Breast reconstruction after cancer surgery
Although the name of our practice New Horizons Center for Cosmetic
Surgery suggests that our physicians specialize only in cosmetic
surgery, Dr Turowski and Dr Lu are fully- trained plastic surgeons
who are committed to providing the most advanced and comprehensive
breast reconstruction after mastectomy or lumpectomy.
We understand that the diagnosis of breast cancer often presents an
emotional and physical strain on you and your family, and we want
you to know that we will work in concert with your team of physicians
to provide the highest quality of care available in a compassionate manner.
You can be assured that our priorities are aligned with you and your cancer
doctors, with the top priority to cure your cancer.
Although you may have already been referred to, or have seen another plastic
surgeon for a consultation regarding breast reconstruction, you should consider
a second opinion from a plastic surgeon specializing in this type of surgery.
The decision-making process and overall surgical experience that is vital for
the success of these highly complex surgeries are of upmost importance.
Therefore, it is important to become fully informed and make an educated decision:
- When considering your choices in breast reconstruction, you should weigh the
pros and cons of having surgery performed at a large teaching institution, where
you may be operated on by a surgeon-in-training under the supervision of an
attending surgeon. This is in contrast to a private hospital, where all your
surgery and care will be performed personally by very experienced attending
surgeons.
- Smaller institutions that specialize in breast cancer treatment usually offer
a more personalized approach to care and yet have the same high standards offered
by its larger counterparts.
- At a consultation, you should be able to view multiple postoperative photographs
of actual patients, who have undergone similar procedures in all stages of the
reconstructive process.
- If desired, you should be able to contact previous patients who have underwent
similar procedures to hear real stories of their recovery and healing process.
The goal of reconstructive surgery is to restore what has been removed by
various approaches based on your preferences and appropriateness of the surgery.
During your consultation, we will discuss in detail the available options for
breast reconstruction, taking into consideration your medical history, need for
adjunctive treatments such as chemotherapy and radiation, and personal preferences.
Based on this information, we tailor a plan and coordinate surgery with your breast
surgeon. If you do not have a breast surgeon, we will be able to refer you to several
surgeons specializing in breast cancer surgery. This is of paramount importance,
since the final results of an immediate breast reconstruction depend greatly on the
teamwork of the breast cancer surgeon and plastic surgeon. It is our goal to provide
you with as much information as possible to assist in making an informed decision
about breast reconstruction.
Many decisions need to be made to decide which reconstructive option is most
appropriate for you. Most breast reconstruction can be performed at the time of
the mastectomy, or in other words, ?immediate breast reconstruction?; however,
there are rare circumstances where a ?delayed breast reconstruction? may be
recommended, depending on if you will require other treatments after the mastectomy.
If the reconstructive surgery was not performed during the initial mastectomy surgery,
depending on circumstances, delayed breast reconstruction can usually be performed
as soon as several weeks after the original surgery. We have also performed breast
reconstructions as late as 30 years after the initial mastectomy. Barring any
coexisting major medical problems, the age of the patient is usually not a
limiting factor.
The reconstructive options available differ in their approach, amount of time
for the initial surgery, length of hospitalization and recovery time, and
need for future procedures. In general, breast reconstruction, from creation
of a breast mound to nipple and areola reconstruction, requires staged procedures,
although the subsequent procedures usually are minor outpatient or in-office
surgeries with significantly shorter recovery times. To provide our patients
an exceptional experience and for their convenience, most of these secondary
procedures can be performed in our private fully- accredited state-of-the-art
surgery center.
BREAST RECONSTRUCTION OPTIONS
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FAQ
Broadly speaking, breast reconstruction can be divided into ?implant-based?
reconstruction or ?autologous?(your own tissue) reconstruction.
However, there are reconstructions, such as the latissimus dorsi flap
from your back, that incorporates both your own tissue with an implant to
create a breast of appropriate volume based on your preferences or to match
the other remaining breast.
IMPLANT-BASED RECONSTRUCTION
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A breast implant is a round or teardrop-shaped shell, filled with saline
(salt-water) or silicone gel. The implant is placed behind the pectoralis
major chest muscle in a manner similar to what occurs during breast
augmentation surgery.
In a select group of women, implants may be placed as a one-stage process,
where a permanent implant is used at the time of the mastectomy.
However, most women require a two-stage process, using a tissue
expander before the permanent implant is placed.
A tissue expander is an implant with a valve/port that can be filled
with saline to stretch the remaining chest skin and soft tissues to
make room for the breast implant. The tissue expander is placed under
the pectoralis major muscle at the time of your mastectomy. After the
incisions have healed, a small valve/port is accessed and saline is
injected into the expander during several office visits, usually over a
6-8 week period of time. This gradual stretching creates more skin and
soft tissue, not unlike how the skin of the abdomen stretches during a pregnancy.
The tissue expander is filled until it is slightly larger than the desired
size to assure that the skin and soft tissue can accommodate the permanent implant.
At a second surgery, the tissue expander is replaced with a permanent saline or
silicone implant.
The advantage of this type of reconstruction is that the initial surgery is
shorter, on average adding only 1-2 hours to the mastectomy surgery and
typically requiring only a single day of hospitalization. Since this
technique does not involve removal of tissue from another site of your body,
it does not create any additional scars or potential ?donor-site morbidity?
(see below for more details).
The disadvantage of this approach is that it typically involves a tissue expander,
which requires at least 2 surgical stages and multiple visits to our office during
the expansion process. There are instances where this may be more challenging for
the patient than a recovery from a latissimus dorsi flap reconstruction (see below).
In addition, an implant does not have the same shape and ?feel? of a natural breast,
so that it may make matching the opposite breast more difficult (for patients only
having a unilateral or one-sided mastectomy). As opposed to other types of reconstruction
this type of surgery may produce a higher risk of early complications when performed as
immediate breast reconstruction. In the short-term, the implant can become infected or
malpositioned, which may require surgery to correct these problems. In the longer-term,
implants may eventually require subsequent procedures to replace them due to capsular contracture,
rupture, or malposition.
AUTOLOGOUS TISSUE RECONSTRUCTIONS
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Breast reconstruction can be performed without implants, using a ?flap? of your own tissue.
A ?flap? entails a combination of skin, fat, and/or muscle that is taken from one portion of
your body and moved to your chest to create a breast. The advantages of using your own
tissues are that it typically has a more natural shape and ?feel? of a native breast,
and that it typically avoids the use of an implant. It also offers immediate reconstruction
of the breast shape that usually requires only minor adjustments during secondary procedures.
The disadvantages of this approach are that it requires a longer surgery and recovery time,
and creates an additional scar on your body, with the potential for ?donor-site morbidity.?
The main autologous reconstructions use tissues from the back or abdomen and are described
below.
Latissimus Dorsi Flap
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A latissimus dorsi flap involves taking the skin, fat, and latissimus dorsi
muscle from your back (in the area below your scapula or shoulder blade) and
tunneling it through the axilla or armpit to create a breast. Sometimes it
is possible to use this flap without implants in order to achieve the desired
size. However, this technique often is used in conjunction with a tissue
expander or implant to reconstruct the breast.
Why use a latissimus flap if you are going to use an implant anyway? There
are several reasons. Using a latissimus flap with an implant typically has
a more natural shape and ?feel? than an implant alone. One way to describe
this effect is for you to imagine putting an implant under a bed sheet.
With only a thin sheet over the implant, all of the contours of the implant
are visible and the implant can be readily felt. On the other hand, if the
implant is placed under a thick comforter, the implant is there only to provide
volume, and is not as visible or palpable. The former analogy describes an
implant-only based reconstruction, while the latter analogy describes the
latissimus flap with implant reconstruction. In addition, placing the skin,
fat, and muscle over an implant may reduce complications relating to infection
and radiation therapy.
Therefore, the advantages of the latissimus flap are that it decreases some of
the risks of using an implant, it typically is easier to match the opposite
breast with this approach, and it replaces deficient skin and soft tissue
which may be missing or damaged after the mastectomy and/or radiation treatments.
In cases of immediate breast reconstruction, the patient emerges from the
mastectomy and reconstructive surgery almost completely restored to a natural
(or sometimes better) size and shape as compared to having a mound of tissue
present if an expander is utilized. After the initial surgery, there often is
no additional expansion necessary. Therefore the recovery period is usually
surprisingly easier than for an expander/implant reconstruction, because there
is no need for the sometimes-painful injections and stretching associated with
the expansion process. We utilize this technique in all age groups (young and old)
with tremendous success. We believe it is optimal for women looking for a
relatively quick recovery and very satisfactory results without the disadvantages of
prolonged expansion and problems of implant exposure.
The disadvantages of this approach are that it requires a longer surgery, and it
results in an additional scar on your back where the flap is obtained
(although this scar is usually well hidden by your bra). The loss of muscle
function is usually well compensated by the other muscles of the shoulder and back.
TRAM Flap
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The TRAM flap stands for a ?Transverse Rectus Abdominus Myocutaneous? Flap.
Put simply, it uses your abdominal skin and fat based on blood vessels that
travel through the rectus abdominus muscle (sometimes known as your ?six-pack?
muscle). There are many variations of this type of flap which indicates the
method by which Dr Turowski or Dr Lu move the abdominal tissue up to the chest
to create the breast. In a ?pedicled? TRAM, the tissue is moved to the chest
by a subcutaneous tunnel in the lower portion of your breast. In a ?free? TRAM,
the abdominal tissue is transferred to the chest by using microsurgical techniques
to reconnect the blood vessels that provide nourishment to the tissues.
The advantages of the TRAM are that it removes abdominal tissue to reconstruct the
breast, which improves your abdominal contour after surgery (similar to an
abdominoplasty or ?tummy tuck?). In addition, it avoids the use of an implant,
has a more natural look and ?feel,? and is durable.
The disadvantages of this approach are that it requires a longer surgery with a
longer recovery time than for both an implant-based or latissimus flap
reconstruction, it creates a scar across your lower abdomen (similar to the scar
after a tummy tuck), it may result in some abdominal muscle weakness, and it is
possible to develop bulging or a hernia at the site where the flap is taken from.
DIEP and SIEA Flap
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The DIEP and SIEA flaps stand for the ?Deep Inferior Epigastric Perforator? and
?Superficial Inferior Epigastic Artery? flaps, respectively. These flaps fall
under the category of ?perforator? flaps, which are advanced microsurgical
procedures that attempt to spare the abdominal muscles. The advantage of using
these flaps is that it spares the abdominal wall fascia and muscles, and may
reduce the incidence of weakness, hernia/bulging, and post-operative pain.
The disadvantages of the DIEP and SIEA flaps are that is a significantly longer
operative procedure, and has the risk of problems with the microsurgical
connections of the blood vessels.
SURGERY ON THE OTHER BREAST
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In some patients who are receiving a unilateral mastectomy, to achieve optimal
results we may recommend surgery on the contralateral or opposite breast in order
to make the breasts more symmetric. This may involve a breast reduction, breast
lift, or breast augmentation. Fortunately, these procedures are covered under
insurance under the ?Women?s Health and Cancer Rights Act of 1998.?
NIPPLE AND AREOLAR RECONSTRUCTION
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After the breast mound is created with a flap and/or implant, the nipple and areola
are reconstructed in a subsequent outpatient or office procedure. The nipple is made
by surgically rearranging a small portion of the skin and fat of your reconstructed
breast, and the areola is tattooed in a separate procedure.
BILATERAL BREAST RECONSTRUCTION
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In some circumstances, bilateral breast removal or mastectomy may be recommended
by your oncologist or breast surgeon. This may either be for treatment of a
bilateral breast cancer or as a prophylactic measure in high-risk patients.
Breast reconstruction in this circumstance often allows Dr Turowski or Dr Lu
more control over the reconstruction and to achieve outstanding and symmetrical
results. We have utilized bilateral implant reconstructions, bilateral TRAM flaps,
and bilateral latissimus dorsi flaps with great success.
