Breast Reconstruction, a Work in Progress

As much as I like to think of the breast reconstructive process as the “light at the end of the tunnel,” I am inevitably met with a look of astonishment when I describe the typical timeline.

Breast reconstruction is almost never a one-step process.  There are so many factors involved with mastectomy and reconstruction so that rarely does everything just fall into place.  Most reconstructions involve the gradual stretching of chest skin and muscle with a tissue expander (a temporary implant-like device used to make space for the permanent implant).  Once it has achieved its goal, the expander is exchanged for the actual implant.  Now that the patient feels more like herself, she may want to consider the possibility of additional (tweaking) surgeries, such as fat grafting and nipple reconstruction.

The whole process takes about a year – if all goes well (no infection, routine chemotherapy, no radiation, etc.).  Treatment for infection can be as simple as intravenous antibiotics or as complex as removing the expander or implant and starting over six months later.  Chemotherapy is usually just a matter of timing. We schedule expansions and surgery around the patient’s chemo sessions.

Radiation is a whole other issue! Radiation causes subtle changes (fibrosis of the tiny blood vessels and skin) that last forever. The timing of radiation will determine changes in the reconstruction timeline.  At minimum, radiation adds about a year to the reconstruction timeline.

The human body is subject to the many forces of change….weight, age, health, medications, gravity, etc.

The natural breast ages by “ptosis,” or droop. This can also happen in a reconstructed breast, but more often than not, we see the opposite: a hardening from scar formation.   This will distort the shape of the breast.  Removing the scar tissue and replacing the implant is sometimes an option.  Sometimes simple “camouflage” with a few layers of fat (fat grafting) helps.  I like the fat grafting option because it also gives me the opportunity to reduce areas of excess fat that may detract from the breast shape (i.e. – bra or back fat).

I can in no way predict when or if these changes will occur.  If a survivor is concerned about the shape of her breasts, a simple evaluation by a plastic surgeon is an option.

Reconstruction is finished when the patient is pleased with her breasts and/or I can offer nothing more.

by Alissa M. Shulman, MD, FACS
Sovereign Plastic Surgery


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