“The objective of breast reconstruction after mastectomy is to create a natural breast with the shape, symmetry and softness of the original,” says plastic surgeon and breast reconstruction specialist Dr. Constance M. Chen. “In most patients, modifications are needed after the initial surgery to accomplish that goal. Women should know that with a customized plan and advanced surgical techniques, we can often improve shape, size, and symmetry after the initial breast reconstruction to help a woman’s breasts look better and feel more normal.”
In most cases, the best aesthetic outcomes are achieved with natural tissue. There is a principle in plastic surgery to “replace like with like.” On the operating room table, the actual breast tissue looks and feels like regular fat – breast tissue and fatty tissue look and feel the same. As a result, when it is feasible to use a woman’s own fat to recreate the breast, the reconstructed breast will feel very much like the original – sometimes it is almost identical.
Women should know that even if they had reconstruction with breast implants that the implants can be removed and replaced with natural tissue. While many women with implant-based breast reconstruction are happy with the results, some women who have undergone breast reconstruction with implants feel uncomfortable because breast implants are usually placed underneath the muscle. In these cases the subpectoral breast implants can cause rigidity and trouble with breathing, and a hyper-animation deformity can also result in which the patient’s breasts move up and down when she flexes her pectoralis muscle.
“In our experience, many women are surprised when their breast implants are removed and replaced with natural tissue. They commonly report feeling much more comfortable and they are pleased that their new breasts feel and look normal,” says Dr. Chen.
Breast reconstruction problems can also arise due to asymmetry. Breasts should look like sisters if not twins, and it’s best when at least they look like they belong to the same family. It is easiest to obtain symmetry with bilateral reconstruction, in which the incisions from the mastectomy and reconstruction method are the same. However, in cases where only one breast has undergone a mastectomy with breast reconstruction it may be necessary to perform additional procedures on the other breast to achieve symmetry. Fortunately, the 1998 Women’s Health and Cancer Rights Act requires all health insurance companies to cover all stages of breast reconstruction and any complications from all stages of mastectomy or breast reconstruction, and symmetry procedures on the opposite breast are also covered. A woman’s right to breast reconstruction at any stage is protected by federal law and many state laws.
Refining and Improving Breast Reconstruction
One common type of secondary breast reconstruction procedure is fat grafting, in which fat is collected from another part of the body through tiny incisions via liposuction. The extracted fat is processed to remove impurities, and then the fat graft is transferred by injections into the breast. This process is used to make the breast larger or to correct contour deformities by sculpting and filling in small areas to improve breast size, shape, and symmetry.
Another common secondary breast reconstruction is called mastopexy or breast lift. Here the goal is to improve the look and/or evenness of the reconstructed breasts. Reconstructed breasts are usually perkier, particularly after implant-based breast reconstruction. If only one breast has undergone mastectomy and breast reconstruction, a mastopexy may be needed on the unaffected breast to match the reconstructed breast. A breast lift will remove excess skin and raise the nipple-areola complex so that the breast sits higher on the chest wall. A breast lift will not significantly alter the size of the breast.
Finally, in some cases the breast size may need to be modified with a breast reduction or a breast augmentation. A breast reduction is similar to a breast lift, except breast tissue is removed along with the breast skin to make the breast smaller. A breast augmentation may be performed with fat grafting or a breast implant.
Any of these procedures can also be implemented on the reconstructed breast(s).
Additional procedures to achieve symmetry are almost always needed for women who have undergone a unilateral (single-sided) mastectomy and breast reconstruction with a breast implant. On the other hand, the best aesthetic outcomes are from bilateral (double-sided) nipple-sparing mastectomies with immediate natural tissue breast reconstruction. When all the breast skin has been preserved and the breast reconstruction is performed with natural tissue at the same time as the mastectomy, it can be nearly impossible to tell that a woman has had a mastectomy.
“Too many women have experienced the devastating upset of a cancer diagnosis and subsequent treatment only to have added disappointment of an unsatisfactory reconstruction outcome,” says Dr. Chen. “Correcting a poor or uncomfortable reconstruction can be the last step in restoring a woman’s physical and emotional health and improving her quality of life.” Even women who have not had the gold standard in mastectomy and breast reconstruction from the beginning can undergo secondary breast reconstruction to improve their initial results.
Constance M. Chen, MD, is a board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine. She is also Chief of Microsurgery at New York Eye and Ear Infirmary of Mount Sinai. www.constancechenmd.com