Breast Reconstruction Health Article

Diagnosis/Preparation

The diagnosis for breast reconstruction is almost always made on a visual basis. The underlying medical reasons include replacing all or part of breast tissue that has been removed during the course of cancer treatment, replacing breast mass that has been lost due to injury, or equalizing otherwise normal breasts that are markedly different in size. Underlying cosmetic reasons include personal preference for larger breasts among genetic females or the creation of breasts in male-to-female transsexuals.

Routine preoperative preparations, such as having nothing to eat or drink the night before surgery, are needed for reconstructive procedures. Blood transfusions are often necessary for autologous reconstructive surgeries. The patient may donate her own blood and/or have family and friends donate blood for her use several weeks prior to the surgery.

Emotional preparation is also important. Breast reconstruction will not resolve a psychological problem the woman had before mastectomy, nor make an unstable relationship strong. An expectation of physical perfection is also unrealistic. A woman who cites any of these reasons for reconstruction shows that she has not been adequately informed or prepared. Complete understanding of the benefits and limitations of this surgery are necessary for a satisfactory result.

Not all women are good candidates for breast reconstruction. Overall poor physical health, or specific problems such as cigarette smoking, obesity, high blood pressure, or diabetes, will increase the chance of complications. Also, a difficult or prolonged recovery period or failure of the reconstruction may be a result. A woman's physical ability to cope with major surgery and recuperation should also be considered.

Aftercare

The length of the hospital stay, recovery period, and frequency of visits to the doctor after surgery vary considerably with the different types of reconstruction. In general, autologous procedures require longer hospitalization and recovery times than implant procedures. For all surgical procedures, bandages and drainage tubes remain in place for at least a day. Microsurgical or free flap procedures are most closely monitored in the first day or two after surgery. The circulation to the breast may be checked as often as every hour. Complete breast reconstruction requires at least one additional surgery to create a nipple and areola. Scars may remain red and raised for a month or longer. They will fade to their final appearance within one to two years. The true, final appearance of the breasts usually will not be visible for at least one year.

Risks

Some women have reported various types of autoimmune-related connective tissue disorders, which they attribute to their implants—usually involving silicone gel implants. Lawsuits have been filed against the manufacturers of these implants. Food and Drug Administration (FDA) guidelines, issued in 1992, now greatly restrict their use, primarily to women who need to replace an existing silicone gel-filled implant. In addition, recipients must sign a consent form that details the potential risks of silicone gel-filled implants and become enrolled in a long-range study. Saline is now the filling of choice for breast implants. Saline-filled implants are permitted for all uses, although manufacturers must continue to collect data on possible risks.

The FDA issued a status report on Breast Implant Safety in 1995, and revised it in March 1997. It noted that studies to date have not shown a serious increase in the risk of recognized autoimmune diseases in women with silicone gel-filled breast implants. It also addressed concerns about other complications and emphasized the need for further study of this issue.

There are a number of risks common to any surgical procedure, such as bleeding, infection, anesthesia reaction, or unexpected scarring. Hematoma (accumulation of blood at the surgical site), or seroma (collection of fluid at the surgical site) can delay healing if they are not drained. Any breast reconstruction also poses a risk of asymmetry and the possible need for an unplanned surgical revision. Persistent pain is another potential complication of all types of breast reconstruction.

Implants have some unique problems that may develop. A thick scar, called a capsule, forms around the implant as part of the body's normal reaction to a foreign substance. Capsular contracture occurs when the scar becomes firm or hardened. This may cause pain accompanied by changes in the texture or appearance of the breast. Implants can rupture and leak, deflate, or become displaced. The chances of capsular contracture or rupture increase with the age of the implant. These complications can usually be remedied with outpatient surgery to loosen the capsule and remove or replace the implant as needed. There is some evidence that using implants with textured surfaces may decrease the incidence of these problems. An implant tends to remain firm indefinitely. It will not grow larger or smaller as a woman's weight changes. Asymmetry can develop if a woman gains or loses a large amount of weight.

The autologous procedures all carry a risk of flap failure, which is a loss of blood supply to the tissue forming the new breast. If a large portion of the flap develops inadequate blood supply, another reconstructive technique may be necessary. Tummy tuck flap procedures can result in decreased muscle tone and weakness in the abdomen, or lead to an abdominal hernia. Arm weakness may occur after latissimus dorsi flap surgery.