Considering Breast Reconstruction After Cancer Surgery

Abida Taher, MD, PhDJanuary 08, 2024

The things breast cancer patients should know & keep in mind.

“While breast cancer numbers have been decreasing since the year 2000, the number of breast reconstruction surgeries performed have been generally trending upward…The increase… may be due to more women taking a proactive role in wellness and recovery following breast cancer survival.”

Breast cancer surgery can be emotionally and physically challenging regardless of your age, stage in life or sexual orientation. Breast reconstruction gives you the opportunity to address those challenges in a way that is comfortable to you. It is a deeply personal decision and there is no right or wrong answer. Of course, going flat, meaning having no breast reconstruction and not using prostheses is an option that many women choose and feel comfortable with.

The goal of breast reconstruction is to restore one or both breasts to pre surgery shape, appearance, symmetry and size following mastectomy, or lumpectomy.

If only one breast is affected, it alone may be reconstructed. In addition, a breast lift, breast reduction or breast augmentation may be recommended for the opposite breast to improve symmetry of the size, shape and position of both breasts. Breast reconstruction can happen right after breast cancer surgery (immediate reconstruction) or months or years later (delayed reconstruction).

Your cancer care team will recommend the most appropriate breast reconstruction technique for you based on:

Your age, overall health, other medical conditions and lifestyle.
The type of mastectomy or lumpectomy you had & how much tissue remains.
The need for additional treatments for breast cancer (such as chemotherapy or radiation) based on your stage and type of tumor.
Previous surgeries that may make it difficult or impossible to take a flap from your belly. One example is abdominal surgery.
Your goals and desired appearance.
Whether you can live with a breast form or prosthesis that you take off and put on?
Are you OK with having more surgery for breast reconstruction after mastectomy or lumpectomy?

When it comes to breast reconstruction surgery after mastectomy, there are two main types of procedures.

Flap Reconstruction

In flap reconstruction, your surgeon takes tissue (also called flap) from your own body and uses it to form a breast. Usually tissue is taken from the belly but it can also come from your thigh, back or bottom. The surgery will involve removal of fat, skin, blood vessels and muscle from these parts of your body to form a new breast. Sometimes, the surgeon may move a flap through your body (called a pedicled flap) which retains its own blood supply or they may detach the flap from its blood supply (free flap) and attach it to blood vessels in your chest.

There are several types of flap reconstruction including:

DIEP Flap: The surgeon takes skin, fat and blood vessels from the lower belly. A DIEP flap does not remove the underlying abdominal (belly) muscle. Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. Because no muscle is used, most women recover more quickly and have a lower risk of losing abdominal muscle strength with a DIEP flap compared to any of the TRAM flap procedures.
TRAM Flap: TRAM stands for Transverse Rectus Abdominis, a muscle in your lower abdomen between your waist and your pubic bone. A flap of this skin, fat, and all or part of the underlying rectus abdominis muscle are used to reconstruct the breast in a TRAM flap procedure. TRAM flaps are the most commonly performed type of flap reconstruction, partly because TRAM flap tissue is very similar to breast tissue and makes a good substitute. There are two main types of TRAM flaps: Free TRAM flap and Attached TRAM flap.
Latissimus Dorsi (LD) Flap: In this case, tissue and muscle from the back is used. The surgeon transplants the LD flap (still connected to its own blood supply) through the back to the breast area.
IGAP Flap: An IGAP flap uses a section of skin and fat from your lower buttocks — basically the lower section of the “butt cheek,” near the buttocks crease to reconstruct the breast. Because no muscle is used, an IGAP flap is considered a muscle-sparing type of flap.
SGAP Flap: An SGAP flap or gluteal perforator hip flap, uses a specific blood vessel as well as a section of skin and fat from your upper buttocks/hip (also called ‘love handles’) to reconstruct the breast. Because no muscle is used, an SGAP flap is also considered a muscle-sparing type of flap.
PAP Flap: Your surgeon removes tissue from the inner and back of your thigh and uses it to form a breast. This procedure does not transplant muscle from your thigh.
TUG Flap: Similar to a PAP flap, this technique uses tissue from your thigh. A TUG flap transplants muscle as well as tissue.

Implant Reconstruction

In implant reconstruction, surgeons use saline or silicone implants to recreate breast tissue. Sometimes surgeons use a combination of implants and tissue from your body. Implant reconstruction can happen along with a mastectomy or you can delay the process to have this procedure after a mastectomy.

The types of implant reconstruction are:

Under the Chest Muscle: Your surgeon lifts up the chest muscle (also called pectoralis muscle) and places the implant underneath it.
Above the Chest Muscle: Your surgeon places the implant on top of the chest muscle. You may not need as much recovery time because your chest muscle remains in place.
Implant with Tissue Expander: First, at the time of mastectomy, the surgeon places a tissue expander underneath the pectoralis muscle in the chest. After a couple of weeks, once things start to heal, the expander is slowly filled with saline so that the muscle and skin gradually stretch out. On average, the expansion process takes around six to eight weeks. Then, after another 6 to 8 weeks, the expander is removed and the final implant is put in its place.

Oncoplastic Reconstruction After Lumpectomy

Oncoplastic surgery is a type of breast reconstruction for patients who have had a partial mastectomy or lumpectomy. In some cases, after lumpectomy, a divot or dent forms and causes visible indentation in the breast, a retractable scar, or distortions in the nipple’s appearance. Any radiation therapy given after lumpectomy can worsen the treated breast’s appearance, and it also can affect the treated breast’s size and shape. Surgeons use the techniques of breast reduction or breast lift at the same time as the lumpectomy. The breast reduction or breast lift helps to fill in the defect created by the lumpectomy and improves the breast shape. In most cases, surgeons perform oncoplastic surgery at the same time as lumpectomy unless there is concern for positive margins after lumpectomy. There may also be a need for breast reduction or lift on the opposite breast for symmetry. Some types of mastectomy leave the nipple and areola in place (nipple-sparing mastectomy). The areola is the dark skin surrounding the nipple. If necessary, surgeons can create a new nipple by grafting skin from another part of the body to shape into a nipple. Another option is to get a 3D tattoo of an areola after nipple reconstruction by trained tattoo artists that create realistic images of an areola.

“Studies have revealed that only 23% of women understand the wide range of breast reconstruction options available.”

The Breast Cancer Patient Education Act (BCPEA) was implemented in October 2016 to inform breast cancer patients about the availability and coverage of breast reconstruction and prostheses. Like all surgeries, breast reconstruction carries its own risks too. It is vital to talk to your doctor/cancer care team while you are considering the procedure. (Use this checklist of questions to clear all your doubts.) It is also recommended that you consult with a plastic surgeon certified by the American Board of Plastic Surgery, and preferably one who is a member of the American Society of Plastic Surgeons. The type and timing of breast reconstruction is unique to each patient; so it helps to involve a plastic surgeon early in the process. One last thing, there is nothing more reassuring like hearing from other women who have chosen to have this procedure. Check out your local cancer support groups to find other women who can help you deal with the process.