Breast Reconstruction

Breast Reconstruction

Breast reconstruction often involves multiple procedures performed in stages and can either begin at the time of mastectomy or be delayed until a later date.

Breast reconstruction generally falls into two categories: implant-based reconstruction or flap reconstruction. Implant reconstruction relies on breast implants to help form a new breast mound. Flap (or autologous) reconstruction uses the patient's own tissue from another part of the body to form a new breast.

There are a number of factors that should be taken into consideration when choosing which option is best:

  • Type of mastectomy
  • Cancer treatments
  • Patient's body type

A note about symmetry

If only one breast is affected, it alone may be reconstructed. In addition, a breast lift, breast reduction or breast augmentation may be recommended for the opposite breast to improve symmetry of the size, shape and position of both breasts.


Case Study

In preparing for breast reconstruction surgery, you may be asked to:

  • Get lab testing or a medical evaluation
  • Take certain medications or adjust your current medications
  • Stop smoking
  • Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they can increase bleeding

Breast reconstruction surgery is typically performed in a hospital setting, may include a short hospital stay and will likely use general anesthesia. Some follow-up procedures may be performed on an outpatient basis and local anesthesia with sedation may be used.

These decisions will be based on the requirements of your specific procedure and in consideration of your preferences and your doctor’s best judgment.

Step 1 – Anesthesia

Medications are administered for your comfort during the surgical procedure. The choices include intravenous sedation and general anesthesia. Your doctor will recommend the best choice for you.

Step 2 – Flap techniques reposition a woman's own tissue to create or cover the breast mound

Sometimes a mastectomy or radiation therapy will leave insufficient tissue on the chest wall to cover and support a breast implant. In these cases, breast reconstruction usually requires either a flap technique or tissue expansion.

TRAM flap uses donor muscle, fat and skin from a woman's lower abdomen to reconstruct the breast. The flap may either remain attached to the original blood supply and be tunneled up through the chest wall, or be completely detached, and formed into a breast mound.

Alternatively, your surgeon may choose the DIEP flap or SIEA flap techniques, which do not use abdominal muscle but transfer only skin and fat to the chest from the abdomen. If there is insufficient tissue on the lower abdomen, other donor sites such as the buttocks or thighs may be selected (SGAP flapTUG flapPAP flap).

latissimus dorsi flap uses muscle, fat and skin from the back tunneled to the mastectomy site and remains attached to its donor site, leaving blood supply intact.

Occasionally, the flap can reconstruct a complete breast mound, but often the latissimus flap provides the muscle and tissue necessary to cover and support a breast implant.

Step 3 – Tissue expansion stretches healthy skin to provide coverage for a breast implant

For women who do not require breast radiation and would like to avoid a separate donor site, implant-based reconstruction is an option. Reconstruction with tissue expansion allows an easier recovery than flap procedures, but it can be more lengthy reconstruction process.

It usually requires several office visits over 1-2 months after placement of the expander to gradually fill the device with saline through an internal valve to expand the skin. Newer air-filled devices may allow patient-controlled expansion at home using a remote dosage controller.

A second surgical procedure will be needed to replace the expander if it is not designed to serve as a permanent implant.

Placement of a Breast ImplantStep 4 – Surgical placement of a breast implant creates a breast mound

A breast implant can be an addition or alternative to flap techniques. Surgeons may also use an implant as a temporary placeholder during other breast cancer treatments until you are ready for more involved flap reconstruction techniques. Saline and silicone implants are available for reconstruction.

Your surgeon will help you decide what is best for you. Reconstruction with an implant alone usually requires tissue expansion. Direct-to-implant breast reconstruction may be an option for some women undergoing mastectomy with certain tumor characteristics and breast shapes.

Step 5 – Reconstructing a nipple and areola, breast revision techniques

For women who are not candidates for nipple-sparing mastectomy, breast reconstruction is completed through a variety of techniques that reconstruct the nipple and areola. Techniques usually involve folding skin to create the shape of a nipple followed by tattooing. Three-dimensional nipple-areolar tattooing may be used alone to create the appearance of a realistic nipple with the illusion of projection. Breast reconstruction outcomes can often be enhanced with staged revision procedures that improve symmetry, use liposuction with fat grafting and improve the appearance of the donor site.

Specialist

During your breast reconstruction consultation, be prepared to discuss:

  • Your surgical goals
  • Medical conditions, drug allergies and medical treatments
  • Current medications, vitamins, herbal supplements, alcohol, tobacco and drug use
  • Previous surgeries

Your plastic surgeon will also:

  • Evaluate your general health status and any pre-existing health conditions or risk factors
  • Examine your breasts and take measurements of their size and shape, skin quality and placement of nipples and areolae
  • Take photographs
  • Discuss your options and recommend a course of treatment
  • Discuss likely outcomes of breast reconstruction and any risks or potential complications

Be sure to ask your plastic surgeon questions. It's very important to understand all aspects of your breast reconstruction. To help, we have prepared a checklist of questions to ask your breast reconstruction surgeonthat you can take with you to your consultation.

It's natural to feel some anxiety, whether it's excitement for your anticipated new look or a bit of preoperative stress. Don't be shy about discussing these feelings with your plastic surgeon.

Disclaimer

The decision to have breast reconstruction surgery is extremely personal. You'll have to decide if the benefits will achieve your goals and if the risks and potential complications are acceptable.

Your plastic surgeon and/or staff will explain in detail the risks associated with surgery. You will be asked to sign consent forms to ensure that you fully understand the procedures you will undergo and any risks or potential complications. The decision to pursue breast reconstruction does not change your risk of breast cancer recurrence.

The possible risks of breast reconstruction include, but are not limited to, bleeding, infection, poor healing of incisions and anesthesia risks. You should also know that:

  • Flap surgery includes the risk of partial or complete loss of the flap and a loss of sensation at both the donor and reconstruction site.
  • The use of implants carries the risk of breast firmness (capsular contracture) and implant rupture.

Breast implants do not impair breast health. Careful review of scientific research conducted by independent groups such as the Institute of Medicine has found no proven link between breast implants and autoimmune or other systemic diseases.

 Information on Breast Implant-Associated ALCL

Visit breastimplantsafety.org for current information.

Where will my surgery be performed?

Surgery for your breast reconstruction is most often performed in a hospital setting, possibly including a short hospital stay, and your doctor will likely use general anesthesia. Some follow-up procedures may be performed on an outpatient basis, and local anesthesia with sedation may be used. These decisions will be based on the requirements of your specific procedure and in consideration of your preferences and your doctor's best judgment.

Frequently Asked Questions About This Procedure

What is the difference between immediate and delayed reconstruction?
Many patients prefer to have reconstruction done (or at least the process started) at the same time as their mastectomy. Breast reconstruction performed at the same time as your mastectomy is called immediate reconstruction. Delayed reconstruction is a term used if you choose to have the mastectomy done and then wait to have the reconstruction at a later date. 

The majority of the surgeries done at Albany Medical Center are immediate reconstruction. With immediate reconstruction, you are decreasing the overall number of surgeries you may need. You have a better chance at an optimal cosmetic result. For many women, there is a psychological benefit to immediately pursuing reconstruction.


Are all women candidates for immediate breast reconstruction? 
The vast majority of women are candidates for reconstruction. There are a variety of reconstructive options and you may not be a candidate for all types. You and your plastic surgeon will discuss which type of breast reconstruction is best for you.


What are the major types of reconstruction available?
There are three types of breast reconstruction. The first is tissue expander reconstruction, also known as implant reconstruction. The second is autologous tissue reconstruction, also known as free flap reconstruction which is a procedure where your plastic surgeon uses your own tissues, typically from the abdomen but can also come from your buttocks and thighs. The third is a combination of the two methods, using your own tissue from the back, latissimus muscle, plus a tissue expander/ implant underneath.

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