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Breast Reconstruction
Common Questions
When can reconstruction be done?
Breast reconstruction is commonly performed at the time of the mastectomy or delayed and is possibly before adjuvant
therapy (such as chemotherapy or radiation) is completed. In certain circumstances, particularly when the tumor is small
and the patient has small breasts, a reconstructive procedure can possibly be carried out at the same time as a mastectomy
(called immediate reconstruction). There are several different types of very successful breast reconstruction techniques
which are based on:
- The amount of skin and nipple tissue needed to be replaced.
- The requirements to match the opposite breast as closely as possible. When an opposing breast is either droopy, too
large or of a less-than-pleasing shape, reconstructive procedures may involve reduction, uplifting or even enlargement in
order to improve the size, shape and symmetry of the final reconstruction. Often times biopsies of the opposite breast
can be incorporated to ascertain the health and risk factors of the opposite breast at the same time.
Although all the necessary steps (i.e., replacing volume, increasing the amount of skin, reconstructing the nipple-areolar
complex and, if necessary, performing sizing and reshaping of the opposite breast) would be ideally performed simultaneously,
most frequently these require "staged" operations. These can be performed in anywhere from one to several stages in order
to obtain an optimum result, improve the safety margin and "tailor" the result to one's individual case. Much as a dressmaker
may need a few fittings or stages to obtain the optimum result, a plastic surgeon may need more than one operation to obtain
the desired result. Consultation, examination and complete explanation would verify the needs of your own particular case.
What type of Implants are Available?
- Single lumen gel: This is an implant in which silastic gel, very much the consistency of jelly, is contained within
a very soft Silicone envelope. These are the oldest type of breast implants and, under certain circumstances, continue to
be used today.
- Saline-inflatable implant: This has a similar soft outer plastic covering and is filled with saline (saltwater is
similar to your body fluid).
- Textured implants: These are implants with a rough covering. Research has shown the body decreases scar tissue formation
around these types of implants. These include silicone and saline. These implants have been available for just a few years.
Their long term scar-decreasing efficiency has not been proven to date.
- Expander implants: These implants are usually placed on a temporary basis to help expand skin. These are placed at the
time of surgery and then removed and replaced with a permanent implant. There are permanent varieties which can be expanded
and left in place. Because of the valvular mechanism, these have not had a long term trial to date.
What are the types of reconstructive procedures available? From simple to complex:
- Insertion of gel implant— If the breasts are relatively small and no additional skin needs to be added,
an implant can frequently be placed under a muscle and add the necessary volume to reconstruct and match the opposite breast.
If there is some expected change, the nipple reconstrucion is usually done between two to twelve weeks after the operation.
- Expansion— If additional skin is needed to reconstruct the breast and match the opposite side, then an expansion breast
prosthesis may be placed at the time of surgery. During the operation, over a course of 20 minutes, "additional skin" is
made available through modern stretching of the skin, or, if more additional skin is needed the expander is left in place.
Once a week for a period of anywhere from four to twelve weeks, a serial expansion is then performed. A small valve is
located under the skin and, under local anesthesia, if needed, a balloon expander is inflated progressively in order to
stretch and obtain the necessary quantity of skin. After the expander process is completed, this "sets" for a period of
an additional one to four weeks, and then the expanders are replaced with permanent implants.
- Latissimus Dorsi Flap— A football-shaped area of skin, along with its underlying latissimus dorsi muscle, is moved
from the back like the pendulum of a clock to reconstruct the breast. This tissue actually replaces the skin and breast tissue
removed during the original mastectomy. The back incision is then closed and the resultant scar usually falls along the bra line.
The skin and muscle are then used to reconstruct the breast. This is particularly useful where the mastectomy site is quite
tight and the first two options above would not work well, or the opposite breast is full and enlarged and more skin and tissue
are needed to obtain symmetry can be obtained. A modification of the latissimus dorsi flap may be that of solely using the
underlying muscle for volume or using local skin and possibly muscle from under or to the side of the breast. This is not
as successful as the latissimus dorsi flap, but can be used for minor modifications. This operation is usually associated
with an implant.
- Transverse Rectus Abdominus Flap Reconstruction (Tram-Flap): This entails a more complicated operation by which the abdominal
skin and muscle are used to reconstruct the breast. Usually an implant is not needed. This is very similar to an extended tummy
tuck operation, but is usually reserved for cases where a complicated reconstructive procedure is necessary.
- Microvascular Tissue Transfer: In this procedure tissue from other parts of the body such as the buttock or groin area is
taken and by means of microscopically attaching blood vessels, new tissue is added to the breast. This is usually isolated to
very complicated procedures where the other simpler steps are not feasible or successful.
Where are the procedures done?
The first stage of breast reconstruction usually takes place in the hospital. Depending on the nature of the operation and
recovery, the hospital stay may be from same-day surgery to a one week hospitalization. Subsequent stages depend on the particular
case recovery, safety factors and the duration of the healing process, but frequently are done outpatient.
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