Breast cancer treatment will depend on the stage of the cancer at diagnosis. Usually those with stage I – III breast cancer will be offered surgery, in combination with radiotherapy and some form of drug treatment (chemotherapy and/or hormone treatment). The type of surgery will depend on tumour size and location, as well as personal preference. Breast-conserving surgery, known as a lumpectomy, removes the tumour, whilst preserving as much of the breast tissue as possible.

A mastectomy removes the entire breast and can be unilateral (one-sided) or bilateral (both breasts). Breast reconstruction surgery is an option for those who want to preserve the appearance of their breasts, although it should be noted that any reconstructed tissue will have little, if any, sensation. Of course, not all women will want to undergo breast reconstruction. Some will choose to use removable prosthetics or simply ‘go flat’. The most important thing is for each woman to take the time to consider which option is best for her.

When to undergo breast reconstruction surgery

Breast reconstruction can be immediate, delayed or staged.

• Immediate. Performed at the same time as a mastectomy/lumpectomy. The advantages to this are that it provides a neater cosmetic result with less scarring and will probably require fewer surgical procedures. The disadvantages are that the reconstruction might be damaged by subsequent radiotherapy and if there are complications during the procedure, it might delay the start of chemotherapy. Women who have prophylactic breast removal, i.e. a preventative mastectomy because they are at high risk of developing cancer, will usually undergo immediate breast reconstruction.
• Delayed. Reconstructive surgery can be performed weeks, or even months after breast cancer surgery. This can be advantageous as it gives a woman time to carefully consider her options. It also means that subsequent treatment will be unaffected by the reconstructive surgery. The drawbacks are that it can result in more scarring and the woman will spend time with no breast (or breasts), which could impact her confidence and quality of life.
• Staged. Some reconstruction is performed during the mastectomy or lumpectomy, with additional procedures later on. This usually involves inserting a temporary expander to preserve the shape of the breast for the short-term. It can then be replaced with a permanent implant once the next stage of treatment is complete. Also called delayed-immediate reconstruction.

Types of reconstruction

Implants can be artificial or made from a flap of tissue taken from elsewhere in the body (autologous).

• Artificial implant. An implant made of either saline or silicon is inserted either underneath or on top of the pectoral chest muscles. Implants can be teardrop-shaped, or round; smooth, or slightly rough. The advantages to artificial implants are that they generally require a shorter recovery time and fewer surgical procedures, as there is no need for concurrent surgery at a donor site. Scarring can also be kept to a minimum by using the same incision site that was used during the mastectomy. The disadvantages to this type of reconstruction are that with time the implant might need replacing; most have a lifespan of between 10 and 20 years. There is also a risk of deflation, rupture and contracture of the implant. Women who have unilateral breast cancer may choose to have artificial implants inserted into their healthy breast too, so that both sides match.
• Autologous reconstruction. A ‘flap’ of tissue is taken from elsewhere in the body, formed into the shape of a breast and used to manufacture an implant. The tissue taken is skin, fat or muscle and it is most often taken from the abdomen, the back, the buttocks or the inner thigh. The abdomen is the preferred donor site. “Free flaps” are completely separated from their original blood vessels and reattached to blood vessels within the chest wall. This requires advanced skills in microsurgery. “Pedicled flaps” are tissue samples that are moved underneath the skin and remain attached to their original blood vessels. This is considered to be a simpler technique. Autologous reconstruction can be delayed or immediate. Advantages to this technique include a more natural looking result, with no risk of implant rupture. These implants also tolerate radiotherapy more than artificial implants. The disadvantages include more extensive surgery and a longer recovery time; as well as multiple surgical sites. Women who undergo this procedure risk experiencing complications, such as hernias and muscle damage, at the donor site. Women that are of a slim build may require “stacked flaps”, whereby multiple free flaps are taken and layered to form the implant.
• Combination. Sometimes tissue flap procedures are used in combination with an implant. For example, when a latissimus dorsi flap is taken from the tissue of the back, it is often used alongside an artificial implant to enhance the overall appearance of the reconstructed breast.

Reconstruction after breast-conserving surgery

Some women do not need a complete mastectomy and it is considered sufficient to remove the part of the breast where the tumour is located using a lumpectomy. Reconstruction is often not needed in these cases, but for those women who are left with a prominent dent, or a large discrepancy between breasts after surgery, there are options available.

• Quadrantectomy and mini flap reconstruction. In a quadrantectomy the surgeon will remove about a quarter of the breast tissue, which can leave the patient with a noticeably smaller breast. To fill the gap, living tissue is taken from elsewhere in the body, often from the patient’s back.
• Reshaping. This is also known as therapeutic mammoplasty and is more suitable for women with larger breasts. The doctor will remove the part of the breast where the cancer is located and then reshape the remaining breast tissue, so that the breast is smaller, but fully formed. Women who undergo this procedure might opt to have a simultaneous breast reduction on their healthy breast, so that the two sides match.

Most breast-conserving surgeries will be followed by a course of radiotherapy to the remaining breast tissue to reduce the chances of the cancer returning.

Additional surgery

Nipple and areola reconstruction is usually done 3-4 months after the original procedure, so that the breast has had time to heal. Normally the artificial nipple is formed from the tissue of the new breast and the surgeon will attempt to match the position, size and projection of it to the other nipple. Tattooing is used to match the colour.

Some women choose to have surgery on their healthy breast, to make both sides match. This is a matter of personal choice and something to discuss with you doctor when considering options.

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Sources:

• “Breast Cancer.” About Breast Reconstruction | Breast Cancer Surgery | Cancer Research UK, 25 Oct. 2017, https://www.cancerresearchuk.org/about-cancer/breast-cancer/treatment/surgery/breast-reconstruction/about.
• “Breast Reconstruction Options.” American Cancer Society, https://www.cancer.org/cancer/breast-cancer/reconstruction-surgery/breast-reconstruction-options.html.
• Djohan, R., et al. “Breast Reconstruction Options Following Mastectomy.” Cleveland Clinic Journal of Medicine, vol. 75, no. Suppl_1, Mar. 2008, pp. 17–23., doi:10.3949/ccjm.75.suppl_1.s17.
• Farhangkhoee, Hana, et al. “Trends and Concepts in Post-Mastectomy Breast Reconstruction.” Journal of Surgical Oncology, vol. 113, no. 8, June 2016, pp. 891–894., doi:10.1002/jso.24201.
• “Types of Breast Reconstruction.” Breastcancer.org, 29 Aug. 2019, https://www.breastcancer.org/treatment/surgery/reconstruction/types.