What is breast reconstruction and why is it important?
Breast reconstruction endeavors to restore normal contour, size and symmetry following mastectomy or lumpectomy for breast cancer. It is important for women who wish to restore normal breast shape and symmetry, to maintain feminine body proportions, and to wear clothing comfortably. Many techniques are available, and no one approach fits every patient.
Only 30% of women who undergo a breast cancer surgery are offered or are informed about breast reconstructive options; therefore the majority of women are not even told that rebuilding their breasts after deforming cancer surgery is an option. Every woman who undergoes surgery for breast cancer has access to reconstruction—the 1998 Women's Health and Cancer Rights Act requires insurance companies to cover the cost of breast reconstruction, as well as for symmetry procedures on a woman's other normal breast. Breast reconstruction has been proven through many scientific studies to improve quality of life. It is a fact that breast reconstruction improves a woman’s body image and psychological wellbeing.
While electing not to have reconstruction ("going flat") is always an option, very few women choose this because of the challenges wearing prostheses, inability to wear certain clothing, and having visible reminders of cancer surgery.
What are my options for reconstruction after a mastectomy?
Consider two different pathways for reconstruction: using implants or using your own tissue.
Each has advantages and disadvantages, and different techniques may be used to achieve great results. On one hand, implants are ideal for women who are slender and who don't have extra fat stores from which to borrow tissue. Alternatively, using your own tissue eliminates potential problems with implants. The advantages and disadvantages of each are summarized below:
Dr. Rad uses FDA-approved “gummy bear” highly cohesive gel teardrop shaped implants. These implants do not leak silicone and are designed to stay in the body indefinitely. In fact, silicone implants can be cut in half and remain in 2 solid halves - the silicone does not leak out of the shell! This silicone technology required many years of R&D and is a major advance in silicone implants as compared to the 1990s when leakage was an issue. While the FDA still recommends routine MRI scans to monitor the implants, for all practical purposes this is not necessary to detect leaks because the silicone remains as a whole.
Dr. Rad is expert in creating natural results with “shaped” or “teardrop” implants. The best candidate for implant reconstruction is a slim woman who chooses a double (versus single) mastectomy, and who has not had radiation therapy.
- a good option for slim or athletic women
- natural shape
- natural feel
- shorter surgery (as compared with tissue reconstruction)
- flexible choice of breast size
- potential for “capsular contracture,” or abnormal scarring (after radiation ~50%)
- potential for future surgery to correct capsular contracture
- potential for wound healing difficulty (especially after radiation)
- potential for seroma (fluid forming around the implant)
- potential for asymmetry with single mastectomy
- potential for “heavy” feeling
- potential for Anaplastic Large Cell Lymphoma (ALCL), a very rare cancer of the immune system (read the FDA position on implant-related ALCL)
Dr. Rad is expert in microvascular surgery. This involves borrowing excess fat and skin from one are of the body (lower abdomen, love handles, or inner/upper thighs) and transplanting it to rebuild a woman’s breasts. Only 2% of plastic surgeons have the skill to perform microvascular surgery, and less than 1% are able to perform the most advanced techniques, such as the DIEP flap and “love handle” flap, in which Dr. Rad is skilled. The best candidate for tissue reconstruction is a woman who has extra fatty deposits. Dr. Rad advises against the TRAM flap because, unlike the DIEP flap, the TRAM flap sacrifices the core abdominal muscles which are critically important for core stability.
- a good option for women with fat in the abdomen, love handles, and/or thighs
- the most natural shape
- the most natural feel (fat is superior to silicone for feel)
- potential for excellent symmetry with either single or double mastectomy
- excellent option when the nipple and/or breast skin must be removed
- improvement in body contour (i.e., tummy tuck)
- eliminates the need for implants
- ideal for patients who receive radiation
- insurance will cover flap procedures
- longer surgery (as compared with implant surgery - this is a minor disadvantage)
- slightly longer recovery (as compared with implant surgery - this is a minor disadvantage)
- additional scars (although this is offset by improvement in body contour)
Dr. Rad's preferred method of tissue reconstruction the DIEP flap, a technique whereby skin/fat are borrowed from the abdomen and transplanted to the breast(s) without disrupting your core abdominal muscles (a key difference from the outdated TRAM flap). Although other tissue sources are available (the buttock region, inner thighs and back), the DIEP flap is ideal for patients who have had radiation, or even those who simply prefer their own tissue for reconstruction. Patients also enjoy the natural feel, natural aging of the breasts, and the improved cosmetic appearance of the abdomens following a "tummy tuck". The downsides to the DIEP flap are the somewhat longer recovery time, and length of scars (although very well hidden). However, these are minor disadvantages as compared with the upsides.
What is “staged reconstruction”?
Staged reconstruction refers to performing reconstruction over 2 or more surgeries. This is necessary if there’s a chance that you may need radiation after your mastectomy. Your oncologist will guide you to determine whether this is needed. In this case, a temporary implant, called a “tissue expander” is placed in the breast after the mastectomy. Tissue expanders can be inflated or deflated in the office, and are designed to hold the breast pocket open, maintain breast shape, and prevent the skin from contracting while you finish your cancer treatments. Most women who undergo mastectomy will have a tissue expander placed as a "place holder" until it is known whether the lymph nodes have evidence of cancer spread thus requiring further treatments.
For reasons related to safety and achieving superior aesthetic results, Dr. Rad often performs breast cancer reconstruction in several stages:
- Stage 1: A tissue expander is placed at the time of a mastectomy. This acts as a spacer to hold the breast shape until stage 2.
- Stage 2: After a 3 to 9 month healing period (depending on whether radiation is needed), the tissue expander is removed and implant or tissue reconstruction is done.
- Stage 3: An outpatient touch-up procedure is usually (but not always) necessary to achieve symmetry – this can involve scar revision, fat grafting and/or breast lift on the normal side.
What Options Do I Have?
- Implant Reconstruction is the most popular option owing to the ease of recovery and simplicity of surgery; however, implant reconstruction often is not a good option due to scar tissue problems caused by prior breast radiation.
- DIEP Flap Reconstruction is the gold standard in tissue reconstruction as it spares critically important core abdominal muscles (unlike the outdated TRAM flap) with the results of Abdominoplasty as a benefit.
- LSGAP “Love Handle” Flap Reconstruction borrows love handle fat and is the most complex breast reconstructive operation in existence; Dr. Rad is 1 of only 30 microvascular surgeons worldwide who is able to perform it.
- Dr. Rad performs Corrective Reconstruction for many women who have had complications or severe asymmetries resulting from radiation or poor outcomes by other surgeons.
- Lumpectomy Reconstruction with Oncoplasty is a win-win as the benefits of a Breast Lift far outweigh the downsides.
Which Option is Best For Me?
The best breast reconstruction choice is different for each patient and it depends on many factors:
the type of breast cancer surgery, either mastectomy or lumpectomy, that you require or have had
- whether radiation is required or has been done in the past
- what breast size you desire compared to the original size of your breasts
- whether tissue or implants are best to meet your objectives
- your personal lifestyle and individual preferences
You have a unique situation and there is no cookie-cutter approach. Dr. Rad spends time with each patient to achieve the best results with the least amount of surgery and in the safest manner possible.
Dr. Rad discusses Microsurgery and the LSGAP “Love Handle” Flap in these news segments:
Is reconstruction safe?
Breast reconstruction is very safe when performed by a skilled microvascular surgeon. The risk of significant complications from anesthesia and surgery for young, healthy patients is very low. In fact, it is lower than the cumulative risks associated with ddriving a car. General anesthesia is light and Dr. Rad works with board certified anesthesiologists and performs surgery at the top hospitals in northern Virginia, Inova Fairfax Hospital and Inova Fair Oaks Hospital, and at Sibley Memorial Hospital in DC. Dr. Rad routinely works with your oncology team to ensure that your care is comprehensive and well coordinated for best results.
Cancer Survivor Support
Dr. Rad recommends the following support resources for patients and families:
- Local breast cancer survivorship resources:
- National breast cancer survivorship resources: