The George Washington University Hospital Center for Breast Care Services offers breast reconstruction for women after a mastectomy. If you have been diagnosed with a condition requiring mastectomy, you and your physician may be considering subsequent reconstructive surgery to create a breast that is as close as possible in form and appearance to the natural breast. At the Center for Breast Care Services, expert reconstructive plastic surgeons are available to discuss current options and to help you determine which course is medically and physically appropriate for you.

The decision to move forward with breast reconstructive surgery inevitably depends upon your individual circumstances. Women whose cancer seems to have been eliminated by mastectomy are the best candidates for reconstruction. Fortunately, the decision to undergo reconstructive surgery is far less urgent than the decisions you’ve probably encountered since your diagnosis.

From a medical standpoint reconstruction can occur:

• Immediately after mastectomy is performed,
• Months or years after mastectomy, or
• Not at all

Many breast surgeons, however, feel it is psychologically beneficial for mastectomy patients to consider reconstructive surgery. If your health condition permits, reconstruction of a breast often is possible immediately following its removal, allowing the patient to awaken from her mastectomy without having to face the experience of viewing her chest without a breast.

Although it may seem more comfortable to choose reconstructive surgery immediately after breast removal, there are several legitimate reasons to wait. First, since planning for reconstruction may begin soon after your diagnosis, you may feel you don’t have enough time to weigh your options regarding which procedure is best and when it should take place. You are encouraged to think about these options carefully and make the optimal decision for you. Some patients undergoing a mastectomy do not want any further surgery than is absolutely necessary.

Your surgeon may also advise that you wait to undergo breast reconstruction due to certain medical circumstances. For instance, if the breast is to be rebuilt using a more complicated procedure (flaps of skin and underlying tissue), it may be in your best interest to have a delayed reconstruction. Women with other health risk factors, such as obesity, high blood pressure, smoking, and those with certain types of breast cancers, may also be advised to wait. Either way, understanding your various options for reconstruction before surgery can help you prepare for a mastectomy with a more optimistic and hopeful outlook for the future.

All surgeries carry some degree of risk and uncertainty. Some uncommon yet possible surgical difficulties, including bleeding, fluid collection, excessive scar tissue and difficulties with anesthesia can occur with any operation. Smokers should also be made aware that nicotine might delay healing and possibly result in conspicuous scars and/or prolonged recovery.

Breast reconstruction has no known effect on the recurrence of cancer since this most often occurs in surrounding skin, not reconstructed tissue. The reconstructed breast will not interfere with chemotherapy or radiation treatment.

After your breast surgeon and reconstructive plastic surgeon at GW have evaluated your health, age, anatomy, skin tissue, and clinical situation, you and your doctor can discuss which reconstruction option is best for you. Weighing the risks and limitations of each option should help you determine which choice is right for you.

The surgical procedure options available at The George Washington University Hospital Center for Breast Care Services include flap reconstruction, implant, and nipple reconstruction.

Flap reconstruction involves the usage of your own tissue to recreate a breast. Since your own skin, muscle and fat are used in this procedure, the reconstructed breast will more closely reflect your bodily changes, such as gaining or losing weight and aging. However, these operations take the longest to complete and are associated with a somewhat higher risk of complications.

There are three types of flap reconstruction:

• The Latissimus Dorsi Procedure uses tissue from your back to reconstruct the breast and is tunneled under the skin to your breast area.
• TRAM Flap (Transverse Rectus Abdominous Myocutaneous) is a common choice. Tissue is taken from your abdomen and used to reconstruct the breast.
• Free Flap Reconstruction is the most complicated flap procedure. Here, tissue is removed from the abdomen or buttocks and transplanted to the breast area. The Free Flap option also reconnects blood vessels to new ones in your breast area.

With any of the flap procedures, scars will appear at the tissue donor site as well as at the reconstructed breast area. When a breast is reconstructed using your own tissue, however, the result will feel more natural, limiting any concern about use of foreign material in your body.

Implants as a reconstructive option are most appropriate for women who want to undergo the least amount of surgery. The implant can be filled with saline (salt-water solution) or silicone gel and is placed under the chest muscle through an incision made by the surgeon. Although it is the least complicated breast reconstruction type, implants may pose some specific surgical risks. For example, there is a low incidence of developing infection due to the implant, which usually occurs within the first two weeks following surgery. In this case, your doctor may decide to remove the implant until the infection clears; a new implant can be inserted at a later time. The most common problem seen with breast reconstruction, capsular contracture, occurs if the scar or capsule around the implant begins tightening; this pressure on the soft implant may cause the breast to feel hard. In addition, implants may rupture, requiring replacement surgery. However, your Breast Surgeon and reconstructive plastic surgeon at GW will work in conjunction with one another to minimize these and other risks.

The most common technique for implant placement is skin expansion, which requires a subsequent insertion of the actual implant. Following a mastectomy, the surgeon will insert a tissue expander to stretch the skin, and create room for a permanent implant. The tissue expander is a small, balloon-like bag inserted beneath the chest wall and expanded over time by periodically adding saline until the breast area is stretched to the desired size. The tissue expander can be placed following mastectomy, requiring only one return visit to remove the expander and insert a more permanent saline or silicone gel-filled implant. Some expanders, though, are designed to leave in place as the final implant.

If desired, nipple and areola (skin surrounding nipple) reconstruction may be performed following any type of reconstructive surgery. This procedure is usually performed at least three months after breast reconstruction to allow for correct positioning of the nipple, or following radiation or chemotherapy if required.

Recovery time is shortest when reconstruction is performed apart from the mastectomy and if implants are used without flaps. Keep in mind that the desired result of reconstructive surgery is improvement, not perfection. Most likely, your reconstructed breast may feel firmer and look rounder or higher than your natural breast. You will not experience the same sensations as you would with a natural breast. The surgery will try to achieve evenness of the breasts, however the reconstructed breast will probably not match your opposite breast exactly and may not have the same contour as your breast before the mastectomy.

Often, (usually at the time of the nipple-areola reconstruction) an adjustment of the opposite breast is necessary to achieve as much symmetry as possible. Women frequently inquire about insurance coverage regarding this procedure; insurance companies are obliged by law to cover all surgeries to obtain symmetry following mastectomy.

After you have determined which alternative best suits your needs, The George Washington University Hospital Center for Breast Care Services will make every effort to ensure the highest degree of comfort, guidance, and professional medical care.