THE SURGERY.

Deciding About Breast Implants for Reconstruction

When thinking about surgery for breast cancer you will have many important decisions to make. One decision is whether to have surgery for breast reconstruction at all. As expected, women have different opinions and views about reconstruction.

A few reasons why some women decide FOR reconstruction with breast implants:

* to restore body image following mastectomy surgery for breast cancer

* to replace an external breast form (prosthesis)

* to avoid being constantly reminded of their breast cancer diagnosis

* to avoid embarrassment in public dressing areas

* to help create a look that makes them feel more comfortable with or without clothes

A few reasons why some women decide AGAINST reconstruction with breast implants:

* they understand that breast implants are not lifetime devices, that they may have to undergo multiple surgeries and they want to avoid more surgery

* they feel the risks of surgery and anesthesia are greater than the benefits

* they are concerned about potential known and unknown risks from breast implants for themselves and their children should they become pregnant

* they feel they are able to adjust to a new body image without reconstruction with breast implants

* they prefer to wear an external breast form (prosthesis)

If you decide on breast reconstruction, there are currently two surgical techniques:

* The "flap" technique. This surgery rebuilds the contour of the breast by taking tissue from other areas of the body. The TRAM (transverse rectus abdominis musculocutaneous) flap technique may be used to reconstruct one or both breasts at the same time. The flap technique involves moving skin, muscle and fat to the breast area from the abdomen, back, or buttock to rebuild the breast. There will be a scar in the area where the flap was lifted. The flap technique is considered a major operation and, for medical reasons, is not suitable for everyone. This, like all operations, should be discussed carefully with your doctor. In some cases, breast implants may be used in addition to the flap procedure.

It is important to note that the TRAM flap operation can be done only once. The TRAM flap can be used to reconstruct one or both breasts, but only in one operation. If the TRAM flap is used to reconstruct one breast, and a mastectomy is later required on the other breast, reconstruction of the second breast must be done through other means (i.e., insertion of a breast implant).

* Insertion of breast implants. The surgeon inserts the implant into a pocket created under the skin. The pocket may be located either behind (submuscular) or in front (submammary) of the chest muscle.

Ask your doctor about the pros and cons of each implant technique. If you decide to have reconstruction for one breast, you may need to think about surgery on the other breast to achieve a similar appearance.

Special Concerns for Women with Breast Cancer

Here are some of the known risks or problems with breast implant surgery for women with breast cancer:

* The physical and cosmetic results with breast implants may be affected by chemotherapy, radiation therapy, or any other factor which significantly alters the healing process.

* Skin necrosis (dying skin) may occur because circulation to the remaining tissue has been changed by a mastectomy or other trauma to the breast area. Also, skin necrosis may be increased as a result of radiation treatment.

* It usually takes more than one operation to achieve the desired cosmetic outcome, especially if this procedure includes rebuilding the nipple.

Timing for Reconstruction with Breast Implants

Reconstruction can be done either at the time of breast cancer surgery or at a later date. If breast surgery and implant surgery are done at the same time, the surgeon usually uses the same incision to insert the implant. Another option is to insert a temporary tissue expander. In this case, in a second operation after the skin has stretched sufficiently, the surgeon will remove the expander and replace it with an implant. Another option is to insert the implants at some time after the mastectomy. With delayed insertion, the surgeon may still be able to use the mastectomy or lumpectomy scar to insert the implant. The surgeon should discuss with you which approach is the most desirable for you, and the associated risks.

Recreation of the Nipple and Areola following Reconstructive Surgery 

After your breast has healed from the original implant surgery, you may want your nipple and areola (darker skin around the nipple) rebuilt. This procedure can usually be performed on an out-patient basis. Ask your surgeon to explain the various ways this can be done.

Your Expectations -- Reconstruction or Augmentation

Your consideration of breast implants, for reconstruction or for augmentation should be based on realistic expectations of the outcome. To help you get an idea of what results may be possible, look at before and after pictures of patients who have had this surgery. Your doctor may have some to show you. You may also want to talk with other women who have had this surgery at least a year before with the same surgeon. Keep in mind, however, that there is no guarantee that your results will match those of other women.

Your results will depend on many individual factors, such as your overall health; chest structure and body shape; healing capabilities (which may be hindered by radiation and chemotherapy, smoking, alcohol and various medications); bleeding tendencies; prior breast surgery(ies); infection; skill and experience of the surgical team; the type of surgical procedure; and, the type and size of implant.

Scarring is a natural outcome of surgery, and your doctor will try to keep scars as subtle as possible. She or he can explain the location, size, and appearance of the scars you can expect to have. For most women, scars will fade over time to thin lines, although the darker your skin, the more prominent the scars are likely to be. Usually the body will develop a fibrous capsule which can be thick or thin around the implant which is a normal physiologic response to a foreign object in the body.

It is important to remember that implants age over time and may need to be replaced. Although your implant may last for many years, you should not expect it to last indefinitely.

General Description of the Surgery

Breast implant procedures can be performed on an outpatient (not hospitalized) basis or at a hospital. Breast implant surgery can be done under local anesthesia, or under general anesthesia.

Breast implant surgery can last from one to several hours depending on whether the implant is inserted behind or in front of the chest muscle, and whether surgery is performed on one or both breasts. Prior to surgery, the doctor should discuss with you the extent of surgery, the estimated time it will take, and the choice of drugs for pain and nausea.

Postoperative Recovery

The doctor should describe to you the usual postoperative recovery process, the possible complications that can arise, and the expected recovery period. Following the operation, as with any surgery, some pain, swelling, bruising, and tenderness can be expected, but they should disappear with time.

Medications for pain and nausea can be prescribed. Some women may experience fever, bleeding or other symptoms of infection; these should be reported immediately to the doctor. Patients should be instructed about wound healing and appropriate wound care.

If the surgery is done in a hospital, the length of the hospital stay will vary according to the type of surgery, the development of any postoperative complications, your general health, and the type of coverage your insurance provides.

Follow-Up

Ask your surgeon about follow-up care, including a schedule of follow-up examinations, advice about limitations to your activities, precautions you should take, and when you can return to your normal routine. (If you are enrolled in a clinical trial, your surgeon should give you a schedule for follow-up exams set by the study plan.)