breast reconstruction surgery. The survey was commissioned by the American Society of Plastic Surgeons (ASPS) prior to the launching of its Breast Reconstruction Awareness Day (Bra Day) campaign.

Previous studies have shown that only a third of women discuss breast reconstruction options with their surgeons before treatment for cancer.^[1]

The goal of the Bra Day campaign, organised by ASPS in collaboration with the Canadian Breast Cancer Foundation, Canadian Society of Plastic Surgeons and many other interest groups, is to “promote education, awareness and access for women who may wish to consider post-mastectomy breast reconstruction”.

On Bra Day in 2012, which was on 17 October, there were awareness campaigns in multiple locations around the US and Canada. Other nations participated, with the UK, Ireland, Finland, Belgium, Italy, Spain and Taiwan joining in. Australia did not participate.

Obviously, getting the information on breast reconstruction out to the Australian public has not been effective. There is a crying need for better communication between breast cancer surgeons and their patients, so that women who have lost breasts to cancer have the information they need to choose—or not choose—to have post-surgical breast reconstruction.

Your surgeon will be able to give you more information and help you better understand the options that are available to you.