Implants or Tissue Transfer: What’s Right for You After a Mastectomy?

We understand how traumatic the thought of a mastectomy can be for people with breast cancer. If your doctors have shared with you that your best chance of treatment and remission includes a mastectomy, take time to explore your options before immediately deciding on breast reconstructive surgery.

Reconstructive surgery can boost your self-confidence and improve your body image. But you’ll want to learn more before deciding which reconstruction option is best for you. But don’t put off your research, as reconstruction can sometimes be done during your mastectomy.

“There are two main reconstructive options,” says plastic surgeon Risal Djohan, MD. “You can get artificial breast implants or opt to have the surgeon recreate your breasts with your own fat tissue.”

“Fortunately, thanks to government regulations and support for breast cancer services, most insurance providers now pay for reconstructive surgery as part of cancer treatment,” Dr, Djohan says.

What are the best breast implant options?

In many cases, breast implants require a two-part procedure. “The surgeon may first need to insert a temporary tissue expander to create space underneath the layer of skin and fat for the implant,” Dr. Djohan explains.

A few months after that, your physician will remove the expander and insert an implant in the newly created pocket.

“For some patients, however, doctors can immediately place the implant,” Dr. Djohan notes.

“Depending on evaluation of the patient meeting certain criteria, we certainly can skip a step of the operation and get everything done at the same time,” Dr. Djohan says.

You have two options for breast implants:

• Silicone implants. “Filled with silicone gel, these implants feel more like natural breast tissue and maintain their shape well,” Dr. Djohan says. They are approved for use by the Food and Drug Administration (FDA) for women 22 and older.
• Saline implants. These implants contain saline solution and offer a uniform shape and feel. “They’re FDA-approved for women 18 and older and best-suited for women with autoimmune conditions, like lupus or Sjögren’s syndrome, who might have a reaction to a silicone leak,” Dr. Djohan says.

“There are pros and cons to breast implants,” says Dr. Djohan. In making your decision, it’s important to think these points over carefully and talk with your surgeon if you have questions.

The pros and cons to breast implants

Dr. Djohan lists important points about breast implants below.

Pros

• Most plastic surgeons can perform breast implant surgery.
• In most cases, it’s not a complex procedure and can be performed in one to two hours of operative time after your mastectomy.
• This procedure can be done as an outpatient surgery, going home on the same day after the operation, or staying overnight, depending on your individual case.

Cons

• Silicone and saline breast implants have a limited lifespan and would need additional surgery for replacement or removal at some point in the future.
• Some people may not be able to tolerate implants.
• Implants sometimes leak within the surrounding capsule. Leaked silicone can escape the capsule and make contact with adjacent tissue in your reconstructed breast. If a saline implant, your body will reabsorb leaked saline, but the implant will deflate.
• Also, in some cases, capsular contracture, when internal scar tissue forms tightly around the implant, may occur. This would occur more commonly in people undergoing radiation treatment.

What is autologous tissue reconstruction?

Autologous tissue reconstruction involves using abdominal fat, skin and fatty tissue from your lower abdomen or other areas, such as your back or thighs, to recreate a breast.

There are two kinds of autologous tissue reconstruction:

• TRAM (transverse rectus abdominis muscle) flap. This procedure uses the blood supply of your rectus abdominis muscle, along with skin and fatty tissue. There are two kinds of TRAM flap procedures: one in which blood vessels are severed and reattached (a free TRAM flap); and one in which blood vessels are left attached (a pedicled TRAM flap) and the tissue is moved under your skin up to your chest to rebuild your breast.
• DIEP (deep inferior epigastric perforator) free flap technique. A variation of the free TRAM flap that preserves your rectus abdominis muscle. The main advantage of the DIEP free flap technique is that complications are minimized.

Dr. Djohan also shares the pros and cons of autologous tissue reconstruction.

The pros and cons of tissue transfer breast reconstruction

Pros

• This procedure relies on your natural tissues.
• Allergic reactions are not a problem.
• There’s never a need for replacement and rarely a need for repairs.
• Your breasts will grow or decrease in size with weight fluctuations, as would your normal breasts.
• Your belly will be flatter and tighter, as if you’ve had a tummy tuck.

Cons

• The surgery for autologous tissue reconstruction is complex. It requires a specially trained plastic surgeon.
• The procedure can last up to six hours.
• You might stay in the hospital for up to three days.

Autologous tissue reconstruction is not recommended in some circumstances, such as if you’ve had previous abdominal surgeries, have obesity, smoke or have a history of blood clots.

When is the best time for breast reconstruction?

In the past, women who had mastectomies waited until after their cancer treatment and surgeries before tackling breast reconstruction. Today, that’s not always the case.

Now, there are options for immediate reconstruction. In this case, the first stage of reconstructive surgery occurs at the same time as your mastectomy. This requires close coordination between the cancer surgery and plastic surgery teams.

In some cases, single-stage reconstruction is possible. Your surgeon inserts implants or fat tissue without additional reconstructive surgeries. “Some women find this option makes recovery easier, socially and emotionally,” Dr. Djohan says.

However, if you need radiation and want to use your own tissue for reconstruction, your surgical team might suggest a mixed approach. In this case, your surgeon would insert tissue expanders during your mastectomy. This prepares your breast skin for further reconstruction after your treatment is complete.

“Ultimately, it’s best to discuss your goals for reconstructive surgery with your healthcare providers,” Dr. Djohan says.

“If you have a mastectomy, you should choose a reconstructive surgery that makes you feel most comfortable,” he says. “A conversation with your doctor and plastic surgeon can help guide your choices so you make the most appropriate choice for you.”