What is breast reconstruction?
Breast Cancer reconstruction is a specialized
group of surgical procedures which recreate the breast, following a
mastectomy. These surgeries are performed by a reconstructive
plastic surgeon, who has undergone training for breast cancer
There are several different options to recreate
the breast and Dr. Burgess guides her patients towards the best option
for their individual situation with an optimal outcome. The
reconstructed breasts will look different from your natural breast, but
they can look very nice and natural in bras and bathing suits.
Below is a general overview of breast cancer reconstruction and the
possible options available in our clinic.
Breast Cancer reconstruction is a very personal
decision. Not every woman will pursue breast cancer
reconstruction after their mastectomy and not every woman is a good
candidate for surgery. However, depending on your unique
situation, you may consider reconstructing your breasts for a myriad of
different reasons. Following reconstruction, many women feel a
stronger sense of self-esteem and appreciate filling out clothing, bras
and bathing suits. Because breast cancer
reconstruction is an elective process, there usually isn’t a strict
timeline on when to start the reconstruction process. Your doctor
will assist you in choosing the best time frame to initiate the process.
Am I a candidate?
If you decide you may be interested in
reconstruction following your mastectomy, the next step is to see if
you are a healthy candidate for surgery. Your doctor will assist
you in evaluating your health status, and ultimately if you would be an
acceptable candidate for the reconstruction process.
Which doctors do what?
Following your breast cancer diagnosis, you will
meet with a general surgeon or breast surgeon who will perform your
mastectomy. Their job is to remove the breast cancer, either
through lumpectomy or mastectomy and quite possible, questionable lymph
nodes. They may be the first to discuss the notion of
reconstruction of the breasts with you.
After your diagnosis, you will also visit with an
oncologist. This physician looks over your cancer treatment and
works to figure out your risks of recurrence and what medications or
chemotherapies will be in your treatment plan, if any. You may
also require a radiation oncologist; if it is determined that radiation
therapy is within the scope of your treatment plan.
After meeting with your breast cancer surgeon and
possibly your oncologist, you may visit with a plastic surgeon to
discuss the possibility of breast reconstruction. Often times,
Dr. Burgess will visit with you before your mastectomy. This
in-depth consultation allows her to provide detailed information
regarding the reconstruction process and to answer questions specific
to your surgery. We encourage your support person to attend as
well. Dr. Burgess’ services would only be needed if you decide to
proceed with mastectomy surgery. For many patients who choose to
have a lumpectomy, reconstruction is not usually needed.
Occasionally women decide to undergo a
prophylactic mastectomy when they do not actually have a breast cancer
diagnosis. This is usually performed when they have a very
prominent breast cancer family history, are BRCA positive or have
extremely fibrocystic, hard-to-follow breasts. This is often done after
patients have spoken with an oncologist and assessed their risk of
developing breast cancer with a breast cancer surgeon.
Once the decision has been made to have a
mastectomy, patients need to decide whether they plan to remove just
the affected breast or both breasts. This decision is a very
personal one, with many factors to be considered. Your oncologist
will review your risk of recurrence related to your specific diagnosis
and treatment modalities. They will help guide you in your
decision and discuss the probabilities of developing a cancer on the
unaffected breast in the future.
Patients also need to consider the emotional
factor of removing both breasts. Some women feel that they will
worry about developing cancer on the remaining breast if it is not
removed, while others want to preserve their appearance. Choosing
to have a one-sided or unilateral mastectomy at the time of
diagnosis does not prevent you from having the other breast removed at
a later date. Again, reconstruction is an elective process, which
usually has no firm time frames.
A third factor to consider is the anatomy of the
unaffected breast. Your plastic surgeon will address these issues
in your consult and guide you toward your reconstructive goals, whether
it is unilateral or bilateral mastectomy. For very large breasted
women, sometimes a breast reduction to the unaffected breast to match
the reconstructed side is a great option. A breast lift or mastopexy,
may be required to match a more moderately sized breast. For
smaller breasted women, an implant may be used to augment the natural
breast and provide symmetry for the reconstructed side.
A nipple-sparing mastectomy is an option
for some patients, depending on tumor size, location, patient’s natural
breast anatomy and type of breast cancer. This may be an option
for patients with small breasts that may have small tumors away from
the nipple, pre-invasive cancers or no cancer, but wanting a
prophylactic mastectomy. This is a question for both your breast
surgeon and plastic surgeon. Some women feel strongly about
keeping the nipple and areola intact when they have their
mastectomy. Not everyone is a candidate for this type of
mastectomy. Your surgeons will exam your breasts, and together
with your breast cancer diagnosis, decide if you are a candidate.
Often times the remaining nipple-areolar complex heals well, but
patients do run the risk of losing the nipple during their recovery due
to blood supply issues. Also, keeping the nipple areolar complex
means you still have breast tissue on the nipple that may need
surveillance or follow up. Your plastic surgeon will discuss the
pros and cons of this type of surgery with you, if you are a
candidate. Keep in mind that your plastic surgeon can surgically
create new nipples and areolas if necessary.
A skin-sparing mastectomy preserves the
skin of the breast, but not the nipple or areola. The breast
tissue is removed, but the vast majority of the skin remains after your
surgery. This surgery is best suited for a smaller breasted
woman. Again, your plastic surgeon and breast surgeon will
determine what type of mastectomy surgery is appropriate for your
Chemotherapy and Radiation
Breast cancer reconstruction depends on input from
your entire team of doctors. The plastic surgeon relies on your
oncologist to treat your cancer and will work around your course of
Chemotherapy refers to medications that
work to kill cancerous cells. Chemotherapy treatment involves
intervals of intravenous infusions set up and managed by your
oncologist. Often times, chemotherapy and reconstruction may be
undergone at the same time. Your plastic surgeon can help
coordinate your specific reconstructive process around your
Radiation therapy is another
treatment modality that may be ordered by a radiation oncologist.
Radiation works to kill cancer cells and shrink tumors. Sometimes
it is not known if patients will need radiation until after their
mastectomy has been completed. Radiation will affect
your reconstruction process. Depending on the type of
reconstruction you undergo, your plastic surgeon may have to delay your
reconstructive surgery to allow your tissue time to recover from the
radiation or employ other techniques to allow for your reconstruction
to be successful. Radiation can alter the skin, tissue and muscle
of the affected area, making it more challenging to work with compared
to a non-radiated mastectomy site.
When patients come in for a new patient
consult, Dr. Burgess will review the various procedures she performs as
well as discuss the other options available to patients. She will
help guide you towards the reconstructive surgery that most compliments
your aesthetic goals, as well as maintain close communication with your
other physicians. Below is a summary of various types of
Depending on the tumor location and size, a
lumpectomy may be an option for you. A lumpectomy involves having
a breast surgeon remove the tumor during a short day surgery.
Often times, patients undergoing this type of surgery require radiation
to the affected breast. In this scenario, patients typically do
not need a plastic surgeon because the breast has been preserved and
breast reconstruction is not necessary.
A mastectomy is a surgical procedure that removes
breast tissue, including the breast cancer tumor(s) and questionable
lymph nodes by a breast surgeon. Mastectomy preserves the
pectoralis (or chest) muscle and leaves behind a thin layer of tissue
At the time of mastectomy, or at a later date, a tissue
expander can be placed underneath the pectoralis muscle and
patients usually spend one night in the hospital after a 1-3 hour
surgery. Drains are also placed to remove excess surgical fluid
and blood. The drains are removed in the office at subsequent
visits, once the drainage volume has decreased to an acceptable
level. Patients normally have drains for one to two weeks.
(photo of Tissue Expander coming soon)
The tissue expander is a
temporary implant that contains a port within its shell. This
port allows for adding more saline or salt water, once the mastectomy
incision has healed, to expand or fill the tissue expander. This
process is known as expansion. Your expansions
normally start several weeks after surgery and usually occur every two
weeks until you have reached your goal. During a quick, in-office
procedure, Dr. Burgess will use a very fine needle to place about 50mL
of saline into the port of your tissue expander through a numb area on
your chest skin. The pectoralis muscle may feel tight and
uncomfortable that evening. Each patient has their own expansion
schedule that can easily work around chemotherapy appointments, as well
as their personal life. The number of required expansions is very
patient-specific. Your final expanded volume depends on your
individual goals for breast size, breast anatomy and how well you
tolerate the overall process.
Once you have reached a volume that you and Dr. Burgess feel is
acceptable, you will undergo a day surgery to remove the tissue
expander and replace it with a silicone or saline implant.
A saline breast implant is a medical device made
up of a shell of silicone elastomer and filled with salt water or
saline. Saline is very similar to the fluid that occurs naturally
in the body. A saline breast implant has a special tube that
allows the doctor to fill the implant at the time of surgery.
There are several types of saline implants. Dr. Burgess will
guide you in the decision-making process when selecting the implant
that will best suit your frame and breast contours.
Saline implants have been used for decades and have a good safety
profile. Keep in mind that implants of any kind are not forever
devices. Although the leak rate is low, no one knows exactly how
long your implants may last. If your implant does leak, you
may require a short day surgery to remove the implant and replace it in
The second type of implant commonly used for
breast reconstruction is a silicone gel breast implant. Silicone
is a polymer, used in many household products, such as hand lotion and
soaps. The outer shell of the silicone implant is the same as the
saline implant, but instead of being filled with salt water, it instead
contains a silicone gel. The silicone implant has a multi-layered
barrier that helps prevent rupture. Some people think that the
silicone implant feels more natural as compared to the saline
Extensive studies have been completed with regard
to the safety of silicone and saline implants. Both implants are
FDA approved and have been involved in clinical studies encompassing
thousands of women since 1992. Please visit mentorcorp.com to get
specific details on these studies.
When choosing what type of implant to have, you should consider the
pros and cons of both. If you were to develop a leak the implant
would simply go flat over hours to days if you have a saline
implant. The breast would look smaller and the salt water or
saline from your implant would be absorbed by your body. When a
silicone implant ruptures, it can be known as a ‘silent leak’, because
the silicone gel may leak over time. The most accurate way to
detect a silicone leak is by a breast MRI. Therefore the current
recommendation is to get a breast MRI 3 years after implant surgery and
then every 2 years. This should be done even if you are not
experiencing any problems. If a leak were detected in either type
of implant, the goal would be to remove and replace the implant.
This is usually a day surgery and patients normally recover very
quickly, as the pocket for their implant has already been created.
It is not unknown how long your implants will
last. Some silicone or saline implants may last decades, while
others may rupture earlier. In most cases, if you are on the
younger side when you have your reconstruction process, (25-50 years of
age), you will most likely need to have your implants replaced at
sometime in your life.
Deciding which implant fulfills your
reconstructive goals and suits your lifestyle is a very personal
decision. Dr. Burgess normally allows for patients to pick which
type of implant they prefer. This is not a decision that has to
be made right away. Your permanent implant will not be placed
until several months after your tissue expander placement
surgery. Therefore you do have time to decide which implant,
silicone or saline, would work best for you.
Fat Grafting is a technique in which your plastic
surgeon is able to transfer unwanted fat from one area of the body to
another, to add volume or to help correct a contour problem of the
reconstructed breast. This is also known as autologous fat transfer.
Fat grafting is a surgical procedure and Dr. Burgess may require
general anesthesia or local anesthesia with light sedation. The
unwanted fat is usually removed from the abdomen, back, or outer thighs
using a gentle liposuction technique. The fatty cells are then
carefully re-injected back into the area of the breast that requires
The advantages of fat grafting are that you are
able to use your own tissue and the recovery is fairly minimal. This
procedure is usually done to patients who have undergone mastectomy
with reconstruction. Since it is your own tissue being re-injected, it
may make the breast feel softer and more natural, especially in areas
of previous radiation. In addition, many women are pleased that they
were also able to have fat removed from an area of the body that they
didn’t want it, such as the belly area.
The disadvantages to fat grafting are that a
certain amount of the fat will resorb back into the body and you may
need more than one fat grafting procedure to reach your desire of
correction. Also, some of the reinjected fat may feel like a tiny lump,
but these tend to soften with time. Dr. Burgess will assist you in your
decision making process as to whether fat grafting is the best option
for your breast restoration process.
Acellular Dermal Matrix
Sometimes the natural anatomy of the pectoralis
muscle may not be adequate coverage for the implant. The muscle
may have suffered loss or be of poor quality. For patients who have had
radiation, utilizing their pectoralis muscle to support an implant can
be challenging. In these types of scenarios, an Acellular Dermal
Matrix (ADM) may be employed. An ADM is often a human cadaveric
or porcine product that is utilized at the time of tissue expander
placement. The ADM is sewn into the pectoralis muscle, allowing
for greater support in the lower breast pole, while supporting the
tissue expander and eventually, the implant. It can provide a
natural shape or “hang” to the breast. The ADMs also support
cellular growth and healing, while providing stabilization of the
TRAM (Transverse Rectus Abdominis
Another option for some patients is another group
of surgeries that involves using your own tissue.
The TRAM is a major surgical procedure that involves using your own
abdominal skin, fat and muscle to create and contour one or both
breasts. This surgery can be upwards of 6-12 hours of surgical
time and a 2-4 day hospital stay. The recovery from this surgery,
as compared to the tissue expander procedure, is a greater length of
time. As with all reconstruction options, your surgeon will help
guide you in choosing . This surgery is best for women who have
some excess abdominal fat. Here, the Transverse Rectus Abdominis
Muscle with fat and skin, is partially released and lifted up to form a
new breast. Since your surgeon is harvesting this tissue from
your abdomen, you also will end up with a tummy tuck but the abdominal
wall will be reconstructed as well, with a piece of mesh. It is
important to remember that this surgery will involve a scar across your
lower abdomen and the breast area. These scars are all easily
hidden with most underwear or swimsuits. Also, it is vital to
avoid sun exposure to your abdomen for one year following surgery,
since your skin may be sensitive to excess heat and could result in
Since your new breasts are created from your own
tissue, they may feel natural. However, the skin sensation and
coloring will be different since the skin and tissue came from a
different area of the body. Many women are however, pleased with
their flatter abdomen as a result of the surgery.
It is important to keep in mind that only certain
people are good candidates for the TRAM flap surgery. Since it
can involve an extended recovery, it is very important to be fairly
healthy going into the procedure. Smokers and those with prior
abdominal surgeries, diabetes, chronic diseases, cardiac conditions, or
on blood thinners may not be the best candidates.
Recovery from this surgery is longer than with the
tissue expander process. Since your abdomen has been
reconstructed, you must plan to be off work and avoiding any strenuous
activity for about 8 weeks after surgery. It is important to have
someone that can assist you at home during your recovery.
Patients have multiple follow-up visits, to ensure that their healing
process is on track.
Delay in TRAM This should be part of TRAM page,
since it is related to this surgery.
Depending on the individual, sometimes another
surgery may be required prior to the TRAM. This procedure is
known as a “Delay in TRAM”. The Delay surgery is normally
performed two weeks prior to the actual TRAM surgery and works to
improve the blood supply to the flap. During the delay procedure,
blood vessels that supply the flap are divided from below. This
promotes blood vessels from above to become larger and more robust,
reducing the risk of vascular insufficiency to the flap. Dr.
Burgess will determine whether you will require the Delay.
Latissimus Dorsi Flap
Another surgical option for some women is to
reconstruct the breast using their own skin, tissue and muscle taken
from the back and tunneling it to the breast area. This surgery is a
favorable procedure for those that are not TRAM candidates or for those
who have undergone radiation and need fresh tissue to the chest.
This is a major surgical procedure that can take 4-5 hours. Most
women require several weeks off of work and should not work out
vigorously for 8 weeks. Some patients require a tissue expander
as well for additional volume, which is then replaced with a permanent
implant once their expansion process is complete. Patients can
expect a scar on the mid-back/shoulder area.
The DIEP Flap is one type of breast
reconstruction, that uses your own skin and fat to recreate the
breast(s). In this microsurgical procedure, blood vessels known
as the deep inferior epigastric perforators, (DIEP) along with skin and
fat are removed from the abdomen and relocated to the chest to create
breasts. This type of flap surgery leaves the abdominal muscles
intact. However, due to the complexity of this surgery there are
few facilities that offer the DIEP technique. There are also
other types of microsurgical flaps and Dr. Burgess does not routinely
Reduction with Lumpectomy
Sometimes a breast reduction may be an option for
larger breasted women who have been diagnosed with breast cancer.
The lump is removed at the same time as the breast reduction and often
the unaffected breast is removed as well. Many factors are
considered, such as the specific cancer diagnosis, stage, tumor
location, breast size, treatment modalities and personal goals.
Following lumpectomy, a breast reduction will
remove excess breast and fatty tissue in one or both breasts, making
them smaller, lifted and more proportional to your body. Your
size, anatomy and tumor location will dictate what type of surgical
approach your plastic surgeon may use. Usually, women are left
with a scar around the areola, a vertical incision from the areola to
the base of the breast fold and sometimes an additional scar along the
Once your breast reconstruction is completed, you
may consider undergoing nipple reconstruction. This usually
occurs 4-6 months after your permanent implant placement or muscle flap
surgery, to allow your new breasts to heal and settle. However,
nipple reconstruction may be done much later, depending on patient
Nipple reconstruction, also known as
Nipple-Areolar Complex, (NAC), is a quick day surgery, which uses your
own tissue on the breast to create a nipple. The reconstructed
nipple has projection, but no feeling or function. The areola is
created by bringing in skin from another area of the body, such as the
lower abdomen and then covering the nipple areolar complex with a
protective dressing for about 4-5 days. Once this dressing is
removed care must be taken to not injure them. Patients should
avoid vigorous exercise for about one month. Most patients do not
require much time off of work, usually only a few days if that, and
find this surgery to be the easiest step in the whole reconstruction
Surgery to the unaffected
chose to only have a mastectomy to the affected or cancerous
breast. This is known as a one-sided or unilateral
mastectomy. To create symmetry between the reconstructed breast
and the natural breast, patients often require surgery. The type
of surgery is patient specific. Some smaller breasted women may
require an augmentation, or implant to the natural breast, while some
women may only need a breast lift. Others still may need a breast
reduction to the non-cancerous breast if they are naturally very large
breasted. Surgery to create symmetry is normally done at the time
your permanent implant is placed to your reconstructed side, or after
you have healed from your muscle flap surgery. With unilateral
reconstruction there is no firm time frame for surgery to create
A Mastopexy, or breast lift, removes a small
amount of skin, breast tissue and fat, to lift and reposition the
breast and nipple. Similar to the breast reduction, a mastopexy
can be done to provide symmetry to the unaffected breast. This
would be a possible option for a woman undergoing a one-sided
mastectomy with reconstruction. A breast lift may be done to
better match the reconstructed breast with the natural breast.
Your plastic surgeon would guide you in deciding if a lift would be an
option for you. There are multiple techniques with regard to a
breast lift. Deciding which approach would provide you with the
greatest symmetry and pleasing aesthetic result is a decision for your
For those who are either not good candidates for
surgery or choose not to reconstruct the breasts, there are
alternatives. Bra specialty shops work to fit women with special
bras and prostheses that look very natural under clothing.
Depending on your health insurance, this may be a covered
Patients who undergo tissue expander surgery
normally have several surgeries to complete their reconstruction.
During the first stage of reconstruction, when the tissue expander is
placed, most patients take a minimum of several weeks off of
work. This surgery does require the placement of drains and the
majority of women prefer to have their drains out prior to returning to
work. Dr. Burgess provides prescription pain medications, a
muscle relaxer, antibiotics and other medications to aid in you
recovery. It is important to avoid lifting anything heavier than
a gallon of milk or vigorous exercise for 4-6 weeks following this
surgery. As you begin your in-office expansions, you may exercise
lightly, but it is important not to push yourself too far, as you can
When your incisions have begun healing from your
tissue expander placement surgery, (normally about 2 weeks after your
surgery), you may begin your expansions. The number of expansions
you require will depend on your frame, the quality of your skin and
tissue, as well as your goals for reconstruction. Following your
expansion, your chest may feel tighter and more uncomfortable.
Dr. Burgess prescribes pain medication to assist you during this
time. Many patients are able to return to work during the
expansion period. Once the final volume has been obtained,
patients undergo a second surgery to remove the tissue expander and
replace it with their final silicone or saline implant. This is a
day surgery and patients normally go home after surgery. We still
require patients to avoid heavy lifting or vigorous exercise for at
least 4-6 weeks after surgery.
Breast reduction patients normally spend one night
in the hospital and then go home with someone who is able to assist
them with medications and personal care. Patients can shower the
second day after surgery, even with their drains in place. Drains
are usually in for about one week, depending on the patient. Dr.
Burgess provides prescription pain medication, antibiotics and other
medications to assist in the recovery period.
It is important to avoid strenuous activity or heavy lifting for a
minimum of one month and most women take about 2-3 weeks off of
work. Because patients still have breast tissue following a
breast reduction, it is crucial to still do breast exams and breast
cancer screening. Usually a new baseline mammogram is done 6
months to one year after your surgery. Final results for a breast
reduction can up to one year, as patients can be swollen and retain
fluid in their breasts.
TRAM flap recovery
Women who are candidates for a TRAM Flap should
anticipate a longer recovery than those having other types of
reconstruction. Dr. Burgess requires women undergoing a TRAM to
avoid strenuous activity for 8 weeks following surgery, but patients
are encouraged to be up and walking. Patients have between 4-6
drains that may be present for several weeks and may wear an abdominal
garment for about a month. The garment provides support during
the healing process, as well as compression to decrease swelling to the
operative area. Dr. Burgess does provide prescription pain
medication, a muscle relaxant, antibiotics and other medications to
assist you through the post operative period. Patients may
experience some abdominal muscle weakness and some of the weakness will
improve with time.
The Latissimus flap surgery involves moving the
Latissimus muscle from the back and tunneling it forward to create a
breast. Occasionally a tissue expander may be required to
supplement the volume of the new breast. During this time patients
should avoid heavy lifting or vigorous exercise that could compromise
their muscle flap for 6-8 weeks. Walking is a great way to
transition back from surgery. Avoiding lifting or pulling
anything heavier than a gallon of milk is important as the new breast
and back incisions heal. Normally patients have several drains
that can be in for a couple of weeks. Patients may shower two
days following this surgery, even while the drains are still
intact. If a tissue expander was needed, the expansion process
will begin several weeks after the initial surgery. Plan for at
least several weeks off of work following the Latissimus surgery and if
an implant is needed, additional time off work would be needed when the
tissue expander is removed and replaced with your permanent implant.
Nipple reconstruction is normally the last surgery
in the reconstructive process. It is also usually the easiest
surgery for patients, as the area can be numb and the pain can be
minimal. The recovery process involves wearing a nipple protector
or bolster for 4-5 days to safeguard the new nipple and areola.
We ask that you avoid getting the bolster wet. When patients
return to clinic several days later, the bolster is easily removed and
they are instructed on how to care for the new nipple. It is
important to avoid lifting any heavy objects against your chest and to
avoid strenuous exercise for at least 4 weeks. We have patients
apply ointment to protect and lubricate the area during the initial
healing phase. As the nipple and areola heal, the scars actually
work to your advantage in helping to disguise mastectomy scars.
Some patients go on to tattoo the areola.