Your Guide to Breast and Nipple Prosthetics
There are typically two situations in which you might consider using breast prosthetics: during breast enhancement or augmentation, or during breast reconstruction following a mastectomy (or in the case of nonsurgical prosthetics, instead of reconstruction).
Generally, only people undergoing breast reconstruction would also need to consider nipple prostheses.
In any case, the options for prostheses are varied, and the pros and cons for each depend heavily on your own situation and your long-term hopes for how your breasts will look, feel and even function.
Regardless, it's important to maintain open communication with your doctors and surgeons before and after any procedure to make sure all your questions and concerns are addressed.
Prosthetics and breast reconstruction
If you know you're undergoing a mastectomy, it's important to think about whether you want to have surgical breast reconstruction after your breast tissue is removed. Plastic surgeons must place a tissue expander at the time of your mastectomy to create space for a future breast prosthesis, such as an implant, to be placed. There is the option to do the expander placement at a later date after your cancer treatments have been completed, but this requires a second surgery.
Your skin and scar tissue can be very tight after breast tissue removal. The role of the expander is to enable a plastic surgeon to gradually stretch the skin by filling the expander with sterile saltwater over a series of doctor's visits. When the skin has sufficiently stretched to hold the desired implant size, the reconstruction can be scheduled, the implant placed and the expander removed. In other words, it's a process and one you should be mentally and physically prepared to undergo.
When implants, rather than autologous tissue from other areas of your body, are used in reconstruction, they're typically highly cohesive "gummy bear" silicone gel implants, according to Rocco C. Piazza, M.D., a plastic surgeon and the owner of the Piazza Center in Austin, Texas.
"This allows them to have excellent stability with less rippling in the device, but if there is a rupture or damage to the shell over time, the gel doesn't migrate or go anywhere; it stays within the device, and that's really important," Piazza explained.
It's a process and one you should be mentally and physically prepared to undergo.
Piazza also emphasized that it's important to take your time and try to exercise as much control as you can through the cancer treatment process, including surgeries and reconstruction. While you may feel like you have to rush to make the decisions, in most cases, you have some time to slow down and consider your options.
"Get a few opinions on reconstructive approaches," Piazza advised. "There are a number of different ways…Implant-based reconstruction is an excellent way to reconstruct a breast, but there are also some really great ways to use tissue from other parts of the body—like the lower tummy, gluteal or thigh region—to reconstruct the breast with natural tissue from yourself.
"A lot of times patients want to rush through the surgical experience because it's like, 'Oh, my gosh, get them off! I've got breast cancer or I've got the gene that's going to give me a higher risk of breast cancer, so I just want to get them off,'" he said. "OK, well, taking the time to do the research to find the best treatment method is really, really important, and patients have time to do that. Do they have six months? Maybe not, but could they take six to 12 weeks to get really informed on the options? Absolutely."
Nipple removal or nipple-sparing surgery
One other decision you may have to weigh as you figure out your treatment and surgery details is whether you want nipple prostheses placed following breast reconstruction.
It's important to realize that nipples aren't always removed during a mastectomy, so it may not be a question you even have to answer. That's why it's essential to understand what your surgeon's plan is regarding cancer treatment and tissue removal and to exercise your own judgment in deciding (if you have the option) whether you want to undergo nipple-sparing surgery.
"What we've seen as far as breast prosthetics or implant placement is a shift in placing the implants above the muscle. It's called prepectoral breast reconstruction, and that means the breast surgeon who takes the breast off and the plastic surgeon who reconstructs the breast use an approach that helps conceal the incision through a fold where the breast meets the chest at the base of the breast," Piazza explained.
This means if there's no reason to involve the nipple, the nipple-areola area may be left untouched in a nipple-sparing surgery. But there are certain instances where the nipples may still need to be removed.
"Most commonly that would happen in a situation where the cancer is in close proximity to the nipple or there is nipple involvement with the disease or there is what's called 'multifocal disease,' where there are multiple origins of breast cancer in the same breast," Piazza said.
But in the case where a surgeon gives you the option to remove the nipple or spare it, make sure you ask lots of questions about the long-term effects either decision may have.
"One conversation…women undergoing mastectomy need to have is whether to have a nipple-sparing mastectomy or to remove the nipples with the breast and have the option for tattooed nipples after expanders are placed," said Jessica Pettigrew, a physician's assistant and senior instructor at the University of Colorado OB-GYN.
Even if you decide to spare your nipple, you should be prepared for a potential change in sensation.
"In our ongoing study on women with breast cancer and sexual function, we heard in focus groups that women who chose both options experienced bothersome changes in nipple sensation," Pettigrew said. "Women who had the nipple removed noted some distress related to this erogenous zone being absent. Some women who had nipple-sparing mastectomy found that while they had their native nipples, the sensation was different, and one participant expressed great discontent with her nipples."
Surgical nipple prostheses
If you decide to undergo nipple removal—or if the decision is made for you due to your cancer diagnosis—you'll also want to consider your options for nipple prostheses. You should weigh your options carefully, as you might actually decide against using a prosthesis altogether. In fact, Piazza said most of the women he treats end up opting out of a prosthesis or opting for a hyperrealistic tattoo instead.
"There are lots of different types of reconstruction methods. The most natural way to do it is to try to utilize tissue that's on the breast to try to reconstruct a nipple-areola complex. That's done typically by folding little flaps of tissue to create a three-dimensional structure to the nipple," he said. "The challenge is that oftentimes that atrophies or decreases in thickness and, therefore, a prosthetic or something inside the nipple may be needed, like a silicone bead or prosthesis, to add a three-dimensionality to the nipple."
Why would women opt out of a nipple prosthesis?
"If you put something hard inside the nipple, then it makes the nipple always 'on,' right? Whereas a natural nipple usually will fluctuate between being more firm or erect and softer tissue. So in women with reconstruction, they usually say, 'I'm not wearing a bra, I'm going to wear whatever I want to wear and I don't necessarily want it to look like my nipples are erect all the time,'" Piazza said.
'When we put something inside the nipple, there's always the chance the body may not like it.'
Additionally, the body doesn't always like foreign objects placed inside it, Piazza emphasized.
"When we put something inside the nipple, there's always the chance the body may not 'like it.' The medical term is that it might extrude or work its way out of the tissue if it's a silicone bead. If it's human dermal tissue that's been decellularized, it may not incorporate and have to come out," he explained.
While this type of procedure can typically be done in the office, it's worth thinking about whether you want the additional stressor after everything else you've already been through. That's something Piazza emphasized about his patients who have undergone mastectomies.
"What they want is freedom. They've gone through a diagnosis of cancer or a genetic predisposition for cancer. They want freedom to wear what they want. They don't want to be tied down or have limits. It's kind of a new lease on life," he said.
Many patients choose the option that's going to give them the most freedom and comfort and the least stress. Often that means opting out of nipple prostheses.
Nonsurgical prosthetics
Some women elect not to undergo breast reconstruction or they look for options to use between their breast removal surgery and breast reconstruction surgery. In these cases, nonsurgical prosthetics, commonly known as breast forms, are available.
Breast forms give the appearance of breasts in the absence of breast tissue. They can be worn inside bras, camisoles or swimsuits, or they can be physically attached to your chest using adhesive strips. They come in various shapes, sizes and materials to maximize comfort while allowing you to look the way you want to look in your clothes. Some are lightweight foam, meant only to give shape to your clothing, while others are weighted silicone and give the look, feel and some of the "heft" of real breasts.
Breast forms give the appearance of breasts in the absence of breast tissue.
One of the benefits of breast forms, whether reconstructive surgery is on the docket or not, is that they give you the option to "play" a little in terms of test-driving different breast sizes and shapes to see what feels and looks the best to your eye. So if you plan on undergoing reconstruction, you can share your favorite breast forms with your plastic surgeon to help explain the look or size you're hoping to achieve.
Being clear about the look you're going for is important. After facing cancer or the stress of learning about a genetic predisposition to cancer, taking control of certain aspects is vital. If you wore a size A bra cup before surgery and you want to know what it feels like to be a C or D cup, go ahead and try out a few different sizes of breast forms. Conversely, if you were large-chested and now want to feel what it's like to have smaller breasts, go for that A- or B-size form.
When you land on a size and a shape—triangular and oval options are available—this can help you decide whether you want to stick with the forms or elect reconstruction.
Regardless, remember you have time, options and control over what type, size and when (or whether) to place breast or nipple prosthetics. It's a highly personal decision at a point in your life that's likely to be emotionally charged and challenging. So while you may be excited about having your breast reconstruction or augmentation done, think through the details carefully and be sure you're making the best choice for yourself.
"This is your body and this is your decision," Piazza emphasized. "I'm here to guide you and help you, but ultimately, it's your choice."
