What are my Breast Reconstruction options?
From a patient perspective, breast reconstruction is one of the most rewarding surgical cosmetic procedures available today. New medical techniques and devices help your plastic surgeon to create breasts that come closer to matching the other natural breast than at any previous time in history. Reconstructed breasts can actually feel warm, soft and supple. Scarring has also been minimized to reduce the stigmata of breast surgery.
Whereas in the past, breast reconstruction was delayed for months to years after the mastectomy, reconstructions are now usually performed at the same time as breast removal (mastectomy). This allows the patient to wake up with her new breast already in place. This has proven to be a huge boost to our patients’ sense of wholeness and self image; our patients are spared the experience of seeing themselves with no breast at all.
This procedure is performed by your triple board-certified plastic surgeon, Dr. Gilbert Lee, who has been voted by the San Diego Medical Society "Top Doctor" for the past 6 years running. Read more about Dr. Lee's qualifications on his CV.
Breast Reconstruction Photos
These breast reconstruction photos were taken of a patient in San Diego who received breast reconstruction surgery at Changes Plastic Surgery. Please go to our breast reconstruction photo gallery for more examples.
BEFORE THE BREAST RECONSTRUCTION
AFTER THE BREAST RECONSTRUCTION
Determining Your Candidacy for Breast Reconstruction
The vast majority of patients are considered good candidates for immediate breast reconstruction. However, there are some who are advised to delay reconstruction: patients with serious medical problems such as heart disease; patients with very large, aggressive breast tumors, or patients who cannot decide if they want breast reconstruction. Most general surgeons will refer you to a plastic surgeon prior to surgery, to determine whether you are a good candidate for immediate breast reconstruction.
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.
Skin Sparing Mastectomy
The essential components of a mastectomy include removal of all of the breast glandular tissue, and the nipple and areola. Depending on the type of breast tumor you have, lymph node removal or sentinel lymph node biopsy may be necessary. In the old days, general surgeons removed all of the skin of the breast. This skin removal was a throw back to the days before breast reconstruction, when general surgeons removed all breast skin so that no sagging skin would be left on the chest following mastectomy. In approximately 1996, the concept of skin sparing mastectomy was introduced into medical practice. We are proud to have been the introducing surgeons in the San Diego area. Since breast cancer is a disease of the breast glandular tissue and is not a disease of the skin, one can safely and completely perform a mastectomy by removing the nipple/areola complex and glandular tissue and leaving all the skin of the breast in place. By leaving all of the breast skin in place, we are able to perform much more realistic breast reconstructions without the extensive scarring associated with older type mastectomies. You should discuss with your general surgeon ahead of time whether or not they are familiar with skin sparing mastectomies.
Breast Reconstructive Procedure Descriptions
Breast reconstructions can be divided into three main groups: breasts reconstructed using implants, breasts reconstructed with your own body tissues (flap reconstructions), and breasts reconstructed with a combination of your own tissue and an implant. There are different benefits and risks associated with each of the above options. A detailed consultation with your plastic surgeon will help you to determine which option is best suited to you and your lifestyle.
Breast Implant Reconstructions
This common technique combines skin expansion and the subsequent insertion of an implant. Following a mastectomy, your surgeon will insert a partially filled implant expander beneath your skin and chest muscle. The implant is placed partially deflated to prevent excessive tension on the skin edges during the healing process. After you have healed, he/she will begin the expansion of the implant. This "expansion" procedure is done in the office by injecting salt water (saline) through a tiny needle into a small valve mechanism buried beneath the skin. Expansions are started about 10 to 14 days after the placement of the expander implant. Two or three expansions are usually required, spaced one to two weeks apart. 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.
If radiation therapy is planned for you following mastectomy, an implant reconstruction is probably not the most appropriate choice for you. Radiation therapy tends to cause significant scarring around the implant, causing a hardening or contracture in up to half of the patients treated. Make sure you inform your plastic surgeon if radiation therapy is a planned part of your treatment.
Breast Implant Options
If your surgeon recommends the use of an implant, you'll want to discuss the type of implant to be used. A breast implant is a silicone rubber shell filled with either silicone gel or a salt-water solution known as saline. Silicone implants are lighter, softer, and feel very similar to breast tissue. Saline implants do a good job of reconstructing breasts, but are firmer, heavier, and may show more rippling in thin patients.
As of November, 2006, the Food & Drug Administration (FDA) has approved the use of silicone breast implants for both breast reconstruction and augmentation. The safety of the implants has been proven through an extensive study lasting over 10 years. That study has demonstrated that there are no proven long term systemic illnesses associated with the use of silicone gel breast implants. Patients may receive either saline or silicone breast implants without the need to join an FDA study.
One of the greatest advances in breast reconstruction is the movement of one’s own vascularized tissue from one part of the body to another (flap reconstruction). Such tissue commonly comes from locations where patients have excess tissue such as the abdomen, back, or buttocks.
The tissue transferred to create the breast must maintain its blood circulation in order to maintain its viability. This is accomplished by one of two ways. The flap tissue can be left attached to its original blood supply (pedicle flap) and tunneled beneath the skin to the chest, where it can be sculpted into a breast mound. Alternatively, the tissue can be completely cut "free" from the abdomen or buttocks (free flap) and then transplanted to the chest by reconnecting the blood vessels to new ones in that region using a microvascular technique. This latter option must be performed by plastic surgeons adept in microsurgery. Our plastic surgeons have many years of experience, performing hundreds of similar procedures.
Breasts reconstructed entirely with your own tissue are generally more natural in appearance and texture since both the native breast and the transferred tissue are comprised mostly of fat. Further the transferred tissue can be sculpted to closely match the other side—an advantage not available with implant reconstructions. Further, when using only your own tissues there are no concerns about implant complications such as hardening, rupture, or shifting. If the abdominal tissue is used, you will have the added benefit of an improved abdominal contour from the tummy tuck done to remove the abdominal tissue. Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular free 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.
Not all plastic surgeons perform all the techniques of breast reconstruction. Make sure that your plastic surgeon is aware of all of these procedures so that he may recommend the best procedure for you.
TRAM Pedicle Flap
Transverse Rectus Abdominis Myocutaneous Pedicle Flap
This flap is one of the most popular tissue reconstructions performed today. Its name is derived from the place on the abdomen where it comes from. Skin, fat and muscle from the lower abdomen are raised. A tunnel is created under the upper abdominal skin to the breast cavity. The TRAM flap is then passed through the tunnel to the breast cavity where it is sculpted into a breast. The flap is left attached to its blood supply during this transfer (pedicle flap), and a tummy tuck is performed at the abdominal donor site.
TRAM Free Flap
Transverse Rectus Abdominis Myocutaneous Free Flap
This flap is the most popular free flap breast reconstruction performed today. This procedure must be done by a plastic surgeon with extensive experience in microsurgery. Its name is derived from the place on the abdomen where it comes from. Skin, fat and muscle from the lower abdomen are completely removed from the body. This tissue is then sculpted side by side with the mastectomy specimen to create a realistic breast. The tissue is then inserted into the breast cavity and is connected to the chest blood supply to re-establish its circulation using a microsurgical technique. A tummy tuck is performed at the abdominal donor site. The advantages of this operation over the pedicle TRAM flap are a two to three fold higher blood flow to the flap (assuring better flap healing), less muscle harvested from the abdomen, and no visible bulge in the upper abdomen (since the tissue is not tunneled under the abdominal skin). The disadvantages over a pedicle TRAM flap are that this flap is more technically demanding, requires close post-operative monitoring, and risks flap loss if the circulation in the flap should stop (1.5% risk).
DIEP Free Flap
Deep Inferior Epigastric Perforator Free Flap
This flap is the newest addition to the free flap breast reconstruction list. It is basically very similar to the TRAM Free Flap procedure. The main difference is that during the harvesting of the flap from the abdomen, the entire rectus abdominis muscle is spared and left in place in the abdomen. Thus, the transferred tissue consists only of skin, fat, and the blood vessels that supply the tissue. This tissue is then sculpted side by side with the mastectomy specimen to create a realistic breast. The tissue is then inserted into the breast cavity and is connected to the chest blood supply to re-establish its circulation using microsurgical technique. This is a very technically challenging procedure and should only be performed by a plastic surgeon expert in microsurgery. A tummy tuck is performed at the abdominal donor site. The advantages of this operation over the pedicle TRAM flap are that no muscle is harvested from the abdomen, and no visible bulge appears in the upper abdomen (since the tissue is not tunneled under the abdominal skin). The disadvantages over a pedicle TRAM flap are that this flap is more technically demanding, requires close post-operative monitoring, and risks flap loss if the circulation in the flap should stop (2% risk).
Gluteal Free Flap
In this procedure, we harvest buttock tissue along with its delicate blood supply from the patient, and then sculpt it side by side with the mastectomy specimen to give a very nice shape to the new breast. The new tissue is then inserted into the breast cavity and is reconnected to the chest blood supply using a microsurgical technique. The donor site is closed leaving an oblique scar on the buttocks. This free flap is very difficult and is considered as a back up procedure when other techniques are unsuitable for the patient.
Latissimus Dorsi Pedicle Flap
Originally described in the 1970’s, this flap has stood the test of time. It serves as a very safe, predictable, and reliable source of tissue for breast reconstruction. The skin, fat, and latissimus dorsi muscle are raised off of the back. A tunnel is created from the back, through the armpit, to the breast cavity. The latissimus dorsi flap is then passed through the tunnel into the breast pocket where it is sculpted into a new breast. The flap is left attached to its blood supply during transfer, making it a pedicle flap. Because of a limited muscle size, the flap is often too small to recreate a breast symmetric with the opposite side. Therefore, an implant is often placed underneath the flap to make it larger. The main downside to the latissimus dorsi flap is the need to harvest a muscle from the back, a visible scar which is left on the back, and the need for an implant.
Most breast reconstructions can be accomplished by using either implants or one’s own tissue alone. However, when the medical situation mandates the use of one’s own tissue, and that tissue is inadequate in size to build a symmetric sized breast, then an implant (silicone or saline) may be placed under the flap tissue to help gain adequate size. Your plastic surgeon should be able to tell you during your consultation if you have adequate tissue for breast reconstruction.
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 refine the shape of the reconstructed breast and to reconstruct the nipple and the areola. Quite often we recommend an additional operation to enlarge, reduce, or lift the opposite breast to match the reconstructed breast. In California, the Tanner Bill assures that surgery on the opposite breast, which is necessary to gain symmetry with the reconstructed breast, is covered by your insurance plan. But keep in mind, this procedure may leave scars on an otherwise normal breast.
Most follow-up procedures are performed on an outpatient basis. Some procedures require a surgical drain to remove excess fluids from surgical sites. These drains are removed within the first week after surgery. Most stitches are removed in a week to 10 days.
After your surgery, you are likely to feel tired and sore for a week or two. Most of your discomfort can be controlled by medication prescribed by your doctor.
Virtually any woman can have her breast rebuilt through reconstructive surgery. There are risks, however, associated with these surgeries. Dr. Lee is a board-certified plastic surgeon and the procedures are performed in a state licensed and Medicare certified surgical center or in a hospital, along with skilled anesthesiologists. These credentials help ensure the highest standards of care and your utmost safety.
Although uncommon, some surgical risks can include bleeding, fluid collection, excessive scar tissue, or difficulties with anesthesia. As with any surgery, smokers are 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 is capsular contracture, which occurs if the scar or capsule around the implant begins to tighten. This squeezing of the 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.
Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment. 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.
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.
You can begin talking about reconstruction as soon as you're diagnosed with cancer. Our plastic surgeons will always work with your breast surgeon 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, goals, and lifestyle. Be sure to discuss your expectations frankly with your surgeon. He will 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.
Your surgeon and Patient Coordinator will also explain the anesthesia plans, the facility where surgery will be performed, and the costs. Health insurance policies vary regarding the amount of coverage for post-mastectomy reconstruction. Check your policy to make sure you're covered and to see if there are any limitations on what types of reconstruction are covered.
Preparing for Surgery
Your oncologist and plastic surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain vitamins and medications. While making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days, if needed.
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 may also be done in the hospital, or a certified outpatient surgical center.
The first stage of reconstruction, creation of the breast mound, is almost always performed using general anesthesia, so you'll sleep through the entire operation.
Follow-up procedures may require only a local anesthesia, combined with a sedative to make you drowsy. You'll be awake but relaxed, and may feel some discomfort.
Returning to Normal
It may take you up to six weeks to recover from a combined mastectomy and flap reconstruction. If implants are used alone, your recovery time may be less.
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. 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.
Your New Look
Chances are, your reconstructed breast may feel firmer and look rounder or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. But these differences will be apparent only to you. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.
"I want to express my thanks and appreciation to you for my reconstructive surgery. And, also for your patience in explaining the surgery so thoroughly beforehand. You are a true professional. I also would like to thank your wonderful staff for their help and support. You all made the surgery and recovery so much easier." -Carol
"This is not the ride I stood in line for! You and your staff have been wonderful! The way you explained everything to me and your warm smile took a lot of the fear out of "Breast Cancer". I will be forever grateful. -Love & Hugs, Leanne"
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