Plastic Surgery - Breast Reconstruction

Breast reconstruction is a complicated subject that will vary greatly between individual patients. Unlike many other medical decisions that are out of your hands, you, the patient, will be crucial in deciding which method is best for you. This informative brochure is intended to help you make an educated decision about the reconstruction that best suits your needs. Certain parts of this letter may not be relevant to your specific case but you will be able to determine this after your consultation and focus only on the issues that pertain to you.

The purpose of breast reconstruction is to help you recover both physically and emotionally from mastectomy. It should restore your body image and allow you to resume all of your preoperative activities. Most women can continue to wear any style of clothing even if it is revealing; it is usually impossible to tell which side is the reconstructed side while dressed. The need for an awkward and sometimes embarrassing prosthesis is eliminated by permanent reconstruction of the breast.

In an ideal situation, the reconstruction can be undertaken at the same time as the resection and you can leave the hospital with reconstruction already under way. However, many women undergo reconstruction at a later time and the timing is completely elective.

No method of breast reconstruction will precisely duplicate a normal breast, and it is impossible to eliminate the scars that result from mastectomy. Scars, however, can frequently be integrated into the reconstruction to be less obvious. It is not possible to restore normal feeling or to accurately recreate the natural sag or softness of a mature breast. Despite the shortcomings, the majority of women are very pleased with the results achieved by breast reconstruction and find it easier to resume normal activities.

The type of breast reconstruction procedure available to you depends on your body habitus, breast shape and size, your general health and lifestyle, and your goals. Every woman's situation is unique.

Reconstruction With Breast Implants
The most common form of breast reconstruction utilizes a saline (salt water) filled implant to rebuild the breast mound. This technique does not add new scars to the body and does not add a significant amount of time to the initial surgical procedure. While implant reconstruction requires less extensive surgery, more procedures are required to complete the process.

Women with small breasts that do not sag are the best candidates for implant reconstruction. Since the goal is for the reconstructed breast to approximate the other side, breasts that are large or have a lot of sag are difficult to simulate with an implant. Women with larger breasts are not automatically excluded however, and may require a reduction or a lift on the normal side in order to achieve symmetry.

Those who have received chest wall radiation prior to reconstruction generally are not candidates for standard implant techniques. Other alternatives are available for those who have received radiation and are presented in greater detail later.
Over the last 10-15 years, implant reconstruction has been and continues to be the most commonly used breast reconstruction procedure. Implant reconstruction is relatively safe. If the reconstruction is unsuccessful, the implant is simply removed and the patient is no worse off than if no reconstruction was performed. Implant-based reconstruction can be considered for patients who may not otherwise be deemed candidates for longer, more complex surgical procedures.

 Procedure For Implant Reconstruction

To reconstruct the breast with an implant requires two separate procedures. The first can be done at the time of mastectomy to insert a tissue expander. The tissue expander must then be removed at a later time and replaced with a permanent implant. A tissue expander is an inflatable plastic bag that is inserted into a pocket under the skin and muscle of the chest. It is similar in construction to a saline implant but the shape is different, it has an adjustable capacity, and it contains a metal port for fluid injection. The tissue expander must be placed prior to the implant because the mastectomy normally removes a variable amount of breast skin along with the nipple. The amount removed depends on tumor size and also the location of the biopsy scar. The skin circulation and its healing ability are also compromised by the mastectomy. These factors prevent the immediate replacement of a permanent implant at the time of mastectomy in virtually all patients. Tissue expansion is a process that replaces the missing skin in preparation for placement of a permanent implant later.
The expander is usually placed in its collapsed form at the time of mastectomy then beginning about two weeks after surgery fluid is introduced by a needle into the tissue expander to partially inflate it. The breast skin is often numb and this is not painful. This is repeated during weekly office visits to gradually expand the skin of the chest. (Not unlike how abdominal skin stretches over time in pregnancy). You may experience pressure or discomfort after each filling of the expander which is temporary and will subside as the tissue relaxes. The amount of pressure created is directly related to the amount of fluid added to the expander at each visit. This amount is adjusted on an individual basis so that discomfort is minimized. Expansion is complete in approximately eight weeks. Four weeks are then allowed for the skin to stabilize and loosen. After this time the tissue expander is replaced with an implant as a separate surgical procedure. This surgical procedure is performed as an outpatient. If needed, a reduction or lift of the opposite side can be performed at the same time.

Many women ask why two procedures are necessary. Geometrically, the goal of the tissue expander is not the same as the implant and the final result requires changing the shape and position of the final implant as well as tailoring the inferior breast crease to match the other side. In addition, the tissue expander is entered from the outside multiple times during the expansion process and contains a metal port for filling; it is best to remove this apparatus to avoid the possibility of complications from bacteria in the long term.

 

Infection, Capsule Formation, and Other Issues
The hard silicone plastic used to make the implant shell is one of the most biologically non-reactive materials known, however, breast implants and tissue expanders, like any other foreign material placed in the body, can become infected and require removal. Although this happens rarely, removal of the expander or implant is usually necessary once an infection is proven. After the infection has subsided it is safe to begin the process again.

The body normally forms a layer of scar tissue around any artificial material implanted beneath the skin. In most women "the capsule" that forms in response to a breast implant remains thin and pliable. In some patients the capsule is unusually strong and results in a firm breast. The variability in capsule formation is a reflection of each individual's biologic response to an implant. As a result, this factor is both unpredictable and uncontrollable.

Excessive capsule formation can be painful and distort breast shape. This condition, called "capsular contracture", may require surgery to relieve symptoms. Fortunately, severe capsular contracture is rare.

Saline implants, like all man-made devices, wear out eventually, however, the majority last at least five to ten years. When the implant shell fails, the saline fluid is released and is absorbed by the body without harm. This situation becomes obvious because the breast decreases in size over the course of a few days. Replacement requires a short surgical procedure performed on an outpatient basis. It is best if the implant is replaced within seven to ten days of deflation if possible.

Saline implants have some aesthetic limitations compared to the silicone gel implants. In thin patients, rippling of the upper breast skin can occur. This may require adjustment by surgery if the ripples are quite prominent. Sometimes a small fold in the implant cover can be felt through the skin. Although this may be of concern when discovered for the first time, this is harmless and does not require treatment.

Although the implant is a foreign body and is subject to problems that autologous tissue is not, the overwhelming majority of complications are minor and can be resolved in an outpatient setting.

Breast Implant Controversies
Breast implants are thin-walled containers made of hard silicone plastic which are filled with saline. They have been is use for thirty years for reconstruction and augmentation and have an excellent safety record. The old form of silicone gel implant are not widely available anymore due to claims made by the media and legal profession that there are safety concerns. All scientific studies performed recently in this field have shown no association between implants and rare connective tissue disorders such as scleroderma. There has also been no evidence of increased cancer in patients who have implants.

Reconstruction With Body Tissue
A breast can also be created with tissue taken from another part of the body. Breasts reconstructed in this fashion are soft and have a natural shape. It is much easier to match the remaining breast using this technique. Fewer procedures are required to complete the reconstruction when compared to implant techniques except in special cases. The reconstruction is permanent and rarely requires "touch up" procedures later in life. The main disadvantages are that there will be a scar left at the site where the tissue is taken from, that the operation takes a longer time, and that the recovery from the initial procedure is longer. So one must take into account the amount of trips to the office for expansions and the second surgery for exchange of implant, the recovery for tissue flap reconstruction, the scar, the overall aesthetic outcome in making a decision.

The most common areas used to donate tissue for breast reconstruction is the lower abdomen and the back.

Tram Flap Reconstruction
You must have sufficient tissue on the lower abdomen to be a candidate for the TRAM flap. Some women may not be candidates for this procedure based on previous abdominal scars, although, in general a horizontal cesarean scar does not interfere with a TRAM flap. You may have too much tissue on the abdomen to be a candidate as well. Certain pre-existing medical conditions may be a reason to exclude you from being a candidate for a TRAM procedure.

The scar that results when the abdomen is used is similar to a "tummy tuck" incision (horizontal, underneath the navel, near the pubic hair) although it is usually somewhat higher on the abdomen and therefore may be more conspicuous. The contour of the abdomen following TRAM flap is usually improved but the abdomen is never perfectly flat, particularly in those who are significantly overweight to begin with. It must be kept in mind that the primary goal of this procedure is to reconstruct the breast, not tighten the abdomen. Complete recovery from this procedure takes six weeks or more.

The excess skin and fat from the lower abdomen is moved to the chest area by sliding it underneath the upper abdominal skin to reach the mastectomy site. The tissue remains attached to one of the abdominal muscles which is loosened enough to allow the tissue to move upward. The muscles provide blood supply to the skin and fat tissue that will form the breast. There will be a small bulge between the breasts from the displaced muscle that will decrease in size with time.
Use of the muscle can result in abdominal weakness because one of the two abdominal muscles is no longer functional. Use of the entire muscle is also responsible for much of the abdominal discomfort experienced right after surgery.

Women who require reconstruction on both sides (bilateral) are more likely to notice abdominal weakness. It is necessary in these cases to use both muscles to move the lower abdominal fat and skin as two separate pieces. The entire muscle is used on each side. The majority of women have bilateral reconstruction with a TRAM flap report little limitation because of abdominal weakness. Those who are physically active (skiing, horsebackriding) may wish to consider another technique if these activities are very important to them.

A small piece of artificial material (usually Gore-tex) may very rarely be used to strengthen the area in the abdomen where the muscle is taken from. This is well tolerated by the body and does not cause problems once healing is complete. Occasionally, a bulge will develop in the lower abdomen despite taking this precaution. Rarely, additional surgery may be indicated to correct the bulge if it is significant.

Every attempt is made at the time of the TRAM flap reconstruction to finalize the shape of the reconstructed breast, however, due to swelling that develops during surgery it is often not possible to match the volume and shape precisely. It may be necessary to touch up the shape later, either at the time of nipple reconstruction or as a separate procedure. This procedure, called revision of the reconstructed breast, is beneficial from an aesthetic point of view. Like breast reconstruction itself, it is optional.

Some women report pulling sensations in the abdomen, tightness, and numbness of the skin. These symptoms almost always improve with time although it may take six months or longer. Irregularities of the skin and abdominal contour are sometimes evident after surgery.


Additional information about microsurgery

TRAM flaps may be performed with or without microsurgery. When microsurgery is performed it is referred to as a free TRAM. Patients who have a history of smoking, diabetes, or are significantly overweight may be candidates for microsurgery. The decision to use microsurgery requires careful consideration. We will discuss the option of microsurgery at length with you if you are a candidate.


Combination Approach: Latissimus Dorsi Musculocutaneous Flap

This involves a combination of both implant and tissue reconstruction techniques using the latissimus muscle flap from the back. This muscle helps with upper arm motion but is not essential for normal function. Through usually an obliquely oriented back incision of ten to twelve inches, this muscle with its overlying fat and skin can be moved through the armpit to the mastectomy site. Unlike the TRAM flap there is not enough volume of fat available to form a breast mound without the addition of a breast implant.

 
Reconstruction After Radiation
Some women have had radiation therapy prior to reconstruction. The difficulty with reconstruction is due to the detrimental effect that radiation has on the skin circulation. The skin is permanently compromised and breast reconstruction performed in this setting is more prone to wound healing complications.

It is not possible to use tissue expanders to stretch radiated skin. Attempts to do so are associated with a very high failure rate and a very poor aesthetic result. The best option in this case is to bring healthy tissue to the reconstruction site. A TRAM flap is an option for those with appropriate physical characteristics. A free flap is not recommended in the radiated patient due to technical limitations regarding the microsurgery portion of the procedure. The latissimus musculocutaneous flap is the other choice. Like implant reconstruction, a tissue expander is placed at the time of the latissimus flap and the permanent implant is placed later, after the new skin is expanded.


Selection Of a Reconstructive Technique
The best method of reconstruction is influenced by a variety of factors including the size and the degree of ptosis of the breasts, and the amount of tissue available in the abdomen. Either an implant or tissue reconstruction is favored based on these physical characteristics. More patients, for a variety of reasons, are reconstructed with implants. Your preference can be accommodated when more than one method is suitable provided that you have a thorough understanding of the pros and cons of each alternative.

Immediate vs Delayed Reconstruction
Breast reconstruction can begin at the time of mastectomy or any time later. Immediate reconstruction is attractive because it saves one hospitalization, one general anesthetic, and the reconstruction is already underway when the patient wakes up and while the mastectomy wound is healing. The negative impact of mastectomy on body image is less evident when reconstruction is begun immediately.

Immediate breast reconstruction using a tissue expander can be done even if there is a requirement for six months of chemotherapy beginning soon after surgery. Expansion is completed in the office as usual but the next surgery (exchange for a permanent implant, reshaping of the breast, and opposite side adjustment) is delayed until after the chemotherapy is finished. If a tissue reconstruction is performed, the chemotherapy issue is not relevant.

Reconstruction Of the Nipple and Areola
Nipple and areola reconstruction is the final step in the reconstruction process. The nipple is usually made from the skin and fat of the reconstructed breast. The areola is formed with a skin graft.

Nipple and areola reconstruction is performed on an ambulatory basis. Local anesthesia is preferred. There usually is very little discomfort associated with this procedure. The breast must stay dry for ten days after the procedure.

The finishing touch in nipple and areola reconstruction is to establish the appropriate color. This is accomplished by a tattoo technique several months after healing has occurred. Local anesthesia is used. The aftercare following tattoo is minimal. Again, the nipple and areola reconstruction are elective.

Treatment Of the Opposite Breast
In a woman with large breasts, a reduction or lift can be considered in order to match the reconstructed breast. Reductions and lifts add permanent scars. These procedures do not alter ability to detect tumors in the normal breast by mammography.

Some women with smaller breasts that have considerable sagging may require only a lift to improve shape and establish symmetry.

Those who have very small breasts may benefit aesthetically by augmenting the normal breast with an implant and reconstructing the missing breast larger than its original size. Placement of an implant behind the normal breast does not compromise physical examination for breast masses, however, all implants impair mammography to some degree. There are special mammography techniques available to minimize this effect but do not eliminate it. If you are considering this option you should discuss it with your breast surgeon.

 

Complications
Complications are not common in breast reconstruction. Although they may lengthen the treatment period and cause anxiety, they usually do not affect the quality of the final result. They type of complications possible are related to the method of reconstruction used. Many of these problems have already been mentioned.

Implant reconstruction complications include capsular contracture, uneven contour, rippling of the skin, size discrepancy, infection, hematoma, and implant deflation. Tissue expanders are similar to implants and are subject to some of the same problems.

Uncommon problems seen with tissue reconstruction include partial or complete loss of the transferred tissue, delayed wound healing of the reconstructed breast or donor site, seroma, hematoma, infection, and abdominal wall weakness. The weakness may result in a lower abdominal bulge that may require a surgical procedure for correction. Very rarely the navel can be lost if both muscles are needed for TRAM reconstruction.

In some individuals, the scars that result from surgery can be prominent regardless of the method selected for reconstruction.

These potential problems are mentioned not to alarm or frighten you, but to provide you with all the possibilities. Most patients do not have any complications associated with their surgery. We have found that an informed patient is a happy patient.

 

Summary
Breast reconstruction requires more than one operation, regardless of the method used. The first one or two operations create the breast mound and establish symmetry by adjustment of the reconstructed breast, the normal breast, or both. The last step is nipple reconstruction. The breasts are allowed to settle for several months prior to nipple reconstruction so that its position on the breast can be determined accurately.

Each of the separate stages in the reconstruction process requires general anesthesia, except for nipple reconstruction. Not all require an overnight stay in the hospital. The later stages can usually be performed on an outpatient basis. There is considerable flexibility that allows each stage to be scheduled around work and family schedules.

You are considering being treated for the loss of one or both of your breasts by breast reconstruction. This is a quality of life issue. This surgery is elective and you do not need it to live a normal life span. The goal of reconstruction is to restore the size, shape, and appearance of the breast as closely as possible. This will aid in the restoration of body image and make it possible for you to wear virtually all types of clothing with confidence.

Medicine is not an exact science and breast reconstruction, in particular, is as much an art as it is science. There are limitations with all of the currently available techniques. It is rare to be able to produce an exact duplicate of the normal breast. As is common in nature, the two breasts may vary somewhat in size, shape, or position following reconstruction. Surgical scars are permanent and variable in their final appearance. Complications can occur with any type of procedure and may require additional surgery for correction. Despite this the majority of women are quite pleased with their results.
It is important that you are fully informed about the breast reconstruction process. It is unlikely that all of your questions will be answered at the first consultation. You may have additional questions after you have considered the discussion further. We are here to answer any additional questions you may have. Please feel free to call the office.