In any operation on the breast, the plastic surgeon considers the three "S's". They are size, shape, and symmetry. These considerations are paramount whether one is reducing a breast, reconstructing a breast, or augmenting a breast.
In breast reconstruction in particular, it is important to perform the appropriate size of reconstruction. The size should allow the patient to have a feminine contour, an appropriate softness of feel with concordance with the patient's body size. For instance, a larger woman would need a larger reconstruction size as compared to a smaller framed woman.
Shape also is important. The goal in breast reconstruction is not the simple creation of a mound of tissue on the chest wall. It has to have the appropriate conical shape with projection of the breast mound and soft and tapering contours melding onto the rest of the chest wall. The surgeon tries to create a smooth transition from the upper chest wall, including fullness in the upper pole with the volume largely in the lower pole to create an attractive and sensual appearing breast tissue. The skin may need to be adjusted to provide an adequate yet firm skin envelope around the newly constructed breast. Additionally, the nipple has to be placed at the appropriate location at the height of the breast mound. This is typically aligned midpoint from the shoulder to the elbow and is considered an aesthetic norm.
The final consideration is symmetry. An appropriately sized and shaped breast is desirable, but it must match the other side. Multiple approaches are available in this consideration.
After the initial reconstruction, additional surgery is often required to shape the reconstructed breast into a proportionate symmetrical appearance. This may include liposuction of the new breast to thin it out for a better match, or excising excess skin or other small "tucks". It may mean changing the tissue expander to a smaller permanent implant or to a larger permanent implant.
At other times, it is the normal breast that must be altered. In preoperative counseling, the patient is informed whether or not the normal breast can be matched in terms of symmetry in the reconstructed breast. If not, the patient is prepared for surgical procedures on the normal breast to have it better approximate the appearance of the reconstructed breast. For most patients, this is a desirable procedure. It may involve performing a mastopexy or lift on the native breast which has sagged with age and has excess skin including stretch marks. Through a procedure called a wise pattern or inverted T incision, the excess skin can be removed, the nipple moved up, and the breast tissue elevated on the chest wall. Besides approximating the reconstructed breast better, this restores the normal breast to a more youthful and desirable appearance.
Occasionally, a breast reduction is required on the normal side. This involves the same pattern of incision as a breast lift and does lift the breast on the chest wall as well as elevates the nipple to a more normal position. In addition, a breast reduction actually removes breast tissue from the normal breast to debulk the breast. This enhances symmetry, and often patient comfort. Some patients (with or without breast cancer) seek out a reduction because of the discomfort of the large pendulous breasts, grooving in the shoulders, back or neck pain, and rashes underneath the breast. The matching or symmetry procedures, covered by insurance, allow the patient to undergo the procedure which they might have sought on their breast such as a lift or a reduction even if they have not had breast cancer.
A small breast lift on a normal breast may also be performed with something called a circum-areolar technique which limits the scar to just around the nipple. Of course, any tissue removed from a normal breast is also submitted for examination by pathology. This would check that breast tissue in the unlikely condition of breast cancer on the normal side.
Occasionally, the normal side will need to undergo a breast augmentation to approximate better symmetry. This is done with placement of a saline or silicone implant through an incision about an inch and half long on the normal breast. Depending on patient suitability and preference, the incision may be placed underneath the breast or around the nipple. In augmenting the contralateral side attention must be paid in terms of achieving symmetric final volume. There are risks associated with augmentation and they include the risk of capsular contracture or excessive scarring, implant deflation, and the possibility, although unlikely, of interfering with mammographic detection of a malignancy in the as yet normal side.
Thus, in summary, attention is paid to creating an appropriate sized breast after mastectomy, ensuring that it has an attractive shape which matches the normal side, all the while respecting oncologic principles of breast cancer management.
