Breast Reconstruction
The technology for breast reconstruction has advanced considerably in recent years and can range from more simple, such and tissue expanders and implants, to more sophisticated, such as DIEP flaps. Techniques and procedures now exist that allow the creation of a reconstructed breast that looks and feels very much like a native breast.
Breast reconstruction is a very personal decision and process and Dr. Granzow’s goal is to produce a finished result that will be as natural and comfortable for the patient as possible.
Who is a breast reconstruction candidate?
Most women are candidates for breast reconstruction with even the most advanced DIEP flap methods. Many different options for breast reconstruction exist, and the final decision about the timing and type of breast reconstruction is determined collectively by the patient, the plastic surgeon and the surgical oncologist. Significant factors in the choice of the method for breast reconstruction include the type of surgery performed, the need for radiation and the training and experience of the plastic surgeon. As with all surgical procedures, different surgical centers and teams may have quite different approaches to the choice of surgical procedure.
What is the difference between "Immediate" and "Delayed" breast reconstruction?
Breast reconstruction may be performed at the same time as the mastectomy (immediate, or primary, reconstruction) or at a time after the initial mastectomy (delayed, or secondary reconstruction). Immediate reconstruction often allows for greater preservation of skin around the breast and allows the patient to awaken from surgery with a new breast. Reconstruction may be delayed for various reasons, including the need or likelihood of radiation therapy after the mastectomy.
Delayed reconstruction means that the mastectomy, lumpectomy or other breast procedure has been performed in the past, or if circumstances exist which may be a contraindication to immediate reconstruction.
The overall aesthetic outcome of a breast reconstruction is usually better with and immediate reconstruction as more of the native chest wall skin is preserved in the final result.
What options are available for breast reconstruction?
Only 2 general types of breast reconstruction currently exist:
1. Using tissue expanders and implants for reconstruction
2. Autogenous reconstruction using a patient’s own tissue (flaps)
Published studies have confirmed that procedures that use a patient’s own tissue result in a more natural-feeling and natural-looking breast. Studies also repeatedly have shown a higher patient satisfaction rate using a patient’s own tissue rather than implants. Over the long term they also require fewer reoperations than with expanders and implants. However, these procedures typically require more significant initial surgery and a longer hospital stay than expander/implants.
In general, procedures which use a patient’s own tissue for reconstruction involve a more significant initial surgery and hospital
stay but result in a more natural feeling and appearing breast. The use of reconstructive microsurgery is the latest
and most advanced form of breast reconstruction.
Previous studies of
DIEP perforator flaps reveal an unplanned surgical revision rate afterwards of approximately 10%.
Procedures using expanders and implants tend to have quicker initial surgeries but higher rates of long term complications.
Nationally collected data for
breast reconstructions performed with tissue expanders and implants showed an unplanned surgical revision rate of 45% - 49% over 5 years.
In addition, Federal Law and
State Laws require insurance coverage
for surgery to the opposite breast for symmetry. These procedures include:
What is microsurgery and why is it often used in breast reconstruction?
Microsurgery allows the transfer of large amounts of tissue, collectively know as a “free flap”, from any part of the body to any other part of the body. “Microsurgery” describes the connection of tiny arteries and veins which provide the critical blood supply to the free flap. The procedures are performed in the operating room with a surgical microscope and suture which approximates the width of a human hair. Microsurgery allows for the most advanced types of reconstruction and requires a plastic surgery who typically has additional experience and training in this type of procedure.
Using a patient’s own tissue (autologous reconstruction)
Using a patient’s own tissue allows the creation of a new breast with tissue which closely resembles the breast tissue removed with
a mastectomy. This results in a reconstructed breast that is soft, warm, and naturally changes with the patient's body over time.
DIEP (Deep Inferior Epigastric Perforator) Flap
The DIEP flap is the latest and most advanced form of breast reconstruction. It provides the advantages of using a patient's own tissue, minimizes the chance for muscle sacrifice and can maximize the chance for the best aesthetic outcome in both appearance and texture. It provides an excellent chance of creating a new breast and abdomen which look and feel like a breast lift and tummy tuck.
The skin and fat used are taken from the abdomen and are almost the same tissue normally removed in an abdominoplasty (tummy tuck).
The major difference is that an artery and vein which supply this tissue are carefully dissected free from between the abdominal muscle
fibers and taken with the flap. The tissue is transferred to the chest, where the artery and vein are reconnected to recipient vessels
and the tissue carefully formed into a breast.
Unlike the traditional TRAM flaps, the DIEP flap does not sacrifice the rectus abdominis (belly "six pack") muscle.
In the hands of a skilled microvascular surgeon, this tissue can be made into a breast which is alive and will grow, shrink and sag
with the body’s natural changes over the rest of the patient’s life. A "side effect" of the procedure is that the remaining abdominal
skin is pulled together into a flatter stomach, similar to that seen in an abdominoplasty (tummy tuck).
SIEA (Superficial Inferior Epigastric Artery) Flap
The SIEA flap uses similar tissue from the abdomen as the DIEP flap. The major difference compared with the DIEP flap is that the
artery and vein used lie more superficial (closer to the skin surface) than the artery and vein of the DIEP flap. This allows the flap
to be taken with a relatively superficial dissection only.
Just as with the DIEP flap, the SIEA does not require the use of the abdominal muscle for breast reconstruction as required by a
TRAM flap.
However, the blood vessels which are required for the SIEA flap are present in a sufficient size and location for the procedure
only in small percentage of patients. Thus, a DIEP flap is much more commonly used. A decision on whether a DIEP or SIEA flap is used
can only be determined during the surgery. The long term results are similar for both the DIEP and SIEA flap.
SGAP (Superior Gluteal Artery Perforator) Flap
Skin and fat is taken from the area of the buttock along with the carefully preserved artery and vein. The flap is transferred to
the chest and carefully shaped into a new breast after the vessels are reconnected. Since the donor site sometimes appears more lifted
than the opposite, unoperated buttock, a patient may decide to later have the opposite side "lifted" as well.
GAP flaps taken from higher on the buttock are usually based on the superior gluteal artery and called SGAP (Superior Gluteal
Artery Perforator) flaps.
The harvest of an SGAP flap may leave a noticeable donor site deformity high on the buttock which may require a greater revision
at a later date and generally will leave the donor site scar inside the bikini line.
IGAP (Inferior Gluteal Artery Perforator) Flap
An IGAP flap is similar to an SGAP flap as described above. IGAP flaps are based lower on the buttock and typically rely on the
inferior gluteal artery.
The harvest of an IGAP flap may leave a deformity lower on the buttock which may or may not require a revision at a later time.
The donor site scar usually falls in or near the crease under the buttock, but may extend slightly out to the side of the buttock.
It also has a higher chance of producing discomfort with sitting after the surgery, although this usually resolves with time.
Free TRAM (Transverse Rectus Abdominis Muscle) Flap
As with the DIEP flap, skin and fat from the abdomen which is normally removed during an abdominoplasty (tummy tuck) is used to
reconstruct the breast. However, some or all of the rectus abdominus (belly "six pack") muscle is taken with the flap around the
artery and vein. The vessels are reconnected in the chest like with the DIEP flap.
The resulting breast reconstruction is similar to a DIEP flap reconstruction. The advantage is an easier and slightly faster
surgery in the hands of many surgeons at the cost of sacrificing of some of the abdominal muscle resulting in a higher risk of
postoperative abdominal difficulties and pain.
Pedicled (non-microsurgery) flaps:
Pedicled TRAM (Transverse Rectus Abdominis Muscle) Flap
This procedure is an older method of breast reconstruction. Like the above flaps, the abdominal skin and fat is used for breast reconstruction. However, almost the entire rectus abdominus
muscle (belly "six pack") on one side is taken around the blood vessels to preserve them. The muscle is turned or folded on itself
and the flap is passed under the chest wall skin up into the chest to provide blood flow for the new flap.
This flap does not require microsurgical expertise or training and is therefore widely used. Also, it is therefore usually quicker
to perform. In unusual cases, such as in certain patients with certain types of previous abdominal surgery, this procedure may be required as an alternate form of breast reconstruction. However, significant complications include a higher risk of abdominal weakness and hernia (especially if done on both sides
for reconstruction of both breasts) and higher rates of fat necrosis in the reconstructed breast.
Some physicians are proponents of a "muscle sparing" pedicled TRAM, used in an effort to decrease the abdominal risks associated with
the procedure. This may or may not lessen the chances of later abdominal difficulties.
This flap typically has a less favorable blood supply when compared to the free flaps described above, and less abdominal skin and
fat often can be utilized.
Latissimus dorsi Muscle Flap
Like the TRAM flaps, this procedure uses muscle in addition to skin and fat to reconstruct the breast. Like the pedicled TRAM flap,
it does not require the surgeon to have specialized microvascular expertise.
The latissimus dorsi muscle and some of the overlying skin and fat are used from underneath the shoulder and from the back of the
chest wall. This tissue is passed underneath the skin of the chest wall and brought forward to reconstruct the breast.
As the skin and muscle of the latissimus dorsi flap may have insufficient volume for a desired breast reconstruction, a breast
implant sometimes is placed under the reconstructed skin and muscle to more completely fill out the tissue.
Using tissue expanders and implants for reconstruction
Tissue expanders and implants are very popular methods of breast reconstruction. They require the shortest surgical time for the
first surgery and do not require special, further training to perform past that received in a plastic surgery residency.
At the time of initial surgery a tissue expander is placed under the pectoralis major muscle and Alloderm may be used. The expander is only partially filled during the surgery to minimize the initial stress of the device on the overlying chest wall skin. The patient is released from the hospital usually in 2 to 4 days.
Multiple visits are required between the first and second stages of the reconstruction for filling of the implant. This is usually
performed in the office by injecting saline solution through a needle through the skin to progressively fill the expander. When the desired volume has been reached, the patient is scheduled for a second operation in which the tissue expander is exchanged for a permanent, usually silicone-filled, implant. Subsequent adjustments and re-operations for complications are not uncommon over the course of a patient’s lifetime.
The advantages of a quicker and technically less demanding initial procedure must be weighed versus the disadvantages of later
complications including capsular contracture, or hardening of the implant which occurs more frequently than with breast implants
performed for aesthetic breast augmentation. These advantages and disadvantages must be weighed carefully for each individual patient.
The look and feel an implant reconstruction will be different than those of a reconstruction using the patient’s own tissue.
A tissue expander may also be placed at the time of the initial mastectomy (breast removal surgery) as a temporary spacer in the
chest if radiation therapy will be required. The tissue expanded may be removed and replaced with a breast reconstruction flap at
a later date. This allows for the preservation of the maximum amount of chest wall skin while sparing the flap the potentially
damaging effects of the radiation therapy.
After Your Surgery
The amount of discomfort felt after breast reconstruction varies considerably between patients and preocedures. Muscle-sparing procedures, such as DIEP flaps, tend to have the least pain and discomfort after surgery with the quickest recovery times for procedures that use a patient's own tissue. Hospital time after surgery for a DIEP flap is usually 4 days. Hospital time for a tissue expander based surgery is shorter. Most discomfort is well controlled with pain medication after the procedure.
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 self dissolving.
Getting Back to Normal
Most patients are up and walking on the first or second day after surgery even for microsurgery procedures. Activity is gradually increased and full activity is generally allowed at 6 weeks for all methods of reconstruction.
Reconstruction cannot restore normal sensation to the breast, but in time, some feeling may return. Most scars will continue to fade with time although they will never disappear entirely.
Most patients are advised to refrain
from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following any type of reconstruction.
Recovery Timeline created by patient
Your New Look
For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.
Breast reconstructions with perforator free flaps, such as DIEP, SIEA or GAP flaps provide a look and feel which may approximate that
of a normal breast. If implant reconstruction is required, chances are your reconstructed breast may feel firmer and look rounder or
flatter than your natural breast. Any breast reconstruction 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.
All Surgery Carries Some Uncertainty and Risk
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.
In general, the usual problems of surgery, such as bleeding, fluid collection, excessive scar tissue, chest wall skin loss from the mastectomy, partial or complete flap loss, 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.
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.
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.
However, over time almost all women who have undergone breast reconstruction, especially with their own tissue and DIEP flaps, are extremely happy with their result and would recommend the procedure to others. Please feel free to contact our office to speak with patients who have previously undergone breast recosntructions with Dr. Granzow.
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