By Dr. Constance M. Chen

The goal of breast reconstruction after mastectomy is to restore symmetry –  to create a breast with the shape and softness of the original that is in proportion with her opposite breast as well as the rest of a woman's body. Matching a reconstructed breast to the existing natural breast may not be possible in a single surgical procedure, however. Follow-up modifications may be necessary to achieve the desired symmetric result.

Breast reconstruction is often a process rather than a single surgical procedure. Lack of symmetry in mastectomy patients after reconstruction can be corrected with adjustments to the reconstructed breast or to its unaffected 'sister.' Asymmetry may also be a problem for women who have had a lumpectomy that conserved the breast but left them with breasts that no longer match. For all these women, advanced surgical techniques that address their individual needs can produce an improved symmetrical outcome to help put cancer behind them.

The gold standard in post-mastectomy reconstruction is natural tissue breast reconstruction, which uses a woman's own tissue to recreate a soft and warm breast. The best possible result is achieved when reconstruction is performed at the same time as the mastectomy, because the surgeon can preserve the entire breast envelope including the nipple-areola complex. Even if it is not possible to preserve the entire breast envelope, the incisions can be carefully planned to preserve as much of the breast shape as possible. In addition, symmetry is often best in bilateral mastectomy with immediate reconstruction, when both breasts are removed and reconstructed at the same time, because it is easier to match size, shape and position.

Reconstructed breasts can be very difficult to distinguish from the original, but there are many reasons why 'best case' scenarios may not be feasible. For example, most breast surgeons do not perform nipple-sparing mastectomies, and the traditional transverse-scar mastectomy distorts the breast shape significantly. In addition, most women undergo breast reconstruction with implants rather than natural tissue, and the resulting breasts may have the artificial shape of an implant. Furthermore, there are medical and personal reasons that reconstruction may be performed months or even years after mastectomy, when the skin envelope has been distorted even more. And finally, if only one breast needs to be reconstructed, symmetry can be more difficult to achieve. In each scenario, however, it is possible to make adjustments not only to the reconstructed breast but also to the unaffected breast to improve symmetry.

Techniques for Improving Symmetry

One of the most common procedures for correcting small defects is fat grafting, which transfers fat from another part of the body to the breast. Using liposuction, fat is removed through tiny incisions from the donor site, processed to remove impurities, and injected into the breast. Fat grafting and liposuction may be used on the unaffected breast, to make corrections to the reconstructed breast, or to fill in deficiencies resulting from lumpectomy. 

A mastopexy or breast lift may be performed on the unaffected breast if its natural droop cannot be replicated in the reconstructed breast. This is often the case with implant-based reconstruction, which tends to create a breast that is “perkier” than the natural breast. A breast lift will remove excess skin and may elevate only the nipple and areola so they are placed higher on the breast or elevate the breast tissue itself so it sits higher on the chest wall. A breast lift will not significantly alter the size of the breast. A breast reduction on the unaffected breast may be needed to match the size of the reconstructed breast. The procedure will remove excess skin and tissue and position the breast tissue and nipple-areola complex higher on the chest wall. Breast augmentation to increase the size of either the reconstructed or the unaffected breast may be achieved with fat grafting or with a breast implant.

Surveys have found that women whose breast reconstruction is symmetrical and aesthetically pleasing have improved postoperative quality of life compared to those who perceive their breasts as mismatched. It's important for women to know that they don't have to live with asymmetrical breasts and that achieving balance will not impose a financial burden. The 1998 Women's Health and Cancer Rights Act requires health insurers that cover mastectomy to also cover all stages of reconstruction and secondary procedures as well as surgery on the opposite breast to achieve symmetry. At the end of the day, after undergoing breast reconstruction, women are entitled to have symmetrical breasts.