Breast cancer

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Types of breast reconstruction

Your plastic surgeon will discuss the type of breast reconstruction that would work best for you. Women with larger breasts may need surgery on the other, unaffected breast to balance the appearance of their breasts.

Breast implants

A breast implant is a round or tear-shaped sac made of rubberized silicone. It is filled with sterile salt water (called saline) or silicone gel.

Types of surgery for breast implants

A breast implant is placed in a space under chest muscle. Doctors can use the following approaches to create the pocket.

Tissue expansion

If the skin and tissues in the chest are too tight or flat for the surgeon to place the implant, they will need to make the space larger. This is called tissue expansion.

Diagram of tissue expansion

The surgeon places an expander implant under the skin and muscles on the chest. An expander implant is an empty bag with a small valve, like a balloon. Sometimes the expander implant is placed during surgery to remove part or all of the breast (called a mastectomy). It can also be placed during a surgery done at a later time.

Once the expander implant is in place, the doctor slowly fills it with saline. The doctor passes a very small needle through the skin and into the valve to inject the saline. This is done every 1 or 2 weeks in the doctor’s office until the skin is stretched enough to fit a breast implant that is the same size as the opposite breast. This may take up to 3 months.

Once the skin is stretched enough, the surgeon does a second operation to remove the expander implant and place the permanent implant. Sometimes the expander implant is left in place as the final implant.

One-step reconstruction

One-step reconstruction is also called direct-to-implant reconstruction. It is a newer procedure that may be an option for some women. This type of implant uses special donated human skin tissue called acellular dermal matrix (AlloDerm, DermMatrix). The cells are removed from the donated tissue to prevent rejection.

Diagram of one step reconstruction

The surgeon stitches strips of the acellular dermal matrix to the breast tissue to create a pocket for the implant. Acellular dermal matrix may also be used to cover the edges of an implant. Over time, the acellular dermal matrix grows into the healthy breast tissue.

One-step reconstruction using acellular dermal matrix is not widely available in Canada. Talk to your plastic surgeon to find out if one-step reconstruction is an option for you.

Concerns about breast implants

Some women may have concerns about how silicone breast implants could affect their health. Recent monitoring of silicone breast implants in Canada found that they were safe and didn’t increase health problems.

In very rare situations, women with breast implants (silicone and saline) can develop a rare type of non-Hodgkin lymphoma called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). It starts in the scar tissue that forms around the implant. Recent research suggests that the risk is higher in women who have textured implants rather than those with smooth surfaces. Health agencies around the world are still collecting more information about how many women are diagnosed with BIA-ALCL.

If you are thinking about breast reconstruction using breast implants, talk to your plastic surgeon about the risks and benefits of saline and silicone implants.

Replacing and removing breast implants

Breast implants need to be replaced after being in the body for a number of years. You may also want to have an implant removed at some point. After a breast implant is removed, there may be dimpling, puckering, wrinkling or other changes to the appearance of your breast.

Talk to your surgeon if you are thinking about having your implant removed. They will discuss your options and help you decide if you want to have the implant removed or replaced.

Side effects

Side effects can happen with any type of surgery. They will depend mainly on the type of surgery and your overall health. Some women who have radiation therapy to the chest as part of breast cancer treatment may have more complications after surgery to place a breast implant.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Breast implant surgery may cause:

  • infection
  • buildup of fluid (called seroma) in the breast
  • pain
  • scar tissue around the breast implant (called capsular contracture), which makes the breast feel hard and lose its shape
  • movement of the implant
  • wrinkling of the implant, which makes the skin on the breast wrinkle
  • leaking or breaking of the implant

Tell your plastic surgeon if you have these side effects or others you think might be from your breast implant. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Autologous breast reconstruction

Autologous breast reconstruction uses fat and muscle tissues from other parts of your body to create a new breast. The reconstructed breast has a more natural feel than a breast implant.

Tissue techniques

Doctors can use the following tissue techniques to do an autologous breast reconstruction.

An abdominal free flap is the most common technique used for breast reconstruction. It is called a free flap because the tissue used to reconstruct your breast is completely removed from your stomach area (abdomen). This type of breast reconstruction may be an option for you if you have had radiation therapy treatment to your chest as part of your treatment for breast cancer. During surgery the flap is connected to blood vessels in your chest or under your arm. There are 3 types of free flaps used for breast construction:

  • the TRAM flap uses muscle, fat, skin and blood vessels from your abdomen
  • the DIEP and SIE flaps use only fat, skin and blood vessels from your abdomen

 

 

Diagram of a TRAM flap

 

 

Diagram of a DIEP or SIE flap

 

A pedicled flap uses an entire muscle from your abdomen, along with skin and fat to reconstruct your breast, like an abdominal flap. The difference is that a pedicled flap stays attached to the muscles and blood vessels in that area. The entire flap is moved under the skin to the breast area. This type of breast reconstruction may be an option for you if you haven’t had radiation therapy.

 

A back flap uses the muscle called the latissimus dorsi (LATS), fat and skin from your back to make a cushion or mound. A breast implant can be used if there isn’t enough tissue to make a natural looking breast. This type of flap is used if you have had radiation therapy to your chest or if you don’t have any extra skin and tissue on other areas to be used for breast reconstruction.

Diagram of a LATS flap

Other free flaps use skin, fat and blood vessels from other areas of your body to reconstruct your breast. Tissue may be taken from your buttocks or your upper thigh. This type of breast reconstruction is not commonly used.

Side effects

Side effects of autologous breast reconstruction will depend mainly on the type of surgery, where the flap tissue comes from and your overall health. Women with larger breasts and women who had radiation therapy to the chest may have more side effects after autologous breast reconstruction.

Side effects can happen with autologous breast reconstruction, but everyone’s experience is different. If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects go away on their own or can be treated, but some may last a long time or become permanent.

If you smoke, it’s strongly recommended that you quit at least 3 months before and for 1 month after having an autologous breast reconstruction. Smoking affects blood flow to the skin and underlying tissues, which can lead to infection, delayed healing and a higher risk that the tissue in the flap will die (called flap necrosis).

Autologous breast reconstruction may cause these side effects:

  • infection
  • bleeding
  • scars on the abdomen, back and reconstructed breast
  • flap necrosis
  • breasts that aren’t the same size or shape
  • weakness of the abdominal muscles
  • slightly different colour and texture in the reconstructed breast compared to the skin in the breast area
  • less muscle strength in the back on the side of the donor site

Tell your plastic surgeon if you have these side effects or others you think might be from your breast reconstruction surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Nipple and areola reconstruction

If a woman had a nipple-sparing mastectomy, the nipple and the dark-coloured skin around the nipple (called the areola) will still be in place.

If the nipple and areola were removed, the surgeon can also rebuild them to create a more natural-looking breast. This procedure is done after the reconstructed breast settles into its final shape, which is usually 3–6 months after breast reconstruction.

The tissue used for nipple reconstruction comes from the newly created breast or the nipple of the opposite breast. Doctors can also use skin from other parts of the body such as the folds of skin on either side of the vagina or the earlobe.

A new areola can be created by tattooing the skin to match the colour of the other breast or by using a skin graft.

A reconstructed nipple has much less feeling than a natural one. The nipple or areola may be a different colour than the other breast.

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