Breast Reconstruction Surgery
Dr. Hootan Daneshmand
Reconstruction of a breast that has been removed due to cancer or other disease is one of the most rewarding surgical procedures available today. New medical techniques and devices have made it possible for surgeons to create a breast that can come close in form and appearance to matching a natural breast. Frequently, reconstruction is possible immediately following breast removal (mastectomy), so the patient wakes up with a breast mound already in place, having been spared the experience of seeing herself with no breast at all.
But bear in mind, post-mastectomy breast reconstruction is not a simple procedure. There are often many options to consider as you and your doctor explore what’s best for you. This information will give you a basic understanding of the procedure — when it’s appropriate, how it’s done, and what results you can expect. It can’t answer all of your questions, since a lot depends on your individual circumstances. Please be sure to ask Dr Daneshmand if there is anything you don’t understand about the procedure.
Am I a candidate for surgery?
Most mastectomy patients are medically appropriate for reconstruction, many at the same time that the breast is removed. The best candidates, however, are women whose cancer, as far as can be determined, stands to be eliminated by a mastectomy.
Virtually any woman who must lose her breast to cancer can have it rebuilt through reconstructive surgery. But there are risks associated with any surgery and specific complications associated with this procedure.
When is the procedure performed?
You can begin talking about reconstruction as soon as you’re diagnosed with cancer. Ideally, you’ll want your breast surgeon and your plastic surgeon to work together to develop a strategy that will put you in the best possible condition for reconstruction.
After evaluating your health, your surgeon will explain which reconstructive options are most appropriate for your age, health, anatomy, tissues, and goals. Be sure to discuss your expectations frankly with your surgeon. He or she should be equally frank with you, describing your options and the risks and limitations of each. Post-mastectomy reconstruction can improve your appearance and renew your self-confidence — but keep in mind that the desired result is improvement, not perfection.
Immediate breast reconstruction has increased in popularity throughout the country. Many women find it comforting to know that they will be beginning on the path of reconstruction at the same time that they are undergoing the mastectomy. Regarding the pros and cons of immediate reconstruction…Psychologically, many women benefit from immediate reconstruction because they don’t need to fear the potential disfigurement of the mastectomy. That’s certainly a “pro.”
There is also an economy of recuperative time. If you are having surgery on your breast(s) and undergo reconstruction at the same time, you are saving yourself an additional trip to the operating room.
It depends on the patient. Some people need to get back to work or back to managing their household rather quickly. For those people a BIG surgery initially may not make sense. I would estimate that about 2/3 of women undergoing mastectomy, undergo immediate reconstruction.
Still, there are legitimate reasons to wait. Many women aren’t comfortable weighing all the options while they’re struggling to cope with a diagnosis of cancer. Others simply don’t want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeons to wait, particularly if the breast is being rebuilt in a more complicated procedure using flaps of skin and underlying tissue. Women with other health conditions, such as obesity, high blood pressure, or smoking, may also be advised to wait. Women who postpone reconstruction may go through a period of emotional readjustment. Just as it took time to get used to the loss of a breast, a woman may feel anxious and confused as she begins to think of the reconstructed breast as her own.
What types of reconstruction are possible?
Most surgeons will place a tissue expander at the time of the mastectomy. This begins a process of “tissue expansion” allowing the body to make more skin which can drape over a breast implant. The tissue expansion process may take weeks or months depending upon the ultimate desired breast size.
Skin expansion. The most common technique combines skin expansion and subsequent insertion of an implant.
Following mastectomy, your surgeon will insert a balloon expander beneath your skin and chest muscle. Through a tiny valve mechanism buried beneath the skin, he or she will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has stretched enough, the expander may be removed in a second operation and a more permanent implant will be inserted. Some expanders are designed to be left in place as the final implant. The nipple and the dark skin surrounding it, called the areola, are reconstructed in a subsequent procedure.
Some patients do not require preliminary tissue expansion before receiving an implant. For these women, the surgeon will proceed with inserting an implant as the first step.
Flap reconstruction. An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the back, abdomen, or buttocks.
In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat, and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself, without need for an implant.
Another flap technique uses tissue that is surgically removed from the abdomen, thighs, or buttocks and then transplanted to the chest by reconnecting the blood vessels to new ones in that region. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well.
Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about a silicone implant. In some cases, you may have the added benefit of a improved abdominal contour.
Does this affect my risk of cancer recurrence?
Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment, should cancer recur. Your surgeon may recommend continuation of periodic mammograms on both the reconstructed and the remaining normal breast. If your reconstruction involves an implant, be sure to go to a radiology center where technicians are experienced in the special techniques required to get a reliable x-ray of a breast reconstructed with an implant.
What are the effects of radiation on breast reconstruction?
What is the expected recovery?
You are likely to feel tired and sore for a week or two after reconstruction. Most of your discomfort can be controlled by medication prescribed by your doctor. Depending on the extent of your surgery, you’ll probably be released from the hospital in two to five days. Many reconstruction options require a surgical drain to remove excess fluids from surgical sites immediately following the operation, but these are removed within the first week or two after surgery. Most stitches are removed in a week to 10 days. In any case, being informed of your reconstruction options before surgery can help you prepare for a mastectomy with a more positive outlook for the future.
Can I proceed with reconstruction during chemotherapy?
Yes. If a tissue expander is placed during the mastectomy, the filling process can take place during chemotherapy. Any surgery will have to be delayed until after chemotherapy is finished to allow your body to recover.
What is the life expectancy of breast implants?
The general wisdom (these days) advises us that implants last between 10-20 years. One of the implant companies relates a failure rate of 2% per 7 years.
What about the other breast?
Some surgeons like to perform “opposite breast surgery” for symmetry purposes at the time of the initial mastectomy or breast reconstruction. We usually perform the opposite breast surgery at the end of the reconstruction process. It is often easier to make the existing (natural) breast look like the reconstructed breast than otherwise.
Will a plastic surgeon perform the mastectomy?
Generally, the plastic surgeon works with a general surgeon together in the operating room. Dr. Daneshmand has extensive experience in this area. I find that this (collaborative operative approach) works best for us in our practice here with surgeons in Orange County because they have extensive experience in chemotherapy, lumpectomy versus mastectomy and other critical, life-impacting decisions.
Do breast implants cause cancer?
There is no evidence that the presence of breast implants causes breast cancer or increases your risk of getting breast cancer. We, as plastic surgeons, would not be able to justify any surgery that would increase the risk of cancer. We do know, however, that mammographic imaging of the breast is more difficult when implants are present. It is therefore necessary to become comfortable with breast self-examination and be sure that your routine mammograms are performed by a professional who is comfortable imaging breasts with implants.
Can you still get a mammogram with breast implants?
You can and NEED to get mammograms on a routine basis, as advised by the American Cancer Society. The American Cancer Society recommends a baseline mammogram between the ages of 35 and 40. There is some debate whether to then go to yearly or every-other-year mammograms between 40 and 45. I generally recommend a baseline mammogram in any of my patients 35 years and older or patients with a family history of breast cancer.
How do you know if an implant ruptures?
In regard to rupture, one always knows when a saline implant ruptures….it deflates and a definite asymmetry becomes noticeable. When silicone ruptures, it is often hard to tell since the silicone is usually contained within the capsule of scar that forms around the implant. When I have patients with silicone implants, I recommend that they undergo replacement of the implant after 8-10 years.
How long is the recovery period after reconstruction?
The length of recovery has more to do with the choice of reconstructive procedure. Implant/tissue expander reconstructions take place in the area of the mastectomy surgery and involve healing in that area alone. Patients who undergo this type of reconstruction often are back at work within 2-3 weeks. Patients who undergo TRAM flap reconstructions or other tissue transfer procedures may require up to 6 weeks or longer of recovery.
Are silicone implants better than saline?
Many reconstructive surgery patients opt for silicone implants because the silicone implants do feel more natural than saline.
Anatomic or round implants?
Teardrop or anatomic implants were introduced to better simulate the natural contour of the breast. Many surgeons like these implants and use them both for reconstruction and augmentation. We typically use round implants, but occasionally anatomic implants are used. One of the disadvantages of the contoured implants is that they are textured. In the saline-inflatable implants, this sometimes means that they will be more palpable, they may have a higher rate of rupture, and there may be more visible rippling.
What percentage of your patients undergo reconstruction with their own tissues (TRAM)
The majority of patients tend to opt for “local tissue” reconstruction using tissue expanders and implants. TRAM flaps and DIEP flaps and other tissue transfer procedures are more common at University Hospitals and are becoming more available across the country.
What about the nipple and areola?
We usually perform nipple-areolar reconstruction as the final procedure. It is truly the icing on the cake. Once the breast mound is just as we want and the opposite breast has been adjusted, if necessary, then it is time to reconstruct the NA complex. We usually use local tissue flaps to reconstruct the nipple (a little like Origami) and then complete the reconstruction with tattoo. If the areola is reconstructed with a skin graft, the graft itself may heal with enough pigmentation to simulate a natural areola. Tattooing allows us to introduce pigment into the skin that simulates the natural areolar coloring.
What are the complications of surgery?
In general, the usual problems of surgery, such as bleeding, fluid collection, excessive scar tissue, or difficulties with anesthesia, can occur although they’re relatively uncommon. And, as with any surgery, smokers should be advised that nicotine can delay healing, resulting in conspicuous scars and prolonged recovery. Occasionally, these complications are severe enough to require a second operation.
If an implant is used, there is a remote possibility that an infection will develop, usually within the first two weeks following surgery. In some of these cases, the implant may need to be removed for several months until the infection clears. A new implant can later be inserted. The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways, and sometimes requires either removal or “scoring” of the scar tissue, or perhaps removal or replacement of the implant.
Is there more than one operation necessary?
Breast reconstruction usually involves more than one operation. The first stage, whether done at the same time as the mastectomy or later on, is usually performed in a hospital. Follow-up procedures are usually performed in an outpatient facility.
Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery may be required to replace a tissue expander with an implant or to reconstruct the nipple and the areola. Many surgeons recommend an additional operation to enlarge, reduce, or lift the natural breast to match the reconstructed breast.
What about sensation?
Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. Most scars will fade substantially over time, though it may take as long as one to two years, but they’ll never disappear entirely. The better the quality of your overall reconstruction, the less distracting you’ll find those scars. Follow your surgeon’s advice on when to begin stretching exercises and normal activities. As a general rule, you’ll want to refrain from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following reconstruction.
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