Breast Reconstruction after Mastectomy

As our practice has evolved we no longer are available for immediate breast reconstruction procedures. With our long experience in breast reconstruction (we  introduced this procedure to Lawrence in 1994) we bring this knowledge to revise and correct the breasts of those who have undergone breast reconstruction many years ago or very recently.  While we urge patients to first seek correction with the plastic surgeon who performed the original reconstruction, this is not always possible.  We’re here to help guide you through your decision to correct your breast reconstruction.

Breast reconstruction revision- why patients undergo revision

Patients see us for breast reconstruction revision for a variety of reasons, most commonly:

  • Changes to the reconstructed breast, the normal breast or both associated with aging or weight change.
  • Dissatisfaction with appearance or symmetry following their reconstruction
  • Concerns regarding their implant(s) such as possible rupture, capsular contracture, or displacement.
  • Fat grafting to correct deformities cause by partial mastectomy.
  • The original surgeon has retired,  moved away, or was unresponsive to their concerns

We occasionally see patients midway through their reconstructive process for an opinion regarding their care and a possible change of surgeons.  While we are happy to see these patients we generally suggest they discuss their concerns with the surgeon who initiated the reconstruction.  They are often in a better position to finish the process they started.

Techniques

After your evaluation, we can discuss what may be needed for satisfactory correction of your breasts.  There is no “one size fits all” approach to revision surgery, and it requires careful discussion and planning with an experienced plastic surgeon.

Breast asymmetry- solutions

  • Breast reduction on the opposite side
  • Breast lift (mastopexy)
  • Implant placement or exchange
  • Fat grafting for volume enhancement

Implant problems- solutions

  • Implant removal and replacement
  • Capsulectomy to remove scar tissue (capsular contracture)
  • Capsulorrhaphy (correction of the implant pocket) to reposition implants

Shape problems- solutions

  • Implant exchange
  • Scar revision
  • Fat grafting

These procedures are all discussed elsewhere on our website.

A single procedure or several may be performed at a given surgical session. These are typically outpatient procedures with recovery times that range from a few days to 1-2 weeks.

Planning your procedure

At your initial consultation we’ll discuss your concerns, evaluate your breasts, and explain available options.  If you have records from your previous procedures please bring them with you.  We will discuss our recommendations and develop an operative plan.  Photographs will be taken and we can initiate the insurance predetermination process.

Insurance

Insurance coverage for revision procedures varies depending on the condition and the insurance provider.  A predetermination process is required before proceeding if you wish to have this covered by your insurance company. We can initiate this at the time of your consultation.

Pre-op visit

Once your procedure is scheduled we will set up a pre-op appointment 1-3 weeks before your surgery.  We’ll review your procedure, discuss post op care and instructions, give you your prescriptions, and finalize your paperwork so that everything is ready to go the day of your surgery.

Surgery

Most of these procedures are performed in the operating room at the Lawrence Surgery Center or Lawrence Memorial Hospital on an outpatient basis and may last 1-3 hours.  Some minor procedures may be performed in our office.

Recovery

Varies by procedure but may range from a few days to 1-2 weeks.  We typically see patients in the office the day following surgery and then 1,3 and 6 weeks after surgery.

 

Reconstruction Guide

Although we no longer provide immediate reconstruction procedures we have included our guide to reconstruction.  Helping patients understand their original reconstruction may also help them better understand what may be required for revision or correction.

We find that the amount of information presented to patients  during  consultations can sometimes leave them overwhelmed with the many factors they need to consider. We  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 we brought this procedure to Lawrence in 1994 and have used a variety of techniques and strategies over the years to achieve the best results for our patients. We have shifted our focus in recent years and now focus on revision of breast reconstruction procedures.  With revision surgery we will continue to coordinate and collaborate with your breast cancer team to assure the best result possible.

View Procedures and Treatments in 3D

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.

Timing

Immediate

The reconstruction is started at the time of your mastectomy.  Your plastic surgeon will 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 the plastic surgeon 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 placed 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 stretch the skin and create a space where a silicone or saline breast implant can later be placed.

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 your next surgery will be scheduled.

At the second operation  your temporary expander will be removed and replaced 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.

Sometimes  an acellular dermal matrix product (Alloderm and others) will be placed 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 has helped plastic surgeons achieve better results, especially with skin sparing mastectomy procedures.

Tissue expander/implant reconstruction is the most common technique used in breast reconstruction.

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 3-5 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, this operation may not be appropriate for patients who 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 involving microsurgery  (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- Talk with patients who have undergone reconstruction or you can attend support group meetings or online chat groups.
  • Books- There are some excellent books written by patients and surgeons giving more details of the breast reconstruction experience.
  • Online resources- There are multiple web sites with good information regarding breast reconstruction.

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