Breast Reconstruction

If you have been diagnosed with a condition requiring mastectomy, you and your physician may be considering subsequent reconstructive surgery. Reconstructive plastic surgeons at The George Washington University Hospital Comprehensive Breast Center are available to discuss current options and help you determine the course that is best for you.

We also provide solutions for recovering sensation after mastectomy, and perform surgery to prevent lymphedema. Talk to your surgeon to determine if you are a good candidate for these options.

Advanced Breast Reconstruction

GW Hospital offers microvascular breast reconstruction for patients who are not candidates for traditional breast reconstruction or who want to avoid prosthetic implants. This advanced procedure uses the patient’s own soft tissue to recreate the breast. Unlike prosthetic implants, the result is permanent, has a natural feel and resists infection. In addition, the microvascular technique has a lower impact on muscle function and results in less scarring than older soft tissue methods.

When does reconstruction take place?

Many surgeons feel it is beneficial for mastectomy patients to consider reconstructive surgery. If your health condition permits, reconstruction of a breast is often possible immediately following its removal allowing the patient to awaken from her surgery without the standard post-mastectomy deformity.

Although it may seem more comfortable to choose reconstructive surgery immediately after breast removal, sometimes waiting is best. First, since planning for reconstruction may begin soon after your diagnosis, you may feel you don’t have enough time to weigh your options. You are encouraged to think about these options carefully and make the optimal decision for you. Your surgeon may also advise that you wait to undergo breast reconstruction due to certain medical circumstances, such as tobacco use, hypertension, obesity or diabetes.

Either way, understanding your various options for reconstruction before surgery can help you prepare for a mastectomy with a more optimistic and hopeful outlook for the future.

What are my options if I decide to have reconstructive surgery?

The surgical procedures available at GW Hospital Comprehensive Breast Center include soft tissue reconstruction (usually microvascular) and implant reconstruction.

Microvascular Reconstruction

Microvascular reconstruction involves the usage of your own tissue to recreate a breast. Since your own tissue is used in this procedure, the reconstructed breast will more closely reflect your bodily changes, such as gaining or losing weight and aging. However, these operations take the longest to complete and are associated with a somewhat higher risk of complications.

There are several types of microvascular reconstruction, including:

• The DIEP flap, which uses tissue from the lower abdomen to reconstruct the breast.
• The TUG/DUG/PAP flap, which uses tissue from the inner thigh to reconstruct the breast.

The best method for you will be determined after consultation with your plastic surgeon. With any of the flap procedures, scars will appear at the tissue donor site as well as at the reconstructed breast area. When a breast is reconstructed using your own tissue, however, the result is permanent, will feel more natural and limits any concern about having foreign material in your body. If a patient requires radiation therapy after mastectomy, soft tissue reconstruction generally has better overall results and fewer complications than implant reconstruction.

Implant Reconstruction

Implants as a reconstructive option are most appropriate for women who want to undergo the least amount of surgery, do not have time for a more complex surgery or prefer the least amount of scarring.

The implant can be filled with saline (salt-water solution) or silicone gel and is placed under the skin or under the chest muscle through the mastectomy incision. Although it is the least complicated breast reconstruction type, implants may pose some specific surgical risks. For example, there is a low incidence of developing infection due to the implant, which usually occurs within the first two weeks following surgery. In this case, your doctor will remove the implant until the infection clears. A new implant can be inserted at a later time. The most common problem seen with breast reconstruction, capsular contracture, occurs if the scar or capsule around the implant begins tightening. This pressure on the soft implant may cause the breast to feel hard. In addition, implants may rupture, requiring replacement surgery. However, your breast and reconstructive plastic surgeon will work together to minimize these and other risks.

The most common technique for implant placement is skin expansion, which requires a subsequent insertion of the actual implant. Following a mastectomy, the surgeon will insert a tissue expander to stretch the skin, and create room for a permanent implant. The tissue expander is a small, balloon-like bag inserted beneath the chest wall and expanded over time by periodically adding saline until the breast area is stretched to the desired size. The tissue expander can be placed following mastectomy, requiring only one return visit to remove the expander and insert a more permanent saline or silicone gel-filled implant. Some expanders, though, are designed to leave in place as the final implant.

If desired, nipple and areola (skin surrounding nipple) reconstruction may be performed following any type of reconstructive surgery. This procedure is usually performed at least three months after breast reconstruction to allow for correct positioning of the nipple, or following radiation or chemotherapy, if required.

Are there any special techniques or technologies used in surgery?

In addition to microvascular breast reconstruction — which uses your own tissue from the abdomen or the thigh — we also offer lymphatic reconstruction to try to prevent lymphedema after lymph nodes are removed for cancer treatment, and lymphatic bypass and lymph node transplant to try to treat lymphedema.

What will happen after I have breast reconstructive surgery?

Recovery time depends on the type of reconstruction performed and the health of the patient. Implant reconstruction generally has a shorter recovery period, but requires multiple outpatient procedures over time for implant exchange. Soft tissue reconstruction involves surgery on more than one body part and has a longer recovery period compared to implant reconstruction.

Keep in mind that there is no perfect reconstructive technique. The goal of reconstructive surgery is improvement, not perfection. Your reconstructed breast may feel firmer and look rounder or higher than your natural breast. You will not experience the same sensation as you would with a natural breast. The reconstructed breast will probably not match your opposite breast exactly and may not have the same contour as your breast before the mastectomy, but your reconstructive surgeon will continue to work with you until you are satisfied. The opposite breast may undergo a lift or a reduction to improve symmetry.

Are there risks associated with breast reconstruction?

All surgeries carry some degree of risk and uncertainty. Some possible surgical difficulties, such as bleeding, fluid collection, excessive scar tissue and difficulties with anesthesia can occur with operation. Smokers should also be made aware that nicotine might delay healing and possibly result in conspicuous scars and prolonged recovery.

Will reconstruction affect any possible recurrence of cancer?

Breast reconstruction has no known effect on the recurrence of cancer since this most often occurs in surrounding skin, not reconstructed tissue. The reconstructed breast will not interfere with chemotherapy or radiation treatment. After your breast surgeon and reconstructive plastic surgeon have evaluated your health, age, anatomy, skin tissue and clinical situation, you can discuss which reconstruction option is best for you. 

Is reconstructive surgery covered under my insurance plan?

Employer group and commercial insurance plans that cover mastectomies are obliged by law to also cover all surgeries to obtain symmetry following mastectomy. Please check with your plan to be sure reconstructive surgery is covered.