What to Consider Before Your Breast Reconstruction

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Today, we’re discussing the intricacies of breast reconstruction. There’s a bunch of information available to those looking to undergo breast reconstruction. We wanted to make things easy and give you an in-depth look into the options available to you. We hope this makes your decision a bit easier!

The Facts

Women who have undergone a double mastectomy (which includes the full removal of both breasts), a mastectomy (which includes the full removal of single breast), or a lumpectomy/segmental mastectomy (which includes the removal of a portion of the breast), often choose to also undertake a breast reconstruction. A breast reconstruction is a medical procedure which involves replacing the tissue which was removed during the mastectomy in order to alter the aesthetic appearance of breasts. According to studies conducted in 2016, 40% of women who underwent a mastectomy went on to have reconstruction surgery. In 2018, 101,600 women in the United States alone underwent breast reconstruction surgery, according to the American Society of Plastic Surgeons (ASPS) and the Plastic Surgery Foundation. 

Considering how many women undergo breast reconstruction every year, it’s astounding only 23% of women are knowledgeable about their breast reconstruction options. This is why the next section will be devoted to a comprehensive overview of the options available to women looking to undergo reconstruction. 

The Options

There are two time-based factors which alter the type of surgery you’ll undergo. The first type of reconstruction is immediate reconstruction. An immediate reconstruction, as the name suggests, occurs immediately after a mastectomy. This type of reconstruction is more common, with three-fourths of reconstruction patients adhering to this type. The positive attributes of an immediate reconstruction include improved aesthetic results, heightened psychological well-being post-operation, and lower costs. Patients are able to mitigate a bit of the body dysphoria which can accompany a mastectomy, as well as lessen scarring, with this method. However, immediate reconstruction can be associated with more postoperative complications when postmastectomy radiation therapy is required. 

The second type of reconstruction is delayed reconstruction. This type of breast reconstruction is done some time after the initial mastectomy and is much less common. The reason for this is because multiple surgeries mean further healing, multiple scars, and longer downtime. However, unlike immediate reconstruction, this type is not associated with higher risk of complications when combined postmastectomy radiation therapy. Therefore, this type might be recommended for breast cancer patients who still have a ways to go in their treatment, even after their mastectomy. 

Underneath the broader umbrella of immediate and delayed, there are further types of breast reconstructions, which are differentiated by their chosen makeup. Implant-based reconstruction (IBR) is the first type and 81% of breast reconstructions consist of this type. Further, within IBR, there are two subsets: single-stage (or direct-to-implant placement) and two-stage. The single-stage IBR entails a single surgery, during which the chosen implant is the only implantation. While the two-stage IBR entails two surgeries, the first of which includes the placement of a tissue expander, and the second of which includes the placement of the permanent implant. Two-stage is actually the more common of the two subsets of IBR, with 68% of women receiving this type. 

Beyond single-stage and two-stage, there’s also the choice between silicone or saline implants. Silicone implants are known to have a more natural appearance and feel, which results in greater levels of patient satisfaction. Thus, silicone implants are used in about 95% of breast reconstructions. 

We’re still not done with IBR, because patients also need to consider the anatomic plane in which their implant will be placed. There are three planes in which the implant could reside: the total submuscular, the partial submuscular, and the prepectoral. Which anatomic plane you choose can affect the final appearance of the breasts after reconstruction and the risk of unintended side effects. Therefore, you should conduct plenty of research and ask your doctor about the implications of each plane. 

While a total submuscular placement lends vascularized soft tissue coverage and does not require the additional placement of an ADM (discussed later), this plane limits the overall size of the implant and has a high rate of animation deformity. Animation deformity is characterized by a distortion of the reconstructed breast when in motion (such as when the major pectoralis muscle is contracted). Around 80% of breast reconstruction patients whose implants are placed on the total submuscular plane experience this deformity. 

A partial submuscular placement with the additional use of an ADM reduces the risk of animation deformity. An ADM, or an adjunctive acellular dermal matrix, acts as a support system for the chosen implant. Whether derived from human sources (allografts), animal sources (zenographs), or synthetic materials, ADMs are scaffolding which serve to revascularize and integrate host cells into the newly placed tissue. ADMs can reduce the rate of capsular contracture and improve aesthetic definition, but also carry the risk of infection and seroma.

Prepectoral plane placement with the use of an ADM is the only IBR which does not carry the risk of animation deformity. As well, since this type does not require surgeons cut into the pectoralis muscle, this method is less painful overall. However, compared to the other types discussed above, there’s been little research done into its efficacy in terms of aesthetics or harmfulness. 

Meanwhile, the other 19% of breast reconstructions outside of IBR consist of autologous reconstruction (AR). Autologous reconstructions utilize the patient’s own tissue for the reconstructive implant. Therefore, types of AR are differentiated by the anatomic region where the tissue flap is harvested. The most common source area is the deep inferior epigastric (DIEP), which consists of the skin and fat located along the lower abdomen. 52% of AR use this region. The second most common source area is the latissimus dorsi (LD), which is the broadest muscle along the side of your back. 22% of AR use this region. There are lower rates of usage among the transverse rectus abdominis myocutaneous (TRAM), which form the deep abdomen, and other regions. Depending on your comorbidities, past surgeries, and preferences prior to surgery, your doctor may recommend one harvest site over another. 

Your Truth

Federal law dictates any insurance company which covers mastectomy must also cover breast reconstruction surgery, however you’ll still need to look into what exactly your insurance company will cover. Beyond this, you’ll need to ask yourself a few questions. How well do you understand the entire breast reconstruction process, from pre-op preparation to recovery from multiple surgeries? Do you feel adequately prepared both mentally and physically to undergo this process? If you’re still currently undergoing treatment for cancer, how will breast reconstruction affect your treatment? 

There’s a likelihood your breast reconstruction will not result in your breasts appearing as they did pre-mastectomy. In this event, will you be able to manage your resulting emotional response? It's better to ask yourself these questions in advance and be honest about your answers. If you have concerns about breast reconstruction, bring them up with your medical provider. With clarity and time, you may solidify your certainty about whether or not breast reconstruction is right for you. 

Your Support

A support system is crucial following any surgery, for emotional reasons as much as practical reasons. While you will probably need someone’s help during your recovery process, nothing is more helpful than a community in which you can discuss your journey. As we quoted above, more than one-hundred thousand women undergo this process every year. There are Facebook groups and online chat rooms where you can learn more about the process you’re about to undertake and ask women who have already undergone the process for their perspective. The value of community resources cannot be underestimated.

The Breast Place is dedicated to provide you with the options and support you need to make the best decision for your breast reconstruction. We offer natural reconstruction (i.e. AR) and impact reconstruction (i.e. IBR) services, as well as nipple-sparing mastectomy, breast lift and breast reduction. Breast reconstruction is about more than just aesthetics. It's about feeling your best in your body and taking the proper steps to do so. For a free consultation, reach out to us today. Thank you for reading and we look forward to hearing from you!