Breast Reconstruction
Standard information adapted from the American Society of Plastic Surgeons If You're Considering Breast Reconstruction...
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 your surgeon if there is anything you don't understand about the procedure.
The Best Candidates For Breast Reconstruction
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, seems to have been eliminated by mastectomy.
Still, there are legitimate reasons to wait. If radiation is planned or thought to be highly likely, reconstruction is delayed until
the radiation therapy is completed. 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. Women with other health conditions,
such as obesity, high blood pressure, or smoking, may also be advised to wait.
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.
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.
Planning Your Surgery
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.
Your surgeon should also explain the anesthesia he or she will use, the facility where the surgery will be performed, and the costs.
In most cases, health insurance policies will cover most or all of the cost of 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 Your Surgery
Your oncologist and your 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.
Where Your Surgery Will Be Performed
Breast reconstruction usually involves more than one operation. The first stage, whether done at the same time as the mastectomy or
later on, is performed in a hospital.
Follow-up procedures may also be done in the hospital. Or, depending on the extent of surgery required, your surgeon may prefer
an outpatient facility.
Types of Anesthesia
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 also usually involve general anesthesia although they may require only a local anesthesia, combined with a
sedative to make you drowsy. In such cases you'll be awake but relaxed, and may feel some discomfort.
The Surgery
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:
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 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.
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
proper volume has been achieved the patient is scheduled for the second stage where the tissue expander is exchanged for a permanent
implant.
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
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 four to six days after the first surgery.
Any subsequent follow-up surgery is much faster and usually requires no hospital stay or possibly a one night stay for certain patients.
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
It may take you up to six weeks to recover from a combined mastectomy and reconstruction or from a flap reconstruction alone. If
implants are used without flaps and reconstruction is done apart from the mastectomy, 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, 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.
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.
Content courtesy of PlasticSurgery.org
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