How To Approach Post-Mastectomy Breast Reconstruction

Since 1985, October has served as Breast Cancer Awareness (BCA) Month — a period devoted to educating the public on the disease that, according to the Centers for Disease Control and Prevention (CDC), is the second most common form of cancer in women, regardless of race or ethnicity. Men can also be diagnosed with breast cancer (albeit at a much lower rate), and The AEDITION is devoting much of its coverage this month to BCA, from expert guides to mastectomies and reconstructive breast surgery to powerful patient perspectives and roundups of products that give back.

From the emotional toll to a whirlwind of appointments, testing, and treatment options, a breast cancer diagnosis can bring a flurry of confusion and fear. Each aspect comes with its own impact — not only on a woman’s health, but on her sense of self. Fortunately, early detection and advances in both technology and surgical techniques have created better breast reconstruction options that help patients to feel like themselves again.

To better understand the intricacies of the mastectomy and breast reconstruction process, The AEDITION spoke to leading plastic and reconstructive surgeons and their patients about the logistical, physical, and emotional aspects of breast reconstruction — whether it’s finding the right surgical team, understanding what the results will look like, or learning how to heal (physically and emotionally) after surgery.

Finding the Best Surgical Team

Although it can be hard for a woman recently diagnosed with breast cancer to focus on the long term, the success of her breast reconstruction may ultimately depend on it. “Some patients are so focused initially on getting the cancer out that they don’t really explore the options for reconstruction,” cautions plastic surgeon Michael Newman, MD, of South Bay Plastic Surgeons in Torrance, CA. “But then they get to that stage when the cancer is out, they’re feeling better, and they really want a better result.”

When that happens, they often try to find another surgeon, and Dr. Newman says he treats a fair number of patients seeking a revision after surgery elsewhere. While he is able to help the majority of such patients, it is not the most optimal way to do things.

“There are a lot of breast surgeons who don’t leave the best tissue behind for the plastic surgeon to work with. When there’s a limited amount of tissue to work with, even the best plastic surgeon can’t do a great job,” he says. “It’s better to optimize their reconstruction from the beginning because they end up with a better final result.”

In order to do so, Dr. Newman recommends women take the time to find the best breast surgeon, so they can “set the stage for an ideal reconstruction.” In a perfect world, he says patients should visit a plastic surgeon at the outset to get a referral for a breast surgeon (though it generally happens the other way around). But, if a patient has already chosen a breast surgeon, Dr. Newman suggests asking her plastic surgeon if that doctor is someone they’ve worked with in the past.

The key, according to Dr. Newman, is to find a breast surgeon capable of achieving a balance between removing all of the breast tissue and leaving an adequate amount of skin, fat, and blood vessels behind to support the reconstruction. And he says you shouldn’t be shy about asking your breast surgeon about their experience level and their philosophy regarding tissue removal.

Another piece of advice? Find support.

Dr. Newman advises women to seek out breast cancer support groups (often offered at hospitals) for advice on which doctors to choose. “When you talk to other people who have been through it, they’ve not only had their own experiences, but they’ve heard from other people too,” he shares.

Once you’ve found your team, the next step is determining the best course of action for your diagnosis.

Removing the Cancer: Lumpectomy vs. Mastectomy

Deciding on a breast cancer treatment plan often depends on the type and stage of the cancer, the philosophy of the doctors, and the patient’s own goals and preferences.

During a lumpectomy procedure, a breast surgeon removes only the tumor, leaving the rest of the breast tissue intact. Less invasive than a mastectomy, a lumpectomy may not have a noticeable impact on the size and shape of the breast — though a growing number of patients are opting to combine the procedure with aesthetic surgery.

“Women with very large breasts who are getting lumpectomy surgery sometimes are getting breast lifts or breast reductions as part of that surgery,” says Dr. Newman. “It’s either to make them feel more comfortable, more symmetric, or to facilitate their secondary treatment such as radiation.”

Additionally, Dr. Newman has noticed that younger women are increasingly choosing to undergo a mastectomy — either unilateral (one breast) and bilateral (both) — during which the surgeon removes all of the breast tissue (read our comprehensive guide to the surgery HERE). “As breast reconstruction results have improved, patients are more likely to move towards a mastectomy or even a double mastectomy than they had in the past,” he says.

Historically, surgeons removed the breast tissue, nipple, and much of the skin, but the rise of nipple- and skin-sparing procedures have been game-changers for breast reconstruction results. During a nipple-sparing mastectomy, the breast tissue is essentially scooped out, leaving the outside of the breast (nipple and skin) virtually intact. “You don’t have to sacrifice the most difficult aspect of the breast to reconstruct,” says Nashville-based plastic surgeon Jacob Unger, MD, of the technique. “To create a nipple, you either need to get a tattoo, which leaves no projection, or reconstruct one, which leaves scarring in the center of the breast.”

According to Dr. Unger, who performs several hundred breast reconstructions per year, data shows that, in most cases, leaving the nipple and skin intact does not adversely impact a patient’s long-term prognosis — but it can do wonders for the post-surgery outcome. Sparing the nipple and concealing the surgical scar in the breast fold allows surgeons to create the most natural-looking results.

Types of Breast Reconstruction

Generally speaking, there are two categories of breast reconstruction: implant-based and autologous tissue (a.k.a. flap)-based.

• Implant: Most commonly used thanks to its shorter surgical and recovery time, implant-based reconstruction can be performed in conjunction with a mastectomy or at a later time and involves using an implant to recreate the breast.

• Autologous Tissue (a.k.a. Flap): In this procedure, the surgeon utilizes the body’s own tissue to construct a breast mound by transferring tissue from one area of the body (known as the donor site) to the chest.

Sometimes, a combination of the two is used to achieve the most natural, symmetrical results. “I want all of my patients to understand their options so that they can make the best choice for them,” says Dr. Unger. “And then my job is to give the best result I can under those constraints.”

Creating a natural and symmetrical result can be challenging — regardless of the type of mastectomy or breast construction technique performed. In patients who opt for a unilateral mastectomy with an implant, for example, it is difficult to match real breast tissue to the standard shape of an implant.

A patient’s unique anatomy, meanwhile, can pose challenges for reconstruction after a bilateral mastectomy, too. “People aren’t always even between their two sides,” UCLA plastic surgeon Jason Roostaeian, MD, points out. “We want the best aesthetic results, but there are a lot of variables out of our control: how the mastectomy was performed, whether they are planning to have radiation, the structure of their ribcage — all of these things that nobody really ever thinks about.”

While surgeons take all of these nuances into account, there’s no such thing as perfection. In fact, relying solely on measurements — particularly for things like nipple placement — can leave a patient with an unnatural result. “The good news is that since nobody is perfectly symmetric, it’s more about making each breast look good on its own,” says Dr. Roostaeian. “They are sisters, not twins.”

Ultimately, the surgeon’s well-trained eye is paramount because the reconstruction process is equal parts art and science, and managing a patient’s expectations is key. “Women who are undergoing breast cancer care today are expecting and hoping for results similar to aesthetic breast surgery,” says Dr. Unger. “It’s about having appropriate expectations and having good lines of communication.”

The Emotional Impact of Breast Reconstruction

While a successful breast reconstruction can have a tremendous impact on helping women start to feel whole again after a cancer experience, the path isn’t always smooth or linear. It is not uncommon for reconstruction patients to experience some degree of post-surgery depression and seeking help through support groups or therapy can make a big difference.

Dr. Roostaeian’s patient Marjan was ultimately very happy with her flap surgery, but it was emotionally challenging at first. “I started getting really emotional,” she says of her experience, which included a flap procedure, refining surgery, and nipple reconstruction. “I was regretting not getting the double mastectomy because I was afraid I’d have to go through all of this again.”

Initially, she says that every time she saw herself in the mirror, her unaffected breast reminded her of what she’d lost, but Marjan sought therapy and eventually came to terms with her new appearance. “I changed my perspective, my outlook on body image,” she shares. “When I see people now who look different, it doesn’t phase me. It’s just normal.”

Hayley, meanwhile, chose a pre-pectoral, direct-to-implant reconstruction in part because she wanted to be done with the process sooner. “I wanted to move on with my life, to feel like my old self again,” she says. But months after her treatments, Hayley experienced symptoms that her oncologist said were long-lasting side effects of everything her body’s been through. “Even though I know that I’ll never truly be my old self after going through something really scary, I grew a lot from it,” she says of her experience.

Caroline* also went through a period of conflicting emotions after her reconstruction. “It hit me at the end,” she says. “You’re so focused on getting through all of the terrible parts — mastectomy, chemo, radiation — to reach this goal of reconstruction, and, when you get there, you have to come to terms with the fact that no matter how well they put you back together, it’s not the old you. You have to learn to embrace the new you.”

One thing that can help give patients peace of mind is knowing that they had the best care. Dr. Unger’s implant reconstruction patient Laura, who chronicled her breast cancer journey on Instagram and her blog, says that finding the right plastic surgeon helped her get through an otherwise incredibly challenging time. “When you’re going through everything, and you’re losing your hair, it’s just such a comfort,” she says. “I call him ‘the good doctor.’”

Kelly feels the same way about the rapport she built with her own plastic surgeon, Leif Rogers, MD. “It’s really important to educate yourself and to find someone you trust,” she says. “It’s a relationship, not a ‘one and done.’”

*Patient names have been changed