By Dr. Constance M Chen

For many women, breast reconstruction is a process rather than a single procedure. Some women have experienced complications, particularly with implants, that require additional surgery. And many women are simply unhappy with the results of their breast reconstruction. The goal of breast reconstruction after mastectomy is to create a natural breast with the shape, softness and symmetry of the original. Sometimes follow-up adjustments are necessary to achieve that goal, and some women may need corrective surgery to reverse the effects of a failed reconstruction. It's important for women to know that with an individualized plan and advanced surgical techniques, we can often improve size, shape, and symmetry problems after the initial breast reconstruction to help a woman’s breasts look more normal again and to restore a sense of wholeness.

In general, the best aesthetic outcomes are achieved with natural tissue. There is a principle in plastic surgery to “replace like with like.” On the operating room table, the actual breast tissue looks and feels like regular fat - the breast tissue and fat are almost indistinguishable. Thus, when it is possible to use a woman’s own fat tissue recreate the breast, the reconstructed breast will feel very much like the original - sometimes it is almost identical. Many patients do not realize that even if they have already undergone reconstruction with breast implants, the implants can be removed and replaced with natural tissue. While many women with implant-based breast reconstruction are very happy, some women who have undergone breast reconstruction with implants feel uncomfortable because breast implants are usually placed underneath the muscle. The subpectoral breast implants can cause tightness and difficulty with breathing, and a hyper-animation deformity can result in which the patient’s breasts move up and down when she flexes her pectoralis muscle. When the breast implants are removed and replaced with natural tissue, women are usually stunned by how much more comfortable they feel and how normal their new breasts look and feel to everyone around them. Women who replace their implants with natural tissue say the difference is like night and day, and they typically remark on how their breasts after natural tissue breast reconstruction makes them feel like they did before their mastectomy.

Breast reconstruction problems can also arise due to asymmetry. While breasts may be sisters, not twins, it is ideal when at least they look like they belong to the same family. Often, it is easiest to obtain symmetry with bilateral reconstruction, in which the initial incisions from the mastectomy and reconstruction method are similar. If only one breast has undergone a mastectomy with breast reconstruction, however, it may be necessary to perform additional procedures on the other breast to achieve symmetry. Fortunately, the 1998 Women’s Health and Cancer Rights Act requires all health insurance companies to cover all stages of breast reconstruction, surgery on the opposite breast to achieve symmetry, and any complications from all stages of mastectomy or breast reconstruction. A woman’s right to breast reconstruction at any stage is protected by federal law.

Refining and Correcting Unsatisfactory Reconstruction

After an initial breast reconstruction, the most common secondary breast reconstruction procedure is fat grafting, in which fat is harvested from another part of the body through tiny incisions via liposuction. The aspirated fat is processed to remove impurities, and then the fat graft is transferred by injections into the breast. Fat grafting can be used to make the breast larger, as in breast augmentation. Fat grafting is also very useful to correct contour deformities by sculpting and filling in small areas to improve breast size, shape, and symmetry.

A mastopexy or breast lift is also a common second stage procedure to improve the appearance or symmetry of the reconstructed breasts. After any type of breast reconstruction, the reconstructed breasts are usually perkier than an unreconstructed breast - this is especially true after implant-based breast reconstruction. Thus, if only one breast has undergone mastectomy and breast reconstruction, it may be necessary to perform a mastopexy on the unaffected breast if its natural droop cannot be replicated in the reconstructed breast. A breast lift will remove excess skin and elevate the nipple-areola complex so that the breast sits higher on the chest wall. A breast lift will not significantly alter the size of the breast.

Finally, the breast size may need to be adjusted with a breast reduction or a breast augmentation. A breast reduction is similar to a breast lift, except breast tissue is resected along with the breast skin to make the breast smaller. A breast augmentation may be performed with fat grafting or a breast implant. Any of these procedures may be performed on the reconstructed breast(s) or, in the case of a unilateral mastectomy and breast reconstruction, on the unreconstructed breast only.

Additional procedures to achieve symmetry are most likely to be needed in women who have undergone a single-sided mastectomy and breast reconstruction with a breast implant. The absolute best aesthetic outcome comes after bilateral nipple-sparing mastectomies with immediate natural tissue breast reconstruction. When all of the breast skin has been preserved and the breast reconstruction is performed with natural tissue at the same time as the mastectomy, it can be nearly impossible to tell that a woman has had a mastectomy at all. Even women who have not had the gold standard in mastectomy and breast reconstruction from the beginning, however, can undergo secondary breast reconstruction to improve their initial results. Too many women have endured not only the crushing blow of a cancer diagnosis and months or years of treatment but the additional trauma of an unsatisfactory reconstruction outcome. Correcting a poor reconstruction can be the final step in restoring a woman's physical and emotional health and improving her quality of life.