Breast Reconstruction Options

If your breast cancer is quite large relative to your breast size or the cancer is scattered throughout your breast you will not have the option of a lumpectomy and you will require a mastectomy, either with or without immediate reconstruction. Also, some patients may choose a mastectomy even though they are candidates for a lumpectomy. 
The overall survival is the same whether you have a mastectomy or a lumpectomy with follow-up radiation therapy. The risk of local recurrence (recurring near the lumpectomy site) after a lumpectomy and radiation therapy is about 5-8% versus about 3% with a mastectomy. If you initially underwent lumpectomy and radiation therapy and then had a recurrence you would require a subsequent mastectomy.
If you don’t have immediate reconstruction your chest will be flat and you could then wear prosthesis inside your bra in order to achieve symmetry. The option of a delayed reconstruction at a later date is available but it is more difficult. This is because when we do an immediate reconstruction we usually perform a skin-sparing mastectomy in which most of the breast skin remains and only the nipple-areolar complex is removed. I remove the breast tissue beneath the skin through a small incision around the nipple-areolar complex. When I’ve finished the mastectomy the Plastic Surgery team completes the first phase of the immediate reconstruction by filling the space between the preserved skin and chest wall, either with a temporary expander that is later replaced with a permanent implant or with your own tissue. The nipple-areolar complex is then tattooed onto the reconstructed breast after the final phase of reconstruction is completed.
If the reconstruction is delayed I would need to take more skin so that there are no folds of excess skin on the chest wall which would create an irregular surface and make it difficult to achieve a good fit for prosthesis. Before the Plastic Surgeons can do a delayed reconstruction the skin needs to be stretched over several months to develop an adequate skin covering for the underlying reconstruction.
There are 3 main types of reconstruction techniques:
1. Temporary expander followed by a permanent implant
2. DIEP/TRAM flap or a variation (taking tissue from lower abdominal wall).                              
3. Latissimus flap (using tissue from your back and swinging it around (to the chest)
These reconstructive techniques are combined with either a skin-sparing mastectomy (standard procedure removing nipple-areolar complex but preserving skin) or a nipple-sparing mastectomy.
Generally speaking the more complex the surgery the more natural the look and feel of the reconstruction. Often a breast reduction and/or lift of the opposite breast is required to provide symmetry.
Prior to making any decisions on reconstruction you will meet with the Plastic Surgeon and they will carefully review with you the various options and together the two of you will decide the best one for you.

Photo courtesy of Dr. Kevin Bethke 
Appearance of patient without immediate reconstruction.