A diagnosis of breast cancer is a severe emotional and physical event for any woman. Current state-of-the-art procedures can minimize the associated emotional and physical loss.
Many patients may be candidates for either breast conservation therapy, involving lumpectomy and radiation therapy, or mastectomy with breast reconstruction. Your breast surgeon will be able to counsel you about the risks and benefits of each type of treatment. In certain cases, breast conservation may not be recommended by your breast surgeon even though your cancer would be adequately treated because the required lumpectomy would disfigure your remaining breast. Various reconstructive techniques have been developed which usually yield very good cosmetic results for many different breast types and shapes. I can discuss these breast reconstruction techniques with you in detail during a consultation at my Dallas practice.
In developing a breast reconstruction treatment plan, appropriate management of the cancer is the first and foremost goal. I will work with your breast surgeon and oncologist in formulating the most appropriate plan. In the vast majority of cases immediate breast reconstruction (at the time of the mastectomy) is possible and will yield optimal cosmetic results. In general, immediate breast reconstruction techniques require one major surgery at the time of the mastectomy, and a second surgery as an outpatient procedure three to six months later.
If chemotherapy or radiation therapy is prescribed for you following mastectomy, the planned reconstructive procedures will have to be carefully timed to coordinate with these regimens, which may be required for optimal cancer treatment. Chemotherapy or radiation therapy will not prevent you from having reconstruction. A requirement of radiation therapy may necessitate the delay of certain reconstructive procedures until after completion of the entire course of radiation.
Shape modification or breast lift of the opposite breast may be required to achieve adequate symmetry with the reconstructed breast. This procedure is usually performed at the time of the secondary day-surgery procedure three to six months after the mastectomy and major reconstructive procedure.
Your breast surgeon may tell you that you have a type of cancer, family history or genetic predisposition which gives you a statistically high chance of developing cancer in your other breast. Only a very small percentage of patients will fall into one of these categories. If you are counseled to consider a prophylactic (precautionary) mastectomy in the opposite breast, reconstructive procedures are available to perform immediate bilateral (both sides) reconstruction.
In general, procedures related to breast reconstruction, including related secondary surgeries and procedures performed on the opposite breast to achieve symmetry will be covered by health insurance. You should contact your carrier prior to beginning a treatment plan to confirm this.
There are two broad categories of breast reconstruction:
- Techniques that use breast implants
- Techniques that use only your body’s own natural tissue
There are many factors and variables to consider, and a breast reconstruction treatment plan is individually formulated to meet your specific needs and goals.
Implant-Based Breast Reconstruction
Reconstruction with breast implants is usually performed in two separate operations. At the time of the mastectomy, a soft-tissue expander is placed beneath the skin on the chest wall. The expander is similar to a balloon and contains a metal expansion port. Usually, the expander is placed completely deflated and the tissues are allowed to heal over it. Beginning two to three weeks after your surgery, after the incisions are healed, addition of fluid to the expander begins in the office. The metal port can be felt through the skin or detected with a magnet. A small needle is then placed through the skin into the metal port and the expander is filled with sterile saline. Sequential expansion is performed over weekly visits until the desired amount of skin expansion is achieved. At a second operation three to six months later, the expander is removed and replaced with a permanent breast implant.
In some cases, adequate implant-based reconstructions can be performed with this type of procedure alone; in many cases, your tissues may be thin and improved cosmetic outcomes will be achieved by supplementing the implant reconstruction with additional tissue, either acellular dermal matrix or latissimus dorsi flap.
Acellular Dermal Matrix
Acellular dermal matrix is derived from donor skin that has been extensively processed to yield a sheet of collagen devoid of any cells. This collagen sheet is used to help internally support the pectoralis muscle over a tissue expander/implant; ultimately, this can result in a more natural shape to the reconstructed breast with a more rounded lower pole. Also, there may be a lower incidence in the development of excess scar tissue around the breast implant. Finally, there is a decreased tendency to see any irregularities resulting from a breast implant underneath thin breast skin.
Latissimus Dorsi Flap
Most commonly, the latissimus dorsi muscle and some of its overlying skin are transferred from the back to partially cover the tissue expander and supplement the breast skin that was removed at the time of the mastectomy. This adds even more tissue cover to the lower pole of the breast, resulting in a very natural appearing breast reconstruction. The subsequent expansion process and replacement of the expander with a permanent implant then proceeds similarly to the regimen described above. This breast reconstruction procedure results in a five to eight-inch scar on the back that can usually be hidden in the bra line.
Patients who elect to undergo this type of breast reconstruction will usually be in the hospital for one to two days following the mastectomy (two to three day total stay). Discomfort is mild to moderate and the recovery is fairly rapid after going home. Usually, there is no perceptible disability or weakness from having the latissimus dorsi muscle transferred for breast reconstruction.
At the time of the replacement of the expander with a breast implant, patients may choose either a silicone gel implant or a saline breast implant. Silicone implants are usually softer and can feel more natural than saline implants. Saline filled implants, however, will have a lower risk of developing a capsular contracture, which is an abnormal hardening of the normal lining which forms around any breast implant. I will discuss the pros and cons of saline filled versus silicone breast implants with you during your consultation at my Dallas office.
Many patients who elect to have an implant-based reconstruction will require a procedure on the opposite breast, usually placement of an implant, a breast lift or breast reduction to achieve symmetry. This normally will be performed on a day-surgery outpatient basis at the same time the tissue expander is replaced with a permanent implant.
Microsurgical Breast Reconstruction Without Implants
Many of my Dallas patients want to have breast reconstruction but do not want breast implants. State-of-the-art procedures have been developed that use only your own tissues to reconstruct your breast after mastectomy.
TRAM Flap Reconstruction
The most common technique using your own tissue for breast reconstruction is the TRAM (transverse rectus abdominus myocutaneous) flap. The skin and fat of the lower abdomen, along with part of the underlying muscle is transferred from the lower abdomen to the chest wall and contoured to the shape of the opposite breast. This procedure usually results in a scar around the areola (colored skin around the nipple) and a lower abdominal scar. The excess skin and fatty tissue removed from the abdomen is similar to that removed in an abdominoplasty or “tummy tuck”. A second operation performed three to six months later involves a final “touch up” or contouring of the breast mound to match the opposite breast. This procedure results in a reconstruction which can look and feel as soft as a natural breast.
The most advanced type of reconstructions based on the TRAM procedure is the DIEP (deep inferior epigastric perforatior) flap; this is a free flap, where the tissue is completely isolated on the artery and vein within the rectus abdominus muscle, removed from the body and microsurgically reattached to blood vessels at the chest wall. The benefits of microsurgical reattachment (DIEP flap) include the ability to reliably transfer more tissue and faster recovery because of less abdominal surgery required. The disadvantage to performing DIEP reconstruction is the possibility of loss of all of the tissue if the microsurgically reattached blood vessel clots. The chance of this happening is very small (less than 5 percent).
Not all patients are candidates for DIEP flap breast reconstruction: this option may not be available in patients who have had certain previous abdominal operations, patients with certain medical problems or patients who are either obese or very thin.
DIEP flap breast reconstruction is a major operation that requires more time in the operating room and a longer hospital stay (usually three to five days total). In addition, there may be a longer recovery time after leaving the hospital.
In general, the nipple and areola (colored skin around the nipple) is removed at the time of mastectomy. These are reconstructed at the time of the secondary outpatient operation, usually using local available tissue. A small skin graft from the abdomen or groin may also be required. If, after the nipple reconstruction, the color of the reconstructed areola doesn’t match the opposite breast adequately, this can be improved with a tattoo procedure. Frequently, skin grafted tissue will be slightly darker in color and will simulate the normal areola.
Your Breast Reconstruction Consultation
At your initial breast reconstruction consultation, I will review with you your medical history, breast pathology, treatment plans of your breast surgeon and your goals for reconstruction. I will perform a physical exam including an assessment of your opposite, uninvolved breast and the quantity and quality of tissues available for reconstruction. Pre-operative photographs are taken which will become part of your record. These are necessary for pre-operative planning, execution and follow up of your reconstruction.
A cosmetically pleasing reconstruction can be achieved using either implant-based or non-implant-based techniques. It is possible you can be offered either type of reconstruction and the decision depends on your personal goals. These include extent and location of donor site scars (lower abdomen versus back), how rapidly you want or need to recover, and simply how you feel about an all natural tissue versus a breast implant reconstruction. There are many variables to consider and an individual plan will be formulated for your case.
Our office will contact your breast surgeon and will make every effort to coordinate our schedule with that of your breast surgeon to accommodate your planned surgery date. If you do not have a local breast surgeon, we can refer you to an excellent local breast oncologic surgeon.
Your Breast Reconstruction
Your reconstructive procedure will be performed immediately following your mastectomy. An expander/acellular dermal matrix reconstruction usually requires one additional hour after your mastectomy; latissimus dorsi reconstruction with a tissue expander usually requires one-and-a-half to two hours after your mastectomy; DIEP flap reconstruction usually requires five to six hours after your mastectomy. During the surgery, small drains will be placed in the operative sites (including the breast, back and/or abdomen depending on the procedure performed). These are connected to drainage bulbs that remove excess secreted fluid from the operative site. These drains typically remain in place for one to two weeks (you will leave the hospital with them). The hospital nursing staff will instruct you on their care and use.
All incisions will be closed entirely with buried sutures which are absorbable. This eliminates the need to remove any sutures in the office after your surgery.
Expect a mild to moderate amount of discomfort after breast reconstruction surgery. We will provide pain medication in the hospital and after discharge and antibiotics for five to seven days after surgery to minimize the chance of infection.
We will encourage you to get out of bed soon after breast reconstruction surgery and be walking by the next day. Regaining normal activity as quickly as possible speeds recovery.
After Your Breast Reconstruction
After you return home, try to resume normal, non-strenuous activities as quickly as possible. You may shower beginning two days after your breast reconstruction surgery (even if you have drains in place). Do not bathe in a tub if any drains are in place or there is any drainage from incisions.
No dressings or bandages are necessary over your incisions unless small amounts of fluid are draining. Contact my office in Dallas for a follow up appointment approximately one week after your surgery date. At that time I will assess the healing of your incisions and remove your drains. In some cases, drains may need to stay in place for two weeks or longer.
If you have a tissue expander in place, I will usually begin expanding it two weeks after surgery, and weekly thereafter until expansion is complete. Expect minimal discomfort with expansions. If your treatment includes postoperative chemotherapy, your tissue expansion will be timed with your chemotherapy.
After three to six months, your reconstruction has had adequate time to heal, soften and mature. At this time your second outpatient operation will be scheduled for permanent breast implant placement, final contouring of the reconstructed breast mound, nipple reconstruction and/or any symmetry or lift procedures on your opposite breast.
Recent advances in breast reconstruction techniques allow most patients to achieve cosmetically attractive symmetric breasts after breast cancer treatment. These results can be achieved for the vast majority of patients in two operations (one major immediately at the time of mastectomy and a minor outpatient procedure three to six months later). Breast reconstruction usually helps decrease the emotional and physical impact of breast cancer.
If you have any questions regarding your decision about breast reconstruction, please do not hesitate to contact my office in Dallas for further information.