The primary part of the procedure can often be carried out immediately following the mastectomy. As with many other surgeries, patients with significant medical comorbidities (high blood pressure, obesity, diabetes) and smokers are higher-risk candidates. Surgeons may choose to perform delayed reconstruction to decrease this risk. Patients expected to receive external beam radiation as part of their adjuvant treatment are also commonly considered for delayed autologous reconstruction due to significantly higher complication rates with tissue expander-implant techniques in those patients.
Breast reconstruction is a large undertaking that usually takes multiple operations. Sometimes these follow-up surgeries are spread out over weeks or months. If an implant is used, the individual runs the same risks and complications as those who use them for breast augmentation but has higher rates of capsular contracture (tightening or hardening of the scar tissue around the implant) and revisional surgeries.
In 1998, the Women's Health and Cancer Rights Act was passed mandating insurance coverage for breast reconstruction in the United States. Prior to this, many insurance carriers did not cover breast reconstructive surgery as they considered it cosmetic in nature. The law is also known as "Janet's Law", named for Janet Franquet, a breast cancer patient who fought her insurance carrier with Dr. Todd Wider, a New York plastic surgeon who helped lobby for the legislation with Senator Al D'Amato. The act mandates insurance coverage for the surgery of the affected breast and also the contralateral side for purposes of symmetry1, 2
There are many methods for breast reconstruction. The two most common are:
|The TRAM Flap Procedure|
|Identification of the target and donor sites||Raising the flap and transposing it to the target site||The result of the reconstruction|
Nipple reconstruction is usually delayed until after the breast mound reconstruction is completed so that the positioning can be planned precisely. There are several methods of reconstructing the nipple-areolar complex, including:
One of the challenges in breast reconstruction is to match the reconstructed breast to the mature breast on the other side (often fairly 'ptotic' - droopy.) This often requires a lift (mastopexy), reduction, or augmentation of the other breast.
Recovery from implant-based reconstruction is generally faster than with flap-based reconstructions, but both take at least three to six weeks to recover and both require follow-up surgeries in order to construct a new areola and nipple. All recipients of these operations should refrain from strenuous sports, overhead lifting and sexual activity during the recovery period (three to six weeks). TRAM flap patients can show abdominal muscle weakness on EMG studies, but clinically most patients who have undergone unilateral breast reconstruction (reconstruction of one breast only) return to normal activities after recovery.
Patients who have undergone bilateral breast reconstruction with TRAM flaps (ie reconstruction of both breasts) require sacrifice of both rectus muscles and tend to have permanent abdominal strength loss. For this reason, many plastic surgeons now frown upon bilateral breast reconstruction with TRAM flaps. This also explains the significant patient interest in perforator flap techniques such as the DIEP flap which preserves abdominal muscle function long term. These patients tend to return to full activity after several weeks without permanent limitations.
There is little information about upper body exercise post-mastectomy. Issues such as simple mastectomy, mastectomy with reconstruction, mastectomy with lymph node excision and reconstruction all factor into limitations to amount and extent of upper body exercise. Generally, cardiac exercise (treadmill, walking, etc.) are approved for rehabilitation post-surgery and for weight control.
Women who have undergone breast reconstruction must still be followed for local or regional recurrence of their cancer with manual exams of the breast/chest wall and axilla.
If there is pain, redness, or swelling in the area, past the reasonable recovery window outlined by the physician, complications may have arisen. Contact your doctor immediately. For more information on breast implant and reconstruction complications: What to do about Breast Implant Problems
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