Breast reconstruction is a procedure that involves the recreation of a breast which has been removed in part (lumpectomy) or in its entirety (mastectomy), usually subsequent to either cancer treatment or prophylactic removal of the breast for patients who are at high risk of developing breast cancer. It’s one of the most rewarding procedures we perform, but because there are so many options available, and every situation differs so greatly, it often prompts many important questions. Today, we’re answering some of the most frequently asked questions about breast reconstruction.
1. Am I a good candidate for breast reconstruction?
All women who have had (or are going to have) a mastectomy should have a discussion with a plastic surgeon about breast reconstruction. In the vast majority of cases, there will be good reconstructive options available to you. The only definite reason why you would not be eligible for breast reconstruction would be if you have other medical issues that would make additional surgery unsafe.
2. Can I have breast reconstruction at the time of my mastectomy?
This is called ‘immediate reconstruction’ and many women are candidates for it. Immediate reconstruction is a great option during prophylactic (preventive) mastectomies or in cases of breast cancer where no radiation therapy is anticipated. The alternative is called ‘delayed reconstruction’ and can take place anytime after your mastectomy. There is no time limit for delayed reconstruction. In other words, your reconstruction can be done as early as several months after your mastectomy or as long as many years later. Your general surgeon and plastic surgeon together will advise you on whether immediate or delayed reconstruction is best for you.
3. How much does breast reconstruction cost?
Breast reconstruction is recognized by OHIP as an important part of your breast cancer treatment. As such, OHIP covers virtually all aspects of your breast reconstruction including the costs of the implants, hospital stay (if necessary), nipple areolar reconstruction and even balancing surgery on the opposite breast if needed.
4. Are breast implants safe?
All the breast implants we use are approved by Health Canada and have a long track record of safety and proven results. Silicone implants are the preferred choice for breast reconstruction but all implants have risks associated with them. The implants themselves may need to be replaced in the future due to a number of possible reasons, including hardening of the scar tissue around the implant (capsular contracture), shifting of the implant from its intended position (implant malposition) or failure of the implant itself (implant rupture). None of these conditions are dangerous but may require additional surgery to correct them if necessary in the future.
5. What are common problems that occur following breast reconstruction?
The most common problems that patients face following breast reconstruction are highly dependent on the type of reconstruction performed. In the short term, patients will have issues related to pain and recovery from surgery. Delayed (slow) healing can be a problem for some patients and minor asymmetries (differences between the two breasts) sometimes require additional minor surgery to correct. Long term potential problems should be discussed in detail with your plastic surgeon. As a general rule, you should understand the possible complication of implants (see question #4 above) as well as the complications from using your own tissues, the most common of which are weakness in the donor area as well as significant scars at these donor sites. Of course, all surgery will result in scarring and your surgeon will advise you on how to best manage your scar.
6. How long from the time of my surgery until I feel back to normal/return to work?
This will vary significantly between patients and between types of reconstructions. In general, you can aim for a return to normal activities by 2-4 weeks for implant-based reconstruction or 6-8 weeks if using your own tissues. Your recovery will be gradual from day one after surgery and your surgeon will guide you through this process.
7. What will my reconstructed breast feel like?
The biggest change here will be in sensation. Regardless of the type of reconstruction, your mastectomy will remove many or most of the nerves to the breast skin leaving you with less sensation in the area. The feel or softness of the breasts themselves will differ depending on the type of reconstruction performed. Implant-based reconstructions tend to produce firmer, less mobile breasts whereas using your own tissue results in more natural feeling breasts. Whether or not you have radiation therapy will also influence both the sensation and softness of the reconstructed breast.
8. What post-operative care can I expect after my breast reconstruction?
Your plastic surgeon will follow up with you closely in the short term and continue to follow up at regular intervals long term. Depending on the type of reconstruction, you will likely have bandages that will remain in place until your first follow up visit. You will be given oral pain medications and antibiotics for your initial recovery at home. You will also likely have drains that can be removed at home by a home care nurse or during one of your follow up visits. Depending on the type of procedure and your support at home, it can be arranged for a nurse to come to your home at regular intervals to help with both drain care and bandages.
9. What are my options to balance my reconstructed breast with the opposite side?
In the case of a unilateral mastectomy and reconstruction, you will have the choice to have additional surgery on the opposite side to better match the shape and/or size of the reconstructed breast if needed. Your options include reducing, augmenting or lifting the non-cancerous breast depending on what can be achieved with the initial reconstruction.
10. Are they any other additional surgeries I will need to consider?
Breast reconstruction is a process that can be divided into stages. Whether immediate or delayed reconstruction, the first stage is the creation of a breast mound using either your own tissues or a tissue expander. This will be separated by at least three months from Stage 2, which could involve finishing touches on the breast mound, nipple/areolar reconstruction, and balancing of the opposite breast if desired. In the case of an implant reconstruction, the time between Stage 1 and 2 may be longer to account for the time required to expand the breast.
Nipple areolar reconstruction can be done during Stage 2 or can be done as a separate procedure at a later time. Generally, nipple areolar reconstruction itself is a two stage procedure with creation of the nipple in the first stage and tattooing of the areola (if desired) in the second stage. In summary, most breast reconstructions will require two surgical procedures with up to three additional procedures until the final result is obtained.
11. Can I keep my nipples?
Traditional mastectomies have always included the removal of the nipple and areola together with the underlying breast tissue. More recently, new techniques have been developed that allow for a Nipple Sparing Mastectomy. This approach, while providing an excellent aesthetic result, is technically more difficult and can only be performed when all of the following criteria are met:
1. Your tumor is of the correct type and in the right location that your breast surgeon feels that no additional risk of recurrence occurs from preserving your nipple.
2. Your nipple is currently in the correct location. The position of a nipple cannot be changed during a nipple sparing mastectomy. Therefore, droopy breasts with low nipples are not appropriate for this approach.
3. Your breast is not too large. This is a decision that must be made on a case by case basis by your breast surgeon. It is technically difficult to remove all the breast tissue from a very large breast while safely preserving the nipple.
If you are not a candidate for a nipple sparing mastectomy, your plastic surgeon will discuss the various options for nipple reconstruction with you. This is done at a second stage once the breast mound itself has been created.
12. Will I still require breast cancer screening after breast reconstruction?
Whether or not you have a reconstruction, a breast that has had a mastectomy does not require ongoing radiological investigation (MRI, Mammogram or Ultrasound). In the case of a unilateral mastectomy, the opposite breast would continue standard clinical and radiological breast cancer screening. Having breast reconstruction does not change these screening recommendations.
13. How do I decide what type of breast reconstruction is best suited for me?
This decision will be made in consultation with your breast surgeon and plastic surgeon who will give you options based on whether one or both breasts is involved, the availability of your own tissue for reconstruction, previous or planned radiation therapy, overall health, and a host of other personal factors including adversity to larger procedures, longer recovery, support at home, etc. In most cases, there will be an option best suited to you, which your surgeon will recommend to you. Ultimately, you will make the decision together.
Our goal is always for you to understand the options available and to be comfortable with the choice you make. At your initial consultation, together with your surgeon, you will review your general medical history, focus on your breast history and have a complete examination. You will then discuss the options that are available to you with the help of anatomical drawings and patient photographs. A second or third consultation is often necessary and can be booked after your initial meeting. You will also have phone and email access to our office to discuss any questions that arise during your pre- and post-operative journey.
