by Kathy Steligo
A woman considering reconstruction after mastectomy has one concern foremost in her mind: How “real” will her reconstructed breasts be? Will her surgical outcome be worth the effort? Will she look good as new? How closely will her new breast match her natural breast?
From an aesthetic viewpoint, good reconstruction recreates the cleavage, projection, and soft contours of a woman’s natural breast. While individual features, like the structure of your chest and the elasticity of your skin, influence reconstruction, it’s worthwhile to choose your plastic surgeon carefully; his skill and experience has everything to do with your reconstructive outcome.
Most surgeons recommend women talk to patients who have been through reconstructive surgery, and who can give a personal perspective that the surgeon can’t.
Taking a look at reconstruction
Using sophisticated procedures, surgeons now fashion breasts that restore a woman’s profile when she is clothed and appear quite ordinary when she isn’t. Here’s an overview of the four characteristics—shape, size, symmetry and scarring—that most determine how reconstructed breasts look:
Shape. Your reconstructed breast may be flatter, more round, or have less projection than your natural breast, depending on whether it is rebuilt with implants or your own tissue. Most implant reconstruction involves round saline implants, producing a very round breast with minimal to moderate projection. Contoured or tear-shaped implants have a more natural slope and projection, but not all women have the chest structure to accommodate them. Implants used for reconstruction are always placed under the chest muscle, so even contoured implants may appear round and flat.
Tissue flap reconstruction requires a lengthier operation and recovery period than implants, but offers distinct advantages for sculpting and customizing the new breast and fine-tuning its overall shape. Tissue flaps are a better reconstructive method after radiation; women who have implant reconstruction after radiation more frequently develop capsular contracture, a tightening of scar tissue around the implant that can harden the breast and distort its shape.
Size. Reconstructed breasts can approximate the size of your natural breasts or can be made somewhat smaller or larger than what nature gave you. If, for example, you’ve always been small-breasted and crave substantial cleavage, this can be accomplished with reconstruction. If age, gravity, or breastfeeding have taken their toll on your natural breasts, reconstruction can restore fullness and position if that’s what you want.
If your new breasts are implants, your surgeon will select a model of appropriate volume to create the size you want. If you have muscle-sparing flap reconstruction, your new breast will be created from excess fat in your abdomen or buttocks. Slender or athletic women who lack sufficient fat may have to settle for a smaller breast. If your abdomen is the source of your tissue flap, for example, the size of your new breast is limited by how much tummy fat you have to spare. Dr. Jeffrey Friedman, Chairman of the Institute for Reconstructive Surgery, Methodist Hospital, Houston, explains it this way: “You can’t build a D-cup breast with an A-cup abdomen.” Additional fullness can be created by adding an implant to the flap reconstruction.
Over time, a breast created with an implant (if unaffected by capsular contracture) retains its original size, while a flap reconstruction loses and gains weight along with the rest of your body.
Symmetry. Most women’s natural breasts aren’t perfectly symmetrical, but women tend to expect perfection from reconstruction. From a surgical perspective, bilateral reconstruction presents a better chance for symmetry, because the surgeon is starting with a clean slate. He can ensure both breasts are of similar size, shape, and position.
Unilateral reconstruction is a bit trickier, because it’s more difficult to match the natural droop of the opposite breast. Dr. Friedman recommends women carefully consider their priorities regarding unilateral reconstructive surgery. “The most important aspect of a patient’s expectation is what does she want her natural breast to look like? If she’s happy with a B-cup that droops somewhat and doesn’t want to alter it, we can never match it by reconstructing the opposite side with an implant—it won’t droop correctly.” For the best cosmetic results, most women will need another operation to reduce, lift, or augment their natural breast.
Scarring. Scarring is a natural part of the body’s healing process and an unavoidable side effect of surgery. Before they are fully healed, scars are red and prominent, but fade considerably within a year or two following surgery.
Even the best reconstruction can’t eliminate mastectomy scars, but when immediate reconstruction is performed, mastectomy incisions can often be camouflaged in the inframammary fold under the breast, or around the areola (in the latter case, the small scars are covered when the areola is later tattooed). So a woman entering reconstruction without any visible breast scars emerges from surgery in much the same way. (Flap reconstruction, however, does leave a lengthy scar at the donor site. Scars on the abdomen or buttocks are usually hidden by bathing suits and underwear.) In some cases, lateral or vertical incisions from the nipple are required to accommodate reconstruction. These scars become less noticeable over time, but never disappear completely.
When immediate breast reconstruction is performed, most of the breast skin is preserved to hold the implant or tissue flap. When a woman has a mastectomy without reconstruction, most of the breast skin is removed through a long incision across her chest. The resulting scar is permanent. If reconstruction is performed sometime later, it is done through this mastectomy scar, which is reopened to accommodate the implant or tissue flap. The mastectomy scar remains on the reconstructed breast, but grows pale over time.
Just how your scars look when fully healed depends on your age, genetics, the way your body heals, and how your incisions and underlying tissues are sewn together. Smoking doesn’t help; it can restrict blood flow and make scars more obvious.
Proper maintenance – keeping the healed scar moist, massaging the scar line, and using a scar management product – can smooth and flatten scars, making them less noticeable. When these techniques don’t do the trick, reexcising the scar – cutting away the hard scar tissue and reclosing the incision – may significantly improve a scar.
Sensation and touch
Lost sensation is an unfortunate byproduct of mastectomy, caused when delicate nerves are severed as breast tissue is removed. Just how much sensation is regained, and to what degree, varies greatly between individuals. Most women regain some feeling in their new breasts as nerves regenerate; this is more likely to occur with tissue flaps than with implants, because the nerves within the flaps regenerate in the chest. Typically, women remain numb in the front of the breast, retaining sensation primarily in the outer perimeters of the breast.
Rebuilding the nipple, and tattooing the nipple and areola, completes the reconstruction process. The new nipple is purely cosmetic. It remains numb after mastectomy, because it lacks the nerve endings and muscle fibers needed to receive sensation.
Women who undergo prophylactic mastectomy may be candidates for nipple-sparing techniques: breast tissue is removed through an incision under the breast or around the areola. If a sample of the tissue underlying the nipple is free of cancer cells, the natural nipple and areola remain on the breast. Nipple-sparing fulfills some women’s desire to keep a small part of their natural breasts, but often, the nipple flattens, changes shape, or loses much or all sensation.
Many women wonder how their reconstructed breasts will feel to their partner. A breast reconstructed with a tissue flap feels naturally soft to the touch. It is, after all, your own tissue. Saline implants tend to feel quite firm, like water balloons filled to capacity, although regular massage often improves their softness. Silicone implants closely mimic the feel of natural tissue; they feel more natural than saline implants, but less so than a tissue flap.
Stacking the deck in your favor
You may not be able to control certain elements of breast cancer, but you can make decisions that are likely to improve your overall satisfaction with your reconstruction:
Expecting reconstructive perfection is setting yourself up for disappointment. You’re more apt to be satisfied with your results if you establish realistic expectations before your reconstruction. “I spend a good deal of time discussing my patient’s expectations,” Friedman says. “I also recommend women talk to patients who have been through reconstructive surgery, and who can give a personal perspective that I can’t provide.”
This article was last reviewed August 2011.