This procedure usually requires multiple steps. First, a balloon-like pouch called a tissue expander is placed under the skin and chest muscle. Every week or so, two to four ounces of salt water are added through a valve. This stretches skin and tissue over about two months to make room for the implant and create a natural-appearing breast shape. After two to four months of recuperation from that surgery -- and, if needed, chemotherapy and radiation -- the expander is removed. A salt-water or silicone-filled implant is placed through the mastectomy scar and under the chest muscle to provide shape and volume.
In general, for two to four weeks, you can't drive, exercise, participate in sports, or lift more than five pounds. Women can return to work two to three weeks after a mastectomy and expander, or after the implant is inserted.
Seventy percent of women have no complications. About 2 percent experience infection or bleeding, and because an implant is foreign to your body, an infection of the chest wall may require implant removal. Up to 10 percent of implants leak within the first year. Excess scar tissue can squeeze the implants and cause pain and contour distortions. Leakage and distortions can occur years later.
The recovery time is about half that of the more complicated flap operations, but "there are two surgeries, thus two recovery times," Wilkins says. An implant also is less likely to match a natural breast in shape and texture. Women may desire an implant in their other breast to create symmetry.
One's own body tissue is used to re-create a breast. There are several potential sources for this tissue. A TRAM (transverse rectus abdominus muscle) flap involves skin, fat, and often muscle from the abdomen to fill the breast. A gluteal flap is one that uses muscle, overlying fat, and skin from the buttocks, while a latissimus dorsi flap uses fat and the swimmer's muscle from the back. Some of these procedures are performed as "free" flaps, in which the surgeon removes skin, fat and, often, muscle from the donor site and transplants it to the chest. Small blood vessels in the transferred tissue are connected to small vessels in the mastectomy site. By contrast, with a "pedicle" flap, surgeons raise a strip of muscle and flesh, leaving it partially connected at the muscle, and then tunnel from that part of the body to the chest, where the transferred tissue is sculpted to create the new breast. This does not require blood vessel reconnection, as the blood supply comes from the abdominal muscles. Which is best: free or pedicle? Experts differ, and it often comes down to the procedure your surgeon is most comfortable doing.
Six to eight weeks
With TRAM flaps, 80 percent of women have no complications, but 6 percent have hernias, or bulging of tissue beneath weakened abdominal walls. About 2 percent of women have bleeding or infection, and less than 1 percent have circulation problems that lead to the loss of the moved tissue. The last occurs more frequently with free flaps.
The surgery is more elaborate, requiring up to six hours (versus one hour for an implant). These procedures will leave a scar at the site from which tissue is taken (from the lower abdomen, back, or buttock area), but you probably won't need to be operated on again once the nipple is created. "It's the closest thing to a breast, versus a sac filled with salt water or silicone," says Joseph J. Disa, MD, a reconstructive surgeon at New York's Memorial Sloan-Kettering Cancer Center and author of 100 Questions and Answers About Breast Surgery (Jones and Bartlett, 2006). If muscle is used, that which remains may not be as strong. If back muscle is used, the shoulder may be less mobile.
Deep inferior epigastric perforator flap is the newest offering. Skin and fat -- but little or no muscle -- are removed from the lower abdomen and reconnected to the breast in microsurgery.
About six weeks
A less than 2 percent danger of infection or bleeding remains. The flap may require surgery to restore blood circulation.
There's a scar at the donor site, but with no muscle moved, you don't have muscle weakness. You also don't need physical therapy to strengthen other muscles to compensate.