Breast reconstruction helps women
get back to a normal life after mastectomy

Breast reconstruction surgery can restore the appearance of a natural breast after a mastectomy—and help a woman look and feel like her normal self again. Many women find that breast reconstruction can significantly improve their self-image, self-confidence and quality of life.

Dr. Rappaport is part of the breast cancer tumor board at Houston's Methodist Hospital, part of the world-renowned Texas Medical Center.

There are many decisions to make when faced with losing a breast due to cancer or another condition. Dr. Rappaport can help you understand your options for breast reconstruction and the results you can realistically expect. He will work in partnership with you, your oncologist and your breast surgeon to achieve the outcome you desire.

Who is a candidate for breast reconstruction?

Whether breast reconstruction is suitable for you depends largely on the type of cancer surgery you are having. Women who undergo a mastectomy are definitely candidates for breast reconstruction surgery.

A promising new trend is nipple-sparing mastectomy and reconstruction. Leaving the nipple and areola in place after mastectomy allows women to have very natural-looking breasts after reconstructive surgery.

Some women who choose a lumpectomy, where only a portion of the breast is affected, do not want or need reconstruction. Others who have a lumpectomy find that reconstructive surgery helps them regain a normal appearance and feel better about themselves.

Dr. Rappaport will evaluate health factors including heart or lung conditions, obesity, diabetes, smoking, back problems, previous breast or abdominal surgery, and bleeding or reactions to anesthesia in determining whether you are a good candidate for reconstructive surgery.

It's important that you are also emotionally ready for breast reconstruction surgery. Dr. Rappaport will discuss the timing of your surgery to help you decide what is best for you.

Which factors help determine
your breast reconstruction options?

• Your physique
• The extent and type of tumor
• Whether you will have radiation therapy

What are the timing options for breast reconstruction?

• Immediate. Breast reconstruction can be performed at the same time as your mastectomy or lumpectomy; or
• Delayed. You may choose to delay reconstruction for weeks, months or even longer after your mastectomy or lumpectomy. It's entirely up to you.

What are the types
of breast reconstruction techniques?

Breast implant after nipple-sparing mastectomy

“There's a trend of conserving the nipple and areola in certain mastectomy patients, with replacement of the breast mound itself but sparing the anatomical landmarks of the breast,” Dr. Rappaport explains. “After nipple-sparing mastectomy and reconstruction, some women actually have a better shape to their breasts than they had before.”

Breast implant with tissue expander

Implant reconstruction involves surgically placing a tissue expander that functions as a spacer to make room for a breast implant.

The tissue expander has a port either integrated into the device or placed under the skin several inches away. This port provides a mechanism to gradually fill the expander and shape the skin in preparation for a breast implant. The port is filled over several weeks during a series of short in-office procedures.

When the tissue has been sufficiently expanded, Dr. Rappaport will perform an outpatient surgical procedure to place a saline-filled or gel-filled breast implant. Some expanders also function as breast implants.

The total time from expander placement to implant placement is approximately three months.

Expander/implant advantages:

• Simplest form of breast reconstruction
• Minimal scarring
• Initial expander is placed immediately after mastectomy
• One-night hospital stay
• Short recuperation

Expander/implant disadvantages:

• Implants are not considered permanent devices; they may require replacement
• Risk of capsular contracture (scar tissue hardening around the implant)
• Implant rupture
• Implant “rippling”—where the edges are visible through the skin
• Deflation of saline implant
• Some believe implants do not look or feel as natural as body tissue

Expander/implant recovery

• Typically one night in the hospital after expander surgery
• Drainage tubes are removed after about a week
• Implant placement is done on an outpatient basis

Creating a breast mound with a tissue flap

Autologous (using one's own tissue) reconstruction, sometimes referred to as flap reconstruction, is another option. There are two primary types of flap reconstruction procedures:

• A TRAM (transverse rectus abdominis muscle) flap uses tissue from the patient's abdomen. Patients with excess abdominal skin and fat are the best potential candidates for this type of reconstruction.
• A back flap uses tissue from the latissimus dorsi muscle in the patient's back. With this procedure, an implant may also be used if the volume from the back flap alone is not sufficient.

Flap reconstructions are more technically demanding and thus have more potential complications than expander/implant procedures. Dr. Rappaport has performed more than 1,000 flap reconstruction procedures of all types and is highly skilled in this specialized reconstructive surgery.

TRAM flap reconstruction

TRAM flap advantages

• Soft, natural appearance of the reconstructed breast mound
• Improved abdominal control

TRAM flap disadvantages

• Donor site scar extends from hip to hip and around the navel
• Risk of total or partial tissue loss
• Possible abdominal weakness
• Longer procedure can pose greater risk

TRAM flap recovery

• Minimum one- to three-night hospital stay
• Drainage tubes are removed after about a week
• Stitches are removed in seven to 10 days
• Resume normal activities in six weeks

Back flap reconstruction

Back flap advantages

• Improved quality and long-term durability of breast reconstruction when paired with an implant by covering it with a layer of healthy tissue.
• Minimal scarring compared with other flap techniques.
• With enough back skin, small-breasted women might not need an implant.
• Reconstructed breast has a more natural appearance than one with an implant alone.
• Removing part of the latissimus dorsi muscle from the back creates no functional loss, except for women who participate in competitive sports.

Back flap disadvantages

• Small scar on the back.
• Can affect performance of competitive swimmers or skiers.
• Longer recovery than with implant placement alone.
• When an implant is used, all associated risks of implants are assumed.

Back flap recovery

• One or two nights in the hospital
• One or two weeks before normal activity can be resumed

Reconstructing the nipple

The expander/implant and flap reconstruction procedures help recreate the breast mound. After a patient recovers from that surgery, a separate procedure is needed to recreate the nipple and areola.

When is nipple reconstruction done?

The timing of nipple reconstruction depends on both the type of breast reconstruction a woman chooses and the cancer treatment prescribed.

• Patients undergoing radiation will typically have to wait three to six months for the effects of radiation to resolve before having nipple reconstruction.
• In implant reconstruction, 12 weeks usually provides enough healing time for nipple reconstruction.

How is nipple reconstruction performed?

Reconstruction of the nipple-areola complex can be done by local tissue rearrangement, or by medical tattooing.

Local tissue rearrangement is done by taking little skin flaps to recreate the nipple, then a skin graft around the new nipple, which usually darkens and becomes the areola.

Does insurance cover breast reconstruction surgery?

Yes. The Women's Health and Cancer Rights Act of 1998 requires group health plans, as well as their insurance companies and HMOs that cover mastectomies, to provide certain benefits for reconstructive breast surgery. However, your coverage may provide only a small part of the total fee.

Dr. Rappaport's office can help you by preparing and submitting the paperwork you need to apply for benefits.

Dr. Rappaport answers questions
about breast reconstruction

When is the best time to have
a breast reconstruction consultation?

“I prefer to see you before you have a mastectomy or lumpectomy if possible. Then I'm able to explain your options and reasonable expectations for breast reconstruction. If you have already had a mastectomy or lumpectomy, I will explain your options available at that time.

“A key point to understand is that reconstruction of the breast is a process—one that may require several procedures to produce the shape of the breast desired. The opposite breast may need to be altered as well in order to produce symmetry.”

What helps determine the timing
of breast reconstruction surgery?

“Of course, the decision is up to you. I think it is appropriate from a medical standpoint to do breast reconstruction at the same time as the mastectomy or lumpectomy. The big concern physically is whether you are going to have radiation following your mastectomy or lumpectomy.”

Should chemotherapy and radiation
affect my breast reconstruction plans?

“The most important consideration is the appropriate treatment of your breast cancer. I will work with you, your surgeon and your oncologist to develop an individualized treatment plan. The timing of your breast reconstruction will depend on the type and frequency of the cancer treatments recommended for you.”

How is radiation therapy a factor
in choosing reconstructive surgery?

“Radiation has a negative effect on the skin's texture and elasticity and its ability to withstand some of the techniques used in breast reconstruction surgery. Radiation therapy affects the skin's blood vessels and makes the skin more firm.”

Is there ever a way to avoid having radiation or chemotherapy?

“In some cases, a woman who is a candidate for lumpectomy, or breast conservation therapy, can eliminate the need for radiation or chemotherapy by choosing a simple mastectomy instead. It depends on the tumor type, grade and location and the size of the margins.

“Most of the time, a woman who is a lumpectomy candidate has a DCIS [ductile carcinoma in situ] or some type of very small, low-grade tumor, and performing a mastectomy in itself may be sufficient, along with sentinel node biopsy. These patients may not require chemotherapy or radiation.

“On the other hand, given the location of the tumor and the size of the margins, the proximity to the skin and the underlying muscle, radiation and/or chemotherapy may be necessary. That's why each woman's case has to be considered individually.”

How well will a reconstructed breast
match the other, natural breast?

“We have a saying when it comes to any kind of breast surgery: We're making sisters, not twins. I think that's pretty evident when we're dealing with breast reconstruction. While we strive for symmetry in performing breast reconstruction, many women's natural breasts are not perfectly symmetrical.

“To achieve better balance between the size and position of the breasts, it is not unusual to perform a reduction or lift on the opposite breast. Or the other breast may need an implant to match the volume of the reconstructed breast.”

Can I have breast reconstruction in stages?

“Yes. If you're going to be having chemotherapy or radiation, it's beneficial for you to at least have some breast mound so you can wear clothes normally and feel better about yourself. So what we start out with may not be the final product. The nipple/areola reconstruction can be done later.”

Which breast reconstruction method is most common?

“It's interesting how time has changed the procedures women choose. It used to be that tissue expanders along with tissue support were by far the most common choice. Today, I'd say that 50% of my breast reconstruction patients choose the expander/implant technique; about 35% choose the TRAM flap and 15% opt for the back flap technique.”

What are the long-term consequences
of breast reconstruction?

“While the TRAM flap is the longest procedure in terms of time to perform, if it goes well, the long-term consequences are pretty insignificant. If you're going to have a complication with that procedure, it's going to occur early.

“With the use of breast implants, we're still uncertain as to the long-term rate of capsular contracture or the need for reoperation.”

Why do I need a tissue expander?

“A tissue expander helps develop an appropriate pocket for the placement of a breast implant with adequate soft-tissue coverage.”

Is there any chance an implant
can cause my cancer to recur?

“There have been no reported cases, nor evidence to suggest that an implant caused a cancer to recur.”

How long can I wait after cancer surgery
to decide on reconstruction?

“Breast reconstruction surgery can be performed essentially at any time if you are undecided at the time of mastectomy or lumpectomy.”

Will I have feeling in my reconstructed breast?

“You may regain some skin sensation in the reconstructed breast, but not in the nipple-areola complex.”

When will my scars go away?

“Most scars will fade and soften with time. However, they
are permanent.”