Patient education: Breast reconstruction (The Basics)

What is breast reconstruction? — 

This is surgery to rebuild the breast after mastectomy. Mastectomy is surgery to remove a breast, for example, to treat or prevent cancer.

Breast reconstruction can be done with implants, or using tissue taken from other parts of your body, called "flaps." Your options for reconstruction might depend on the type of mastectomy you had.

Reconstruction can be done during mastectomy or later. If you have cancer, the timing for reconstruction depends on the stage of your cancer and what other treatments you need.

Breast reconstruction is an open surgery. This means that the doctor makes a cut, or "incision," in the skin. This lets them see directly inside the body when they do the surgery.

How can doctors reconstruct a breast? — 

The 2 main ways are with implants or with flaps. The doctor will talk to you about your options and help you choose.

●A breast implant is basically a breast-shaped container filled with salt water (called "saline") or something that feels like gelatin (called "silicone"). The implant can be inserted partly or completely under a layer of muscle in the chest. Implants are best for people with smaller breasts that don't droop.

●A flap reconstruction uses tissue from another part of the body to create a new breast. That tissue might be rotated in place, keeping its own blood supply (called a "pedicled" flap). Or it might be disconnected and then reattached to a new blood supply (called a "free" flap). How complicated the procedure is, and the risks involved, depend on the type of tissue used.

The doctor can also rebuild your nipple if needed. This is usually done a few months after breast reconstruction. The doctor can also tattoo the new nipple and area around the nipple (called the areola). This lets them match the color of your other nipple and make the new nipple look three-dimensional.

How do I prepare for breast reconstruction? — 

The doctor or nurse will tell you if you need to do anything special to prepare.

Before your procedure, your doctor will do an exam. This will also include information about treatment plans if you have cancer. They will look at the size, shape, and skin quality of your breasts. They will also carefully examine the possible donor sites for skin, fat or muscles.

They might send you to get tests, such as:

●Lab tests

●Chest X-ray or other imaging tests – These create pictures of the inside of the body.

●Electrocardiogram ("ECG")

Your doctor will also ask you about your "health history." This involves asking you questions about any health problems you have or had in the past, past surgeries, and any medicines you take. Tell them about:

●Any medicines you are taking – This includes any prescription or "over-the-counter" medicines you use, plus any herbal supplements you take. It helps to write down and bring a list of any medicines you take, or bring a bag with all of your medicines with you.

●Any allergies you have

●Any bleeding problems you have – Certain medicines, including some herbs and supplements, can increase the risk of bleeding. Some health conditions also increase this risk.

You will also get information about:

●Eating and drinking before your procedure – You might need to "fast" before surgery. This means not eating or drinking anything for a period of time. In other cases, you might be allowed to have liquids until a short time before the procedure. Whether you need to fast, and for how long, depends on the procedure you are having.

●Lowering the risk of infection – You might need to wash the area with a special soap.

●Quitting smoking (if you smoke) - Smoking can cause problems with healing after surgery.

●What help you will need when you go home – For example, you might need to have someone else bring you home or stay with you for some time while you recover.

Ask the doctor or nurse if you have questions or if there is anything you do not understand.

What happens during breast reconstruction? — 

When it is time for the procedure:

●You will get an "IV," which is a thin tube that goes into a vein. This can be used to give you fluids and medicines.

●You will get anesthesia medicines. This is to make sure that you do not feel pain during the procedure. Most people get general anesthesia. This makes you unconscious so you can't feel, see, or hear anything during the procedure. If you have general anesthesia, you might get a breathing tube to help you breathe.

●You might get medicines to help control pain after the procedure.

●The doctors and nurses will monitor your breathing, blood pressure, and heart rate during the procedure.

●To reconstruct the breast with an implant:

•First, the doctor inserts a device called an "expander." Often, another piece of material (called "ADM") is added to support the expander, and later the implant. The expander stretches the skin and muscle in the chest. Over time, the doctor gradually adds more and more fluid to the expander until the skin and muscle are stretched enough for the size of the implant.

•Then, they do another surgery to replace the expander with the implant (figure 1).

●To reconstruct the breast with a flap, the steps depend on the type of flap:

•Perforator flaps (figure 2) – This is the most common type used for breast reconstruction. It is usually taken from the belly. One type is called a "DIEP flap." It is made up of skin and fat, but not muscle.

•TRAM flaps (figure 3) – This is also taken from the belly, but is made up of skin, fat, and muscle.

•Latissimus dorsi ("LD") flap (figure 4) – This is taken from the back and is made up of skin, fat, and muscle. People who have this kind of flap often also get an implant.

●The doctor might place 1 or more drains. These remove fluid and help with healing.

●They will close your incisions and cover them with clean bandages.

●The surgery takes about 1 to 4 hours.

What happens after breast reconstruction? — 

You will be taken to a recovery room. The staff will watch you closely as your anesthesia wears off. In some cases, you can go home the same day of implant surgery. In others cases and for flap reconstruction, you might spend a night or 2 in the hospital.

As you recover:

●You might feel groggy or confused for a short time. You might also feel nauseated or vomit. The doctor or nurse can give you medicine to help with this.

●If you had a breathing tube, you might have a sore throat. This usually gets better quickly.

●The staff will help you get out of bed and start moving around when you are ready.

●You will get medicine if needed to help with pain. You might need other medicines, too.

●When you are ready to eat, you will start with clear liquids. Then, you can start eating as you are able. You might feel better if you start with bland foods.

What are the risks of breast reconstruction? — 

Your doctor will talk to you about all of the possible risks, and answer your questions. Possible risks include:

●Bleeding

●Infection

●Scarring or wrinkled skin over an implant

●Change of sensation in the breast – This might be short term or long-lasting.

●Problems with the implant

●Problems with tissue used for a flap

●A bulge or hernia where muscle was removed to make the flap

What else should I know? — 

Before you go home, make sure that you know what problems to look out for and when you should call the doctor. Make sure that you understand your doctor's or nurse's instructions. Ask questions about anything you do not understand.

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