Reconstruction - Overview
If you've chosen to have a mastectomy (or have been advised to have a single or double mastectomy), you will probably be given the option of reconstruction - sometimes carried out at the same time as surgery, sometimes at a later date. Of course, you may also decide that reconstruction is not for you and you'd prefer to remain flat. There's a large number of women who choose this route and there's not a "right" or "wrong". Whether to have a reconstruction or not is totally an individual decision and what's right for one person, may not be right for another.
I think there is a common misconception that having a mastectomy and reconstruction is similar to having a "boob job". Nothing could be farther from the truth. Please bear in mind that if you have a reconstruction, you will lose all feeling and sensation in the breast area. You will lose functioning, sensitive nipples. With a boob job, you retain most or all sensitivity so there's a significant difference.
Having a mastectomy (and making the right choices) is not to be downplayed. It's a huge operation and one that has a significant impact on you and your body. A decision to have a mastectomy should not be taken lightly (especially if it's an elective mastectomy). Surgeons will often want you to meet with a psychiatrist or counseller beforehand to ensure that you fully understand what's going to happen and you are as prepared for it as you can be. This is particularly important for ladies choosing to have an elective, preventative mastectomy which may involve removing healthy tissue (ie one breast is affected and the other isn't - or - in the case of somebody who is BRCA positive, both breasts). Even the strongest person, on the day of surgery or a few days after, is going to have a wobble and think "what have I done?" and I think that's to be expected.
I have concentrated on the reconstruction of the breast itself in this section but nipples are treated separately and/or at the same time as surgery. You have a few choices regarding nipples/reconstruction an please look at the Feeling Good tab for more information of what you may have available to you.
The first thing to say is that you may decide you want a reconstruction and have your heart set on a specific type of reconstruction but you may not be suitable for it. This can be disappointing but at the end of the day you will want the best "look" and outcome you can achieve so it's good to listen to your team. So what are your options? I'm going to list the more common options below but I will include a page dedicated to each with a first hand account from somebody who has had the procedure within the next few months.
- No reconstruction - If you'd like to stay flat then there are lots of ladies (and of course men) who have done this. Some have wonderful chest tattoos, others are just happy to be flat. If you'd like to get in touch with ladies who have taken this route, I've linked to a Facebook page in the tab marked "links".
- No Reconstruction / Prosthetics - What if you've decided that you don't want a reconstruction but also don't want to go flat? Well, you might want to investigate prosthetics. Prosthetics come in all shapes, sizes, colours, ones with nipples, ones without some are weighted, some are not, some are made of silicone and others are knitted. There's a huge range to choose from. There are a number of ways of wearing prosthetics that range from slipping into a pocket in a specially made bra, or adhering with glue, or attaching with magnets and glue! There are so many options so there's something to fit everybody.
- Implants - this is the procedure that's often confused with a boob job because it uses the same (or similar) implants. However, there are significant differences. With implant reconstruction, it can be done in one of several ways and be one surgery or two staged surgeries (or in some cases more). Although implants have a shorter recovery time, they may require more maintenance in the long term than other surgeries and there's potentially more complications (for example rejection, capsular contraction, rippling, slipping, implant rupture etc) in fact the complications are very similar to those of a normal boob job. Implants can be silicon, saline or a mixture of both and whereas years ago, implants only had a life span of around 10 years, implant construction now means that they may have up to a life-time life span (meaning if there are no complications, no further surgery)! The implant will sit either over or under the chest muscle and will be either round or teardrop shape - there are pros and cons with all so it's important to discuss thoroughly with your surgeon to decide what's best for you. However, as there is no longer any breast tissue, it is fairly common that a surgeon will create a sling under your breast skin but over the implant to support it. Scars can be in an anchor shape (ie a circle around your nipple then a line down to the underside of your breast where it meets a scar what runs from side to side (under the breast). Surgeons operate differently so if you're interested in this procedure, please ask your surgeon how yours will be done. Surgery (if you have a mastectomy with immediate implant reconstruction) takes approximately 6-8 hours and recovery normally takes 3 months to fully see the final result but within 4 weeks things should have fully settled down.
- TRAM (transverse rectus abdomini) - a Tram flap operation is a very common procedure and a flap of skin from your tummy, fat, and all or part of the underlying rectus abdominus muscle are used to reconstruct the breast. There is an alternative TRAM procedure that leaves the muscle in tact. The TRAM flap tissue is very similar to breast tissue and makes a good substitute but with this surgery it requires a cut through muscle. As this surgery uses tummy fat, you will have the equivalent of a tummy tuck with this procedure but the scars may be more higher than a bikini line. This operation isn't suitable for ladies who are slim and may not have a lot of tummy fat to create the new breast(s). This operation takes about 4 hours on it's own but with a mastectomy it will be longer.
- DIEP (deep inferior epigastric perforator) - this surgery takes fat from your tummy area (still connected to a blood supply) to make your new breast(s). The advantage of using your tummy fat is that there is far less risk of rejection but there is the risk of the fat dying if the blood supply fails. Before the surgeon agreeing to carry out this operation you do need to have a test to see if the blood vessels in your lower abdomen are suitable for transfer and are working efficiently. If you've had previous stomach surgery, there is a risk that the blood vessels required to be transferred to the chest are not working as they should which would result in a lack of blood supply to the tissue being transferred. Like all the other surgeries, there are always ways to correct anything that goes wrong. As tummy fat is taken to create your breast(s), you will have the equivalent of a tummy tuck (although the scar will be slightly higher than a traditional bikini line scar of a tummy tuck but will typically be from hip to hip). Surgery is between 6 and 10 hours and requires specialist micro-surgeons. Due to the specialist nature of this procedure, it's not available in all areas of the UK at the moment. You may also not be suitable for this procedure if you need a bilateral mastectomy and do not have enough tummy fat to create two breasts.
- LD (latissimus dorsi) - the latissimus dorsi muscle is the muscle that runs on either side of your back - below the shoulders. It's the muscle that's involved in twisting and turning. Unlike the DIEP (and some TRAM surgeries), the LD is considered a muscle type reconstruction rather than fat. This gives it unique properties in that it creates a harder to touch type of breast (perhaps feeling tight) and because it uses the skin from your back, it can be a different colour to your normal breast tissue (although over time this should even out somewhat). With the LD procedure, there probably isn't enough fat on the back to create anything other than small breasts, so patients may offered a combination of LD and implants. Of course this means that you have the advantages and disadvantages of both operations. Due to the muscle relocation, it can leave you with some restricted movement. For the very active and sporty, this may be a consideration as it could possibly limit the ability to swim or play tennis for example. This restriction could be temporary or permanent. The operation itself takes around 3-4 hours (longer if done at the same time as a mastectomy) and is usually offered to ladies where the TRAM, DIEP and others may not be suitable.
(transverse upper gracilis) - with this reconstruction, it uses the gracilis muscle which is on the inner thigh. Skin, fat, blood vessels and muscle are transferred to the breast area. Typically this will recreate smaller breasts so if you want to be larger, you may need to combine a TUG with Implants. Occasionally a TUG may be performed is a patient has previously had a TRAM or DIEP that may not have been successful and more fat is required. So it can often be used as a back up option. You will typically have scars on your inner thighs and may have to wear compression garments for several weeks after surgery. The scars are very similar to having a thigh lift and after your breasts are reconstructed, your thighs will be slimmer too. It might be wise to bear in mind that if you're only having one breast reconstructed, this may mean having one thigh slimmer than the other.
- Nipple Reconstruction - You may also be offered the chance of having a nipple recreated from your existing nipple that can be done at the same time as surgery. However, if your breast cancer has been near to the nipple area your surgeon may not want to do this. Other options are of course available, for example, a nipple "bump" can be created at the time of surgery to give you the appearance of a nipple. An areola can then be tattoo'd around that area. Medical tattooing has come on in leaps and bounds in previous years and there are now tattooists who offer 3D nipple tattoos. These look amazing and do give the impression of a nipple. Be warned that like any tattoo, a nipple tattoo can fade and it may take several appointments to top up in the first year (and then at various points afterwards to ensure they look their best). This service is offered on the NHS or privately via specialists tattooists. Please make sure you get a recommendation if you're not using a tattooist suggested by your surgeon. The photo on the right is of a 3D nipple tattoo.
- Fat Grafting / Lipofilling - there have been some reconstructions that have used fat from areas of the body without any other form of reconstruction. This is very much in its infancy and there have been no long term studies to support it as a viable option at the moment. However, where it has and is used successfully is for helping to correct areas that may need filling. For example if a dip is left in the breast after a lumpectomy or where there are obvious areas of rippling with implants or a more even look needs to be achieved. This can be done using your own fat (fat grafting) or by lipofilling. One of the biggest drawbacks however is that in some people, the body reabsorbs the fat/lipofilling. It's impossible to know who this will happen to and therefore surgeons sometimes add a little more than required to allow for some loss in volume.
An important thing to note is that if you are opting for reconstruction,
with nearly ALL the procedures, you may need more than one surgery to
tweak the final look. This is fairly normal and it's best to understand that at the start.