Timing of Reconstruction

Immediate Reconstruction – An immediate reconstruction is performed during the same surgery as the mastectomy.  Normally reserved for patients with early breast cancer, who will likely not require radiation therapy, this timing of reconstruction may involve placement of a final breast implant, a tissue expander, or the patient’s own tissues.

Delayed-Immediate Reconstruction – A delayed-immediate breast reconstruction has a portion of the reconstruction performed at the time of the mastectomy, and a later, secondary procedure to complete the reconstruction.  This is most commonly used in patients who may require radiation therapy, based on the results of their mastectomy and lymph node specimens.  This type of reconstruction places a tissue expander immediately after the mastectomy, in order to preserve the original breast pocket.  This tissue expander will later be replaced in a second procedure with either a final implant, or the patient’s own tissues.

Delayed Reconstruction – A delayed breast reconstruction is any reconstruction performed after the patient’s mastectomy, without any intervention at the time of the patient’s mastectomy.  This reconstruction may be months, or years, later.

Methods of Breast Reconstruction

Implant-Based Reconstruction – The most common method of breast reconstruction, this requires a two-stage, two-operation process.  At the time of the mastectomy, a temporary tissue expander is placed underneath the chest muscles and partially inflated. The remaining breast skin is closed and allowed to heal.  Following surgery, patients return weekly to clinic, adding volume to the tissue expander until the desired breast size is reached.  The tissue expander is then removed in the second procedure, and a final breast implant placed.  Additional procedures, such as a nipple reconstruction, can be performed in a later surgery.

Some women are candidates for a one-stage, implant-based reconstruction, where the final implant is placed at the time of the mastectomy.  This method of reconstruction depends on multiple factors, including cancer diagnosis, skin quality, and preoperative and postoperative breast sizes.

Autologous Reconstruction – This breast reconstruction method uses the patient’s own tissues, termed flaps, to recreate a breast mound.  This procedure can be performed at the time of the mastectomy, or in a delayed fashion.  Typically requiring only one surgery, these reconstructions do require placement of additional incisions on another part of the body, but create a more natural appearing breast than reconstructions with implants.

The more common flaps that Dr. Castillo employs in his practice include: DIEP, muscle-sparing free TRAM, and Latissimus Dorsi flaps.  A discussion of each of these will occur at the time of your breast reconstruction consultation.

Autologous reconstructions can be combined with an implant, normally with the Latissimus Dorsi flap, when additional volume is needed to match the desired breast size.  This can be done either in a single operation or, as in an implant reconstruction, a tissue expander can be placed along with the flap, and once expanded to the desired breast size, can be replaced with a permanent implant.

Recovery time is dependent on the type of reconstruction pursued.  In general, flap reconstructions will require more initial hospital time than implant-based reconstructions.  Implant-based reconstructions, however, require more clinic visits in order to accomplish tissue expansion, and more surgeries to complete the reconstruction.  Details regarding recovery will be discussed during the consultation.

We believe in being preemptive to avoid common risks associated with surgery, but occasionally the following may occur:

Bleeding/Hematoma – A small amount of bleeding is common after surgery, but if severe enough, another operation may be required to stop it.  Bleeding can also form a collection, termed a hematoma, which presents as a swollen, painful, and enlarged breast.  These require drainage to prevent secondary problems.

Seroma – A fluid collection may form within the breast, or around an implant, and may require drainage.

Infection – Breast reconstruction has a risk of infection. If an infection does occur, it may necessitate the need for oral, or intravenous, antibiotics.  In rare cases, the removal of the implant may be required.

Blood Clots:  Breast reduction can result in the development of blood clots in the legs.  These clots can travel to the lungs where they can be fatal.  Precautions before, and after, surgery are taken to avoid blood clots from forming.

Poor Cosmesis: This may include poor wound healing, a widened scar, irregularity of a scar, or partial wound separation.  There may also be asymmetry in nipple positions, breast sizes, shape, or contour, between the two breasts.

Capsular Contracture: A circumferential scar is formed around every implant.  Occasionally this scar can affect the appearance or placement of an implant, or cause a painful tightness.  When severe enough, surgery is required to remove the scar, but the chance of recurrence remains.

Implant Rupture: There is a small risk that an implant ruptures.  With a saline implant, deflation is readily apparent, while a silicone implant rupture is more difficult to diagnose as the silicone remains within the breast pocket.

Rippling/Waves:  Implants may cause skin rippling or the appearance of a fluid wave.  This may require additional surgery to correct.

Partial/Complete Flap Loss:  When tissues are rearranged during autologous flap reconstructions, there is the risk that a portion, or all, of the flap loses its blood supply and does not survive.

Fat Necrosis:  When operating on the breast, there is the possibility that a part of the tissue loses its blood supply.  This can lead to a localized area of hardness within the breast

Contralateral Breast: In women receiving a mastectomy on only one of their breasts, procedures can be performed on the non-affected breast to better match the reconstruction side.  This may entail a breast lift, or breast reduction.

Breast Sensation:  The skin sensation in a reconstructed breast will be different compared to before mastectomy. Some breast sensation may return, but the degree of sensation cannot be predicted.

Long Term Changes:  Time, weight changes, and gravity will continue to affect the appearance of a reconstruction.  These changes may require surgery to restore a more youthful contour.

Do I need to have a breast reconstruction?

The decision to pursue breast reconstruction is a personal one. An elective procedure, and not deemed medically necessary, some women choose to have a mastectomy and forego any reconstructive option.  For other patients, breast reconstruction allows them to regain feelings of femininity, intimacy, and “wholeness.”

What is the difference in immediate, versus delayed, breast reconstruction?

Immediate reconstructions take place at the time of mastectomy, and are best suited to women with early stage breast cancer, or those having prophylactic mastectomies due to a high genetic risk of breast cancer.  Delayed reconstructions take place at any point in time after a mastectomy, even years later.  This may be due to the need for radiation therapy, or a patient’s desire at the time of mastectomy.

There is also a “delayed-immediate” timing to breast reconstruction.  This involves placement of a tissue expander at the time of the mastectomy to preserve the breast pocket, while awaiting the pathology results of the mastectomy and lymph node specimens.  If radiation is indicated, the tissue expander can be left in place, radiation completed, and a reconstruction used to replace the tissue expander in 4-6 months.