Breast Reconstruction Surgery: Considering All Your Options

Typically, breast reconstruction surgery is the next step after undergoing a mastectomy or lumpectomy. Amy Wandel, M.D., a plastic surgeon with Mercy Medical Group, a service of Dignity Health Medical Foundation, offered insights into the different surgical options, each with a different road to recovery and healing.

Dr. Wandel specializes in breast reconstruction, and she explained that the main choices for reconstruction are implants, fat grafting, autologous tissue reconstruction, and total reconstruction with fat grafting.

Implant Reconstruction

Implants can create a youthful well-shaped breast but cannot always match the patient's opposite breast. Frequently, patients are offered procedures on their other breast to create better symmetry. Implants can be a popular choice for patients who want to get back to their regular life as quickly as possible. "We have the ability to make a breast look like what a 20- to 30-year-old woman would have, and it will last for the rest of your life," Dr. Wandel said.

Implant reconstruction is most commonly a two-stage procedure. At the time of the mastectomy, an expander is placed. The expander is then slowly filled over several weeks to months. Once complete, the patient returns to have the expander exchanged for a permanent implant. This process usually takes 3-9 months.

The benefits to this surgical option include:

• You can choose the exact size you want.
• The first procedure doesn't add downtime to your mastectomy recovery.
• The second procedure is outpatient with 48 hours to five days of downtime.

A more recent technique using implants for reconstruction involves placing the implant at the time of the mastectomy, which is called direct-to-implant reconstruction. This is a good choice for smaller-breasted women who do not wish to change the size of their breast and want a shorter reconstructive procedure.

There's one potential downside to reconstruction. If scarring thickens — called capsular contracture — you may need another surgery. This is a risk for about 25 percent of women, but a new acellular collagen matrix reduces that to 10 to 12 percent.

Fat Grafting

Fat grafting can be used with implants to diminish irregularities or increase volume. It's also a good choice for lumpectomies. Radiation can reduce cells' ability to replicate, resulting in a loss of volume. When fat is used to fill the deficit, it generates more cells and can stimulate ingrowth of new blood vessels. This can reduce some of the damaging effects of radiation, Dr. Wandel said.

A silver lining is that you can take the fat from anywhere, such as the inner thighs, abdomen, back, or buttocks. The main risk is a cosmetic deformity where the fat is taken. "It's really nice for a patient who's gone through a fairly devastating operation," Dr. Wandel said. "You can say, 'Hey, you don't like the fat on your thighs? We can take that and put it in your breast.' It's a nice benefit for the patient."

Autologous Tissue Reconstruction

This reconstruction uses a "flap" of a woman's tissue to rebuild her breast — often taken from the stomach, back, buttocks, or thighs. The tissue is either left connected to its blood supply and rotated into the area, or it's connected to a blood supply in the breast region. Women who choose this option want something that looks, feels, and ages like a natural breast.

Here are some points to keep in mind:

• You have a second surgical site, so you may feel more pain and have a longer recovery.
• The downtime is 4-10 weeks, depending on where the tissue is taken from. Frequently, it's done at the same time as the mastectomy. If the patient needs radiation, this is delayed until six months after radiation is completed.
• You may not need another operation.

This is a popular choice for women with slightly larger breasts if an implant won't be enough to match the size.

Total Reconstruction With Fat Grafting

One of the newest options is fat grafting to recreate the entire breast. It's an outpatient procedure for women with enough fat to recreate an entire breast.

This procedure is minimally invasive but requires multiple appointments. "You go in, have liposuction to harvest the fat, inject the fat into the breast area, and go home," Dr. Wandel said. "Although it means multiple procedures, they're all outpatient." The recovery for each fat graft is 24 to 48 hours, done every three to six months until the desired breast sized is achieved.

The biggest downside is the need for multiple visits and wearing a BRAVA device 23 hours a day. The BRAVA is a plastic cup worn on the chest that generates a little suction. The device can be uncomfortable and hard to hide, and its cost isn't covered by insurance. Additionally, while this procedure will eventually look as good as autologous reconstruction — without the scar or potential need to take muscle to recreate a breast — women might need up to two years of fat grafting after the mastectomy.

The type of breast reconstruction surgery a woman chooses, in many cases, depends on the individual needs and desires of the patient regarding her breast appearance, size, and recovery time. Whether the patient needs chemotherapy and/or radiation may influence her choice of reconstruction and also the timing, explained Dr. Wandel. Each option has its benefits and drawbacks. Some allow reconstruction to be completed sooner but may take a longer time to recover, whereas another option may have a shorter recovery time but take more steps to complete the reconstruction. The bottom line: Research your options and decide what is best for you. There's no wrong answer.