Breast Reconstruction after Mastectomy

Choosing to undergo breast reconstruction is an important decision that requires careful thought, consultation and education.  There is no substitute for a thorough and in-depth consultation with your plastic surgeon.

However, we find that the amount of information we present our patients with during our consultations can sometimes leave them overwhelmed with the many factors they need to consider. We have put together this guide to help summarize the information and considerations involved in choosing a breast reconstruction strategy.

We have been performing breast reconstruction at Lawrence Plastic Surgery since 1994 and have used a variety of techniques and strategies over the years to achieve the best results for our patients.  We always work closely with your general surgeon, oncologist, radiation oncologist, primary physician and others involved in your care to coordinate our reconstructive efforts with your cancer treatment.

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Breast reconstruction- Do you need it?

Over 100,000 women a year choose to undergo breast reconstruction.  They choose to do so they can replace what has been removed, restore their body to a more normal appearance, and free themselves from having to wear external prostheses.   They feel it is important for their emotional well being and are generally glad they chose reconstruction.  Others choose not to undergo reconstruction and are also satisfied with their choice, feeling that this is an extra unnecessary operation they can do without.  We feel both points of view are equally valid.  The choice is a personal one only you can make.

Whether you choose to undergo breast reconstruction or not, you can at least be reassured that you have the choice.  Both federal and state legislation passed in the 1990’s mandates insurance coverage for breast reconstruction, including surgery on the opposite breast for symmetry.  Medicare also covers breast reconstruction, as does the Kansas Medicaid program.

Breast reconstruction- how is it done? How can we arrange it?

If you choose to undergo breast reconstruction, there are two basic factors that need to be considered.  First, it needs to be determined whether the reconstruction can be done at the time of your mastectomy or needs to done at a later time.  Second, we will need to decide whether to reconstruct your breasts using implants, your own tissue, or both.   Once these decisions have been made we can begin planning your reconstruction in coordination with your breast surgeon, oncologists, and others.

Timing

Immediate

The reconstruction is started at the time of your mastectomy.  We work in conjunction with your general surgeon and arrange to be present at the time of your mastectomy.  The general surgeon will remove your breast and we will place a tissue expander, breast implant, or utilize your own tissues to rebuild your breast mound.  Immediate reconstruction may allow for the general surgeon to perform a skin sparing, areola sparing, or nipple sparing mastectomy when your cancer permits.

Advantages

  • Combines the mastectomy and initial reconstruction process into single operative procedure, hospital stay, and recovery period
  • Allows us to use more of your own breast skin and nipple/areolar complex to potentially achieve a better result

Disadvantages

  • Wound healing problems from mastectomy skin can compromise or complicate reconstruction
  • Longer operation and recovery time
  • Potential to delay post operative treatment (chemotherapy, radiation)

Delayed

The reconstruction occurs after you have healed from your mastectomy, potentially months or years later.

Advantages

  • Allows greater time for the patient to consider her options and plan for the operation
  • Shorter procedure than if combined with mastectomy.

Disadvantages

  • An additional trip to the operating room and recovery period as compared to an immediate reconstruction
  • Generally cannot be used with skin/nipple/aroelar sparing techniques

Short-delay immediate reconstruction

The reconstruction is done in a separate operation a few days or weeks after your mastectomy

Advantages

  • Final pathology is known and decisions regarding the need for post operative chemotherapy and radiation can be made prior to reconstruction
  • Allows for use of skin/areola/nipple sparing techniques
  • Allows plastic surgeon to determine weather the skin remaining after mastectomy can be used in reconstruction
  • Greater flexibility in scheduling, logistics. Mastectomy and reconstruction can take place in separate settings, even separate towns

Disadvantages

  • An additional trip to the operating room as compared to a standard immediate reconstruction

Reconstruction Methods

Tissue expander/implant reconstruction

In this type of reconstruction a tissue expander is place at the mastectomy site either at the time of your mastectomy (immediate reconstruction) or at a later time (short delay or delayed reconstruction).  This is a temporary inflatable device placed under the muscle which helps us stretch the skin and create a space where we will later place a silicone or saline breast implant.

The expander is only partially inflated with saline (salt water that matches your body chemistry) at the time of placement.  Beginning 2-4 weeks after placement, you will return to the office to have additional fluid added to the expander.  This is typically a minor, quick procedure which will not disrupt your activities.  Expander fills are usually scheduled on a weekly basis, but can be done less frequently to accommodate your schedule.  After 1-6 fills, your expander will reach the desired size and we will schedule your next surgery.

At the second operation we will remove your temporary expander and replace this with a breast implant filled with either silicone gel or saline.  Surgery on the opposite breast to achieve symmetry can be performed at this same operation.  This is typically an outpatient procedure with fairly short recovery time.

We sometimes will utilize an acellular dermal matrix product (Alloderm) at the time of expander placement to help achieve a better breast shape, decrease the number of post operative expansions required, and better protect the expander/implant.  This is a relatively new technique that is helping plastic surgeons achieve better results, especially with skin sparing mastectomy procedures.

Tissue expander/implant reconstruction is the most common technique used in breast reconstruction, both nationally and in our practice.

Advantages

  • Adds only about 1-1½ hours to mastectomy procedure, no additional scars
  • Can be done on outpatient or overnight basis
  • Suitable for wide variety of breasts
  • Shorter operative, hospitalization, and back to work time than reconstruction with the patient’s own tissue

Disadvantages

  • May be complicated by previous or planned radiation
  • Implant or expander can become infected and need to be removed
  • Scarring may develop around implants (capsular contracture) causing firmness or distortion.
  • Implants can leak and may need to be replaced many years later.
  • May not feel as soft and natural as breast reconstructed with a patients own tissue.  Implants sometimes show rippling, especially in thin patients.

TRAM flap reconstruction

This reconstructive technique uses excess abdominal fat and skin to replace tissues lost in a mastectomy.  It can be used for both immediate and delayed reconstruction.  During the operation the skin and fatty tissues of the lower abdomen are transferred into the chest defect with a strip of the abdominal wall muscle, which serves as a blood supply.  The area where the tissue is removed is closed with a long, low abdominal incision, similar to one we use with our cosmetic tummy tuck patients.  The operation takes 4-6 hours, and patients typically stay in the hospital for 3-6 days afterward.  Patients are sometimes to thin for this procedure (not enough abdominal fat to make a breast) or too heavy (obese patients have a high complication rate).  While many patients are good candidates for this operation, we will sometimes advise patients against this if they have multiple medical problems making them unsuitable for this more extensive operation.

Advantages

  • Utilizes your own tissue, not a foreign body to recreate the breast
  • Can result in the most natural feeling breast
  • Eliminates long term problems sometimes associated with implants (capsular contracture, implant leakage, etc.)
  • Better success in previously radiated chests than with expander/implant reconstruction
  • Can be utilized with skin/areola/nipple sparing mastectomies

Disadvantages

  • Longer operation, hospitalization, recovery
  • Creates donor site scar, although this is well placed
  • Some weakening of abdominal wall musculature, although this is not functionally significant in most patients
  • May be impossible in very thin or obese patients

Latissimus Dorsi Reconstruction

This technique uses skin, fat, and muscle from the back, along with an implant, to recreate the breast mound.  The first operation usually takes about 2 hours and involves moving the tissue from the back and placing a tissue expander beneath the tissue.  This can be done at the time of mastectomy or as a delayed procedure.  Patients usually stay in the hospital or surgery center overnight following the surgery, which can be done as at the time of the mastectomy or as a delayed procedure.  Additional fluid is added to the tissue expander during office visits following surgery.  3-6 months following the initial procedure the patient returns to the operating room on an outpatient basis where the expander is removed and the permanent implant placed.

Advantages

  • Can be used successfully with previous radiation
  • May be used in patients who are not candidates for TRAM flap due to body shape, previous abdominal surgery, etc.
  • Less extensive surgery, recovery time than TRAM flap

Disadvantages

  • Donor site scar on back
  • Requires the use of an expander/implant to achieve adequate volume
  • Requires second outpatient procedure to remove expander, place implant

Other reconstruction methods

Over 90% of breast reconstructions in the US are done using tissue expanders/implants, TRAM flaps, or latissimus dorsi flaps.  There are other techniques occasionally used (DIEP flaps, TUG flaps, gluteal flaps, and others) that we are not performing at our hospital, but we would be glad to refer you to institutions where these operations are available.

Opposite breast surgery

Surgery on the opposite breast may be required to give you the best possible symmetry after reconstruction.  This may involve a breast lift, breast reduction, or implant placement.  These procedures are typically covered by insurance and can usually be performed at the time of your reconstructive procedure or on an outpatient basis.

Nipple/areolar reconstruction

When the nipple/areolar complex is removed by the mastectomy procedure we can reconstruct this as part of your breast reconstruction.  We typically recreate the areola using tattoo techniques and recreate the nipple using either local skin or tissue from the opposite nipple.  This procedure can be done during in the operating room during your breast reconstruction or as an office procedure.

Your Decision

We urge you to take your time, think it over, and come to a decision about reconstruction that feels right for you.  Beyond this outline, we will try to answer your questions during your consultation.  Our patients have found it helpful to use these other sources of information as well:

  • Other patients- We can arrange for you to talk with previous patients of ours who have undergone reconstruction or you can attend support group meetings or online chat groups.
  • Books- We have copies of books available to loan if you are interested in learning more.  Just ask.
  • Online resources- There are multiple web sites with good information regarding breast reconstruction.

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