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Although a good match can often be achieved by reconstructing the affected breast alone, the best symmetry is obtained by also considering surgery to the unaffected breast. For some women, reconstruction gives an opportunity to address any concerns with shape or size of breasts, and it is possible to complete reconstruction with bigger, smaller or less drooping breasts than before. The options can be considered as follows:
Many women feel that performing surgery to a healthy breast is unacceptable and would prefer reconstruction that best matches the existing breast without any change. Remove the remaining breast and reconstruct both breasts
Women at high risk for breast cancer may decide that it would be preferable to remove as much breast tissue as possible so that they do not need to worry about breast cancer in the future. In this case creating symmetry between the two breasts with any reconstructive technique is relatively easy.
Breasts containing implants are generally less affected by gravity and appear fuller in the upper half of the breast. Inserting an implant to enlarge the healthy breast can reduce the difference in shape and improve symmetry, especially with implant-based reconstructions.
Creating a new large breast requires a large volume of tissue, which almost always limits the reconstructive options to only a DIEP flap. Performing a breast reduction on the unaffected breast can widen the choice of suitable reconstructive options or reduce the amount of tissue needing to be moved to make the breast. In addition, if large breasts have been causing problems, breast reduction can be helpful.
Over time, gravity has an effect on all breasts. As the breast tissues become less elastic, breasts hang lower on the chest, the nipples hang lower on the breasts and the areola (darker skin surrounding the nipples) become larger. Women with 'droopy' breasts may prefer a breast lift for the unaffected breast, and a reconstruction to match the new position.
For the first 3-6 months following any type of reconstruction surgery, the new breast will change. Tissue flap based reconstructions generally shrink slightly and even purely prosthetic reconstructions will change shape as scars form and slowly soften. When all of these changes are complete, the breast is ready for the creation of a new nipple.
Many women are content to leave their reconstructed breast without a nipple. You may feel that you do not wish to face another procedure or that having a nipple on the reconstructed breast is not important.
Before deciding to undergo nipple reconstruction, there are several factors to consider about the new nipple. As they do not react to sensation, reconstructed nipples do not grow and flatten as natural nipples will, which can lead to asymmetry between the two nipples at different times, and there will be no feeling in the reconstructed nipple.
All of the techniques to reconstruct a nipple can be performed without the need for a general anaesthetic, and can be a good time to adjust the breast reconstruction, if necessary, now that it has settled into its final position.
Even without an operation, a silicone prosthesis can provide a realistic, natural looking nipple and areola (surrounding darker skin). This can be used immediately after reconstruction, either as a short term measure while waiting for the breast to settle, or in the long term as a substitute for nipple reconstruction.
Tattooing the reconstructed breast can create an areola to match the natural breast, and can even create the illusion of a nipple. Although there will be no texture or projection from the breast surface, the results can be very realistic. Tattooing can be performed by the reconstructive surgeon, a specialist nurse or by a tattooing artist.
There is a large variety of different colours to choose from, and there are swatches to help choose a colour or to match the colour to the natural areola. Areolar tattooing can fade by as much as 40-50%, so you may be recommended to use a darker colour than would appear natural, or to have the tattoo applied in 2-3 layers to provide a more even and colourfast tattoo. Areolar tattooing is a painless procedure because, although some women regain some feeling in their reconstructed breast, at a few months after reconstruction the nipple area of the reconstruction is numb.
There are many types of nipple reconstruction using flap techniques, but they all involve freeing a small area of skin and fat from the surface of the reconstruction and twisting or folding it in a way to create a nodule on the surface of the breast, which is sutured in place.
Flap based nipple reconstruction may be supplemented with areolar tattooing to provide a natural looking colour to the nipple and surrounding darker skin. As with nipple grafting, the new nipple shrinks over the first year, so is made 'too big', but the extent of the shrinkage is more constant than with nipple grafting and flap based nipples are less likely to flatten or lose their shape. The disadvantage is that new scars are created in the skin around the nipple, but these can be well hidden with tattooing.
Infection (5%) - this ranges from a superficial wound infection, easily treated with antibiotics, to an infection of the implant if one is used. Implant infections are especially troublesome as, generally, the implant must be removed to fully treat the infection, and re-inserted at a later date
Bleeding (5%) - Although any bleeding points are cauterised during the procedure, it is possible that you may develop a collection of blood under the skin. Very occasionally, this can become infected or need to be let out by returning to theatre and re-opening the wound.
Flap failure (below 1%) - this is a very rare complication.
Nipple Flattening - a reconstructed nipple may lose its projection and flatten at any time from a few weeks to a few years after surgery. Although this can occur with any technique, it is more common with nipple grafts than with flap-based techniques Poor position - Over time breasts change in shape and size, and a reconstructed breast will change in a different way to a natural breast