Breast reconstruction is an elective procedure that is performed after a mastectomy (removal of the breast) or large lumpectomy (removal of a large piece of breast tissue) to treat breast cancer. Most patients who decide to undergo reconstruction find that having the procedure makes it easier for them to restore their body image, resume normal dress and activities, and recover faster psychologically.
Many patients have reconstruction done at the time of the mastectomy, called immediate reconstruction, but reconstruction can be performed at any time after the initial procedure, called delayed reconstruction. In general, the results are superior when cancer surgery and reconstruction are done at the same time. Patients who have reconstruction at the time of mastectomy usually feel better about their recovery. However, for some patients it may be better to delay the reconstruction due to the extent of the cancer.
Before you consider breast reconstruction, you must first speak with your breast surgeon. You should then make an appointment with a plastic and reconstructive surgeon.
Options for Reconstruction
There are multiple options for breast reconstruction. Some require an implant while others use only your own body tissue in what is called a "flap" procedure. The implant option is often considered the "easiest" option because the surgery is the shortest and does not take tissue from other areas of your body. However, this option requires more than one procedure. Some of the flap procedures take longer but only require one surgery. There is no best option; every patient has different issues to consider. Your surgeon may suggest you contact other patients who have undergone these procedures for more information.
All breast reconstructive procedures can be performed safely if your general health is good, even if you need chemotherapy. Your surgeon will discuss with you your overall health, your breast size and shape, activity level, and expectations. It is important for you to tell your doctor if you smoke or have diabetes or heart disease. Your doctor will then discuss which option(s) might be best for you.
All of the following breast reconstruction options can be performed on one or both breasts at once. Flap surgery on two breasts can be more complicated than on one breast and should be discussed in detail with your surgeon.
Tissue expansion with implants:Implant reconstruction often requires more than one procedure in order to make enough space for the implant. Implant reconstruction is usually combined with a procedure called tissue expansion, during which saline (salt water) is slowly added over a period of time to a type of implant called a tissue expander. When the space is large enough to fit an implant that will match the natural breast, a permanent implant then replaces the expander one. The procedures for placing expanders and implants are usually short and do not require overnight stays in the hospital.
We are often asked if implants are safe. Implants used today are made of saline or silicone. If a saline implant leaks, the fluid is absorbed by the patient's body with no harm. Silicone is also used to fill an implant. A silicone implant feels more like a natural breast. Most recent studies show that silicone is also completely safe. If you are considering a silicone implant, your doctor will discuss it with you in detail.
Flap surgery: Flap reconstruction uses a piece of body tissue - usually skin, fat, and muscle - this can be done as a free flap or pedicle flap that is transferred to the breast area to recreate a soft, natural-looking breast. Although flap surgery takes longer than implant surgery, the procedure can be finished during one procedure and the risk of complications is minimal. Most patients will spend no more than two to three days in the hospital. You will be walking and eating within a day. Blood transfusions are rarely required, although your surgeon may ask that you donate a unit of your own blood several weeks prior to the procedure. The most common type of flap used in breast reconstruction is a TRAM (transverse rectus abdominus muscle) flap. A TRAM flap is taken from the abdomen; this can also be done as a free flap.
Another popular flap is the Latissimus Dorsi Flap from the back. Free flaps use micro surgical techniques to reconstruct the breast. This allows less muscle to be taken with the flap. Such flaps include perforator flaps like the DIEP and the Gluteus maximus flap from the buttocks.
The DIEP (Deep Inferior Epigastric Perforator) flap breast reconstruction uses the body's own skin and fat to make a new breast. This procedure represents the state of the art in breast reconstruction. Replacing the skin and soft tissue removed at mastectomy with soft, warm, living tissue is accomplished by borrowing skin and fatty tissue from the abdomen.
A slim incision along the bikini line is made much like a tummy tuck. The necessary skin, soft tissue and tiny feeding blood vessels are removed. These tiny blood vessels are matched to supplying vessels at the mastectomy site and reattached under a microscope.
Unlike conventional TRAM flap reconstructions, use of our refined perforator flap techniques allows for collection of this tissue without sacrifice of underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. The abdomen is the most common donor site, since excess fat and skin are usually found in this area. In addition to reconstructing the breast, the contour of the abdomen is often improved much like a tummy tuck.
Restoration of the nipple and areola follow. Scars fade with time. For many women, the reconstructed breast may be firmer and have a more youthful appearance than their natural breasts.
Nipple reconstruction:Most patients undergo nipple reconstruction after breast reconstruction. This is usually a separate outpatient procedure that can be performed with minimal anesthesia. Recovery is not difficult, although the final outcome may require a tattoo for a better match in color.
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