Results from breast reconstruction can vary significantly between patients. Several factors affect outcomes and appearance. Patients should consider these factors before undergoing surgery to make sure their expectations are realistic.
Breast Size Prior to Surgery
Reconstruction is generally more difficult in patients with large breasts who require a mastectomy. Frequently, a breast reduction or lift is performed on the healthy breast so it can match the reconstructed side. There are several reasons for this. One is that large breasts are frequently ptotic, meaning that the nipple points downward and a large proportion of the breast tissue hangs below the breast crease. Breast implants, even implants shaped to look like a natural breast, do not look like a ptotic breast. Reconstruction using your own tissues – and in particular a TRAM flap, DIEP flap or TUG flap – can result in a reconstructed breast with mild to moderate ptosis. A TUG flap, however, can only be used to build a small to moderate-sized breast. Of all of the available flap procedures, a free TRAM flap (or, in some cases, a stacked free TRAM or DIEP flap) creates the largest breast possible using a woman’s own tissues.
Body Mass Index and Body Shape
Reconstructions with breast implants generally look the best on people who are thin or have a normal body mass index (BMI), which measures a person’s weight relative to his or her height. Patients with a BMI greater than 30 will notice more abnormalities in the armpit region. This may include extra skin folds and the illusion that the implants are narrow or the chest is wide.
Patients with a BMI between 26 and 35 frequently are candidates for a pedicled TRAM flap, free TRAM flap, DIEP flap or SIEA flap. Very thin patients may not have enough abdominal tissue available for this type of reconstruction. And patients with a BMI between 35 and 40 have higher complication rates.
The latissimus flap is suitable for patients with the widest range of BMIs (18 to 45). Usually it is accompanied by a breast implant to provide shape and volume to the breast. Patients with a higher BMI (more than 40) will notice a contour depression on their back – where tissue for the flap is harvested – after the procedure is performed.
The TUG flap can be used to reconstruct breasts in patients with a BMI between 24 and 40 in appropriate candidates.
Click here to calculate your BMI. Click here for a chart that rates reconstruction options for women with various BMI ranges.
Breast Cancer Treatments Required
The type of treatment required for breast cancer will have an impact on how a breast is reconstructed and how it will look.
- Mastectomy Versus Lumpectomy: After mastectomy, the entire breast requires reconstruction. After lumpectomy, only a portion of the breast is removed, so different reconstructive strategies are used.
- Chemotherapy: Chemotherapy can affect reconstruction in several ways. Some forms of chemotherapy may delay wound healing, increase the risk of surgical infection or cause a woman to feel poorly, thus altering the timing of reconstruction. Other types, like Herceptin, can temporarily affect heart function. A woman may need to wait to recover from this therapy before reconstruction can be completed.
- Radiation Therapy: Radiation therapy may be recommended to treat breast cancer after lumpectomy or mastectomy. Radiation can cause both temporary and long-term changes to the area of the breast it treats. Temporary changes include red discoloration, injury to the top skin layer and delayed wound healing. Long-term changes include scar tissue, darkening of the skin and other skin changes. Often, if radiation is required, surgeons will recommend reconstruction with a woman’s own tissues (a flap) because there is a higher incidence of complications when breast implants are used alone after radiation.
Type of Breast Reconstruction Chosen
Reconstruction with a flap will result in a lens-shaped scar that surrounds the new skin that was transferred with the flap. Generally, reconstructions with flaps have more ptosis, the natural shape that accompanies an aging breast. Implants, when used alone, are associated with a linear scar. In addition, reconstructions with implants generally have more fullness in the upper part of the breast.
Willingness to Undergo “Touch-up” or Revision Surgery
Breast reconstructions frequently require some form of touch-up surgery to optimize results. This can include repositioning the breasts, fat grafting, liposuction, adding an implant for volume or projection, and modifying the shape, position and size of the other breast so it matches the reconstructed breast. Every patient’s priorities are different. Some patients are more willing than others to undergo these additional “touch-up” or revision procedures. Generally, patients who pursue these additional procedures can achieve more aesthetically pleasing results.
Presence of Complications That May Affect Your Result
Breast reconstruction is complex and can be affected by infections, wound healing problems, loss of the tissues or implant used to perform your reconstruction, additional breast cancer therapy or other setbacks. These factors can delay reconstruction and alter how your breast reconstruction looks.