A diagnosis of breast cancer can be quite scary. Finding out that a mastectomy (surgery to remove one or both breasts) is required to treat the cancer can compound the devastation. For some women, the emotions surrounding the loss of one or both breasts can be almost as overwhelming as the cancer diagnosis itself.
Recent advances have expanded the range of reconstructive options available to women today. Patients can have excellent cosmetic results whether they choose to have the procedure done with breast implants or using their own tissue, generally known as flap surgery.
At Memorial Sloan Kettering Cancer Center (MSK), our plastic surgeons work tirelessly to improve reconstructive options, and many of them are innovators in the field. Establishing good communication with patients is key to their success.
MSK also has physician assistants specially trained in the art of tattooing who create highly realistic 3D nipples and areolas for hundreds of patients annually. You can learn more here.
To help you better understand your options, we spoke with MSK plastic and reconstructive surgeon Michelle Coriddi, MD.
“Reconstruction involves many options, and deciding which is best is a personal one,” says Dr. Coriddi. “I take time with each patient to discuss all of their options and the likely outcome of each.”
What is the goal of breast reconstruction and what factors do you consider when making a recommendation?
The goal of breast reconstruction after mastectomy [the removal of a breast] is to restore the breast mound, or mounds, and achieve symmetry. At MSK’s Center for Advanced Reconstruction, breast surgeons who perform mastectomies, plastic surgeons who reconstruct breasts, and realistic nipple tattoo specialists work closely with medical oncologists, radiation oncologists, and the patients themselves to develop the best surgical treatment and breast reconstruction strategy.
Factors I consider when making a recommendation to my patients include:
-
the patient’s goals regarding the appearance of their breast
-
patient’s own wisdom about the type of surgery she might want
-
the type of breast cancer — including the location and stage of the cancer
-
Body type
-
general state of health
-
additional treatment that may be required before or after surgery
What is involved in a breast implant reconstruction procedure?
A breast implant is the most common form of breast reconstruction and involves the use of either a silicone shell filled with either saline (sterile saline) or silicone (gel). At MSK, we use silicone more often because it is softer and more like a natural breast.
For many of our patients, implant surgery involves a few steps.
-
First, at the time of the mastectomy, we place a temporary tissue expander under or over the pectoralis muscle in the breast. Your surgeon will consider which approach is best for you.
-
After a few weeks, once things start to heal, we slowly fill the expander in the clinic with saline so that the skin – and the muscle, if the tissue expander is under the muscle – gradually stretches. On average, the extension process takes about six to eight weeks.
-
Then, after another six to eight weeks, we remove the expander and put the final implant in place. Before this second surgery, you will decide between a silicone-filled or saline-filled implant.
Is there an ideal candidate for breast implant reconstruction?
The best candidates for implants tend to be women with smaller to medium breasts. Women with larger breasts can have implant reconstruction, but if they have a unilateral mastectomy [when one breast is removed], sometimes we need to make a reduction in the natural breast to achieve symmetry. Accordingly, for women with a smaller breast size, we may need to do breast augmentation of the natural breast to achieve symmetry.
Implants can break or become infected, which may require another procedure afterward. In addition, the US Food and Drug Administration (FDA) has required that silicone implants be monitored for rupture with an imaging study every few years. However, implants can provide excellent results and are a great option for many women.
Is there a risk associated with breast implants and cancer?
The FDA stated that a small number of cases of squamous cell carcinoma (SCC) had been found in the scar tissue of women with breast implants. In addition, the FDA has stated that approximately 1,000 cases of breast implant-related anaplastic large cell lymphoma have been found in connection with certain textured implants. While the findings seem rare among the millions of women with implants, any new change in or around a breast implant — such as swelling, pain, a new lump or a new rash — should be evaluated by a doctor.
What is soft tissue flap breast reconstruction surgery?
Flap reconstruction uses the woman’s own tissue – including skin, fat and occasionally muscle – to reconstruct the breast. This tissue and skin can be obtained from a variety of places, and the site and method chosen will depend on factors such as the quantity and quality of tissue available as well as patient preference.
TRAM Flap (Abdominal Muscles) Breast Reconstruction
TRAM pedicle flap reconstruction, the original method, involves using tissue from the area below the umbilicus. Skin, fat, and at least one abdominal muscle tunnel under the skin up into the breast area, but remain attached to their blood vessels in the abdomen. This allows the transplanted tissue to continue to receive blood from where it came from, making it the simpler of the flap procedures. The downside is that it requires muscle sacrifice, which can potentially affect function in the abdominal area.
Free DIEP breast reconstruction and TRAM muscle flap
At MSK, our overall approach is to sacrifice the least amount of abdominal muscle possible to maintain abdominal function, and in most cases no muscle at all. We can do this using either — the TRAM free flap that protects the muscles or the free DIEP fin. These procedures involve moving the tissue and also reconnecting the tissue’s blood supply, which means microvascular surgery techniques are required to complete them. [Microvascular surgery refers to surgery that’s performed on very small blood vessels using an operating-room microscope and a variety of tiny, special instruments.] In a TRAM free muscle flap, very little muscle is removed, and in a DIEP flap no muscle is spared.
Breast, thigh and buttock reconstruction
In addition to the abdomen, other areas that often have a lot of tissue are the thighs and buttocks. The TUG and DUG flaps use skin, fat and a small piece of muscle from the thigh to reconstruct the breast. The buttock flap uses the buttock as a source of skin and fat for breast reconstruction.
What are the benefits of using your own tissue for breast reconstruction?
Using your own tissue creates the most natural breast. So if you want a bigger, softer breast, a flap is a very good choice. Additionally, it usually provides the best match with a contralateral natural breast if you are undergoing a unilateral mastectomy. With flaps, newly reconstructed breasts tend to age in the same way as a natural breast.
What the research has shown
The choice is a very personal one that women should make in close consultation with their doctor. Every case is different. You must have enough tissue available to donate, whether it is from your abdomen, thigh or buttock. For women who are very thin, implants can be a great alternative.
What are the risks or disadvantages of flap surgery?
It takes longer—performing a flap often adds three to six hours to a mastectomy, while a tissue expander usually only adds about 45 minutes. The main disadvantage of the flap is the potential effect it has on the area you are taking the tissue from. If the muscle is removed, there is a risk of weakening the abdomen.
What factors may prohibit reconstructive breast surgery?
As a general rule, we at MSK like to consider all patients as potential candidates for breast reconstruction surgery. Those who are not candidates tend to be patients with very advanced disease or those with other serious conditions.
When is the best time for breast reconstruction — at the time of the mastectomy or after?
We generally recommend reconstruction at the time of mastectomy, unless there are special circumstances. This allows us to use much of the natural breast skin during reconstruction and allows women to return to their normal lives as quickly as possible. That said, we see patients at all stages, including women who have had mastectomies without reconstruction or who have had mastectomies at other hospitals and are now reconsidering their original decision not to have reconstruction.
Additionally, if you have had a mastectomy without reconstruction and radiation, implant reconstruction may no longer be a good option for you. Your surgeon will review all options and help you decide what is best.
This story was originally published in 2022 and has been updated.
