Rachel McKenna, MSN, CRNP & Allyson Burke, MSN, CRNP
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: March 1, 2013
It is never medically necessary to have breast reconstruction. This is considered an elective procedure, meaning you can choose to have it done or not. Some women choose to have a mastectomy (removal of all of the breast tissue) without reconstruction. Although it is considered elective, it is not considered solely cosmetic. This means that almost all insurance plans pay for breast reconstruction.
Many patients prefer to have reconstruction done (or at least the process started) at the same time as their mastectomy for a number of reasons. If you have breast reconstruction done at the same time as your mastectomy, this is called immediate reconstruction. Delayed reconstruction is the term used if you choose to have the mastectomy done and then wait for reconstruction to be done months, or even years, later. The majority of surgeries done at our institution are immediate reconstruction. With immediate reconstruction, you are decreasing your overall number of surgeries, you may have a better chance at an optimal cosmetic result and, for many women, there is a psychological benefit to immediately pursuing reconstruction.
The vast majority of women are candidates for breast reconstruction. There are a variety of reconstructive options, and you may not be a candidate for all types. You and your surgeon will discuss which type of breast reconstruction best fits your situation.
There are 3 major types of breast reconstruction. The first is a tissue expander/implant reconstruction. The second uses all your own tissues, typically from the abdomen but can come from your buttock or thighs. The third, less common option is a combination of the 2 methods using your own tissue from the back, the latisimus muscle, plus an implant underneath.
Implant reconstruction is almost always at least a two-step procedure. At the time of mastectomy, we will put in a tissue expander, which is a balloon device that is placed underneath the skin and muscles of the chest wall. At the time of surgery, the surgeon will put in a small amount of saline (salt water) into the expander through a valve in the device; however, you will be essentially flat. You are usually in the hospital for 2 days for this surgery, and recovery time is about 4 weeks.
After you heal from the mastectomy, approximately 3-4 weeks, you will begin the process of tissue expansion. This means that you will need to come into the office on a weekly or every other week basis. At your office visit, a small needle will be inserted through the skin in the chest wall and into the valve in the tissue expander. A small amount of saline is added at each visit. The chest muscle and skin are slowly stretched to accommodate the appropriate sized implant. Once your tissue expanders have the correct amount of saline in them you will need to wait another 4-6 weeks before the second stage of the surgery. If you need to undergo chemotherapy, the next stage is delayed until chemotherapy is completed.
In the second stage we will go in through the same incision on the breast, remove the tissue expander and place implants. This can be either silicone (gel) or saline filled implants. Both types of implants are made of a silicone shell, the difference is what the implants are filled with. Both are safe. Your surgeon will help you to make the choice of permanent implants that are best for you. This surgery does not require an overnight stay in the hospital and recovery takes about 2 week.
The whole process from time of mastectomy to when the final implants are placed takes anywhere between 3-6 months.
Implants are not lifetime devices, and both saline and silicone implants can rupture and leak. If you have saline implants, you will notice a slow deflation of the implant. The body is able to absorb the salt water leaking out of the implant, and over a few days to weeks, you will notice that your implant gets smaller. If you have silicone implants, there may be a change in the shape of the implant; however, often times, there is no change at all. Many times, the only way to detect a leak in a silicone implant is through MRI. If you choose silicone implants, MRI will be scheduled by your doctor when clinically indicated to ensure that your implants are still intact. Implant rupture, regardless of saline or silicone, occurs at a rate of approximately 1% per year; this means that your implant can rupture at anytime after being placed. Most implants will need to be replaced every 10-15 years.
Placing implants after mastectomy is very different than putting in implants for cosmetic augmentation. When women have an augmentation, their skin and breast tissue are left intact. These healthy tissues are better able to stretch to accommodate and cushion the breast implant. After a mastectomy, your breast skin is very thin. The breast surgeon needs to make sure that all breast tissue is removed and in order to do this you are left with only a very thin layer of breast skin. This breast skin is not able to stretch in the way it needs to in order to accommodate an implant. This is why we have to very slowly and gently stretch the tissues using a tissue expander.
Women who need post mastectomy chemotherapy are still candidates for implants. Sometimes we need to change surgery dates based on your chemotherapy. For example, we will postpone your second stage surgery (to remove the tissue expanders and place the implants) until you are a safe period of time from your last chemotherapy. This time period can vary from 3 weeks to several months and will be determined by your surgeon and medical oncologist. This gives your body the necessary time to recover. Women undergoing chemotherapy may also take longer to heal their incisions. This is normal and expected.
Radiation and the impact on implants is something that needs to be discussed carefully with your surgeon. It is true that women who have implants and radiation can be at higher risk for multiple complications, such as capsular contracture. However, the timing of the radiation and implant, as well as the type of implant, can be adjusted to help minimize this risk.
The TRAM flap stands for transverse rectus abdominus myocutaneous flap. This type of reconstruction is when the skin, fat, and blood vessels are taken from your abdomen and transferred to the chest and made into a breast mound. There are two very different types of TRAM flap reconstruction and it is important to understand the difference.
One type of TRAM flap is a pedicled TRAM, this means that the flap is left attached to its original blood supply and is tunneled under the skin to the breast area. This type of surgery can significantly decrease the strength that you have in your abdomen.
The other type of TRAM flap is a free TRAM, In this type of flap, the surgeon cuts the flap of skin, fat, blood vessels, and only a portion of the muscle from its original location, and sutures the blood vessels to donor blood vessels in the chest. Although this type of flap requires more skill, it preserves the strength and function of your abdominal wall.
There are 2 other special flaps that can be taken from the abdomen called the DIEP or SIEA flap, that also require suturing the blood vessels together. These flaps take NO muscle from your abdomen.
The most common flaps performed are the free TRAM, DIEP, and SIEA flaps. The remainder of this Q&A will only address this type of surgery.
It is true that breast reconstruction using a free flap is more work up front; you are in the hospital for longer (usually 4 days) and has a longer recovery, 6 weeks. However there are many advantages to this type of breast reconstruction. Below is a brief summary of advantages and disadvantages. However, you will need to speak to your surgeon to decide the best type of reconstruction for you.
Although it is always a priority to take no abdominal wall muscle it is impossible to guarantee this prior to surgery. This type of surgery is based on blood vessels. We do not know the quality or exact location of your deep blood vessels until we get into surgery. If you choose to have this type of surgery you must understand that there is a chance we will need to take a small piece of muscle from your abdomen to ensure the success of the breast reconstruction.
Yes, there are several different types of free flap breast reconstruction.
Usually the tissue is taken from your lower abdomen. There are 3 possible types of free flap reconstruction from the lower abdomen. As discussed previously, the decision of which of these three is best for you is not finalized until the surgery is started and we can look at the anatomy of your abdominal wall.
If you have had a previous major abdominal surgery such as an abdominoplasty (tummy tuck) or if you do not have enough tissue on your lower abdomen to reconstruct your breast we can also use tissue from your buttocks or inner thighs. Many abdominal operations, such as Cesarean sections, do not limit our ability to use the tissue of the lower abdomen.
After surgery, you will be admitted to an intermediate care floor (level of care between a regular bed and an intensive care unit bed). A nurse will be checking the blood flow to your flap every hour for the first 48 hours, then every two hours for the remaining 48 hours of your hospital stay. This is done in a noninvasive way and is not painful or uncomfortable.
You will have several drains called Jackson-Pratt or "JP" drains post-operatively. These drains will remove the excess fluid from the surgical sites that would otherwise collect there. You will be going home with some or all of these drains. You will receive education while in the hospital on how to care for these.
You will be out of bed to a chair on the first day after surgery and up and walking on the second day. You should also be eating regular food by the second post-operative day. Patients typically spend 4 to 5 days in the hospital after this surgery before going home.
For implant reconstruction most women take 3-4 weeks off of work following the mastectomy and placement of the tissue expanders and one week off of work after the second stage surgery (removal of tissue expanders and placement of the permanent implant). Many women are able to return to work during the tissue expansion process.
For tissue flap reconstruction women generally take 6 weeks off of work.
It is safe to resume driving when all the drains are out (more about these below), when you are off all pain medication and when you have regained safe range of motion of your arms. For most women this is about 3 weeks after the mastectomy.
Jackson Pratt (JP) drains are placed under the skin during surgery to remove a collection of blood and other fluids. The drain looks like a narrow plastic tubing that connects to a drainage bulb (which is about the size of a closed fist). The JP drains expedite the drainage process and help decrease the chance of infection. You usually will go home with the drains. On an average, drains may stay up to 1 to 3 weeks. You will have at least one drain underneath the arms on the side of your mastectomy. If you use your own tissue you will have two drains in the abdominal area. The drains are fairly easy to take care of. You and your family members will be taught to care for them while you are in the hospital. Generally three times per day you will need to strip the tubing (clean it from the outside to make sure the tube stays open) and empty the fluid in the collection bulb. You will need to keep track of the 24 hour total of fluid coming out of each drain. A plastic surgery nurse will use these totals to determine when the drains need to be removed. The drains are easily removed in the office.
While the drains are in you cannot take a bath or submerge yourself in water. Showering with the drains in is fine. You also want to limit reaching and excessive stretching of your arms immediately after your mastectomy. Once the drains for the breasts are removed you may be given exercises to start. Generally these range of motion exercises are not started until 48 hours after the drains are removed.
If you have had tissue taken from your abdomen you will not be able to lift anything more than 7-10 lbs or do any strenuous exercise for 6 weeks. Walking is fine and can actually speed your recovery.
Bring to the hospital a shirt that either buttons or zips up the front. Just after surgery it can be painful to raise your arms overhead.
Sometimes your surgeon will request that you buy a special supportive bra to wear after surgery. This should be a bra without underwires and one that closes in the front. Many department stores sell these in the sports bra section. There are specialty boutiques that specialize in post mastectomy products and bras, ask your nurse if they know of a local shop. Some women are also more comfortable in a camisole with a shelf bra.
Whether you have had implant reconstruction or autologous tissue reconstruction you can expect to return within 2 weeks of your date of surgery to see your surgeon. You may return sooner for a visit with the nurse to have JP drains removed.