42 yo F who underwent bilateral nipple-sparing mastectomies with immediate breast reconstruction with placement of tissue expanders and acellular dernal matrix placement. Subsequently, she underwent exchange with placement of Mentor smooth round high profile 375 cc silicone implants.
46 yo F who underwent right-sided nipple mastectomy with immediate breast reconstruction with placement of a tissue expander and acellular dermal matrix. She subsequent right sided expander implant exchange with placement of Mentor high profile smooth silicone 500cc with symmetrization augmentation on the left.
35 yo F who had underwent a right-sided mastectomy with immediate breast reconstruction with placement of a tissue expander. She underwent radiation therapy. Unfortunately, she developed severe radiation changes with capsular contracture. I removed the expander and performed a TRAM flap bringing healthy tissue to the right breast and achieving a pleasant shape and symmetry.
65 yo F who underwent bilateral nipple-sparing mastectomies with immediate two-stage implant-based reconstruction. Her final implants were Mentor silicone high profile smooth 275 cc implants.
58 yo F who underwent bilateral nipple-sparing mastectomies with immediate two-stage implant-based reconstruction. Her final implants were Mentor silicone high profile smooth 350 cc implants.
59 yo F who had a diagnosis of left breast cancer. She wished to undergo breast conservation therapy with lumpectomy and radiation. Her postoperative picture shows her after undergoing bilateral breast reductions and left breast radiation therapy.
51 yo F who had a history of recurrent left breast cancer with a history of lumpectomy and radiation. As a result, she required autologous tissue transfer in the form a latissimus skin and muscle flap with implant placement on the left and expander-implant reconstruction on the right.
78 yo F who had undergone prior breast reconstruction presented wishing to undergo revisional breast surgery with replacement of the bilateral implants and a right-sided breast lift. She had undergone a prior left-sided mastectomy with implant reconstruction and right-sided breast augmentation in order to achieve symmetry. These can be quite challenging as different sized implants were used to acheive symmetry.
Breast Reconstruction Options
Breast reconstruction restores and at times, improves the overall shape and volume of the breast after mastectomy, allowing to retain the natural feminine silhouette of the chest. Breast reconstruction can occur on an immediate basis (at the time of mastectomy) or in a delayed fashion (preferred in a patient at high risk for complications such as smokers). Below are the four main options for breast reconstruction which serve as a general overview. Our consultation is tailored to your particular goals and expectations which will include a detailed discussion that takes into account your overall health, anatomy, and history of prior breast surgery and treatment, if applicable. Our discussion is highly personalized and I make every effort to provide an environment that is conducive to questions in a comfortable and approachable fashion.
Below are links for additional resources that encompass various aspects of breast cancer including treatment, surgical options and reconstruction:
- The most common form of reconstruction.
- Relative shorter recovery period.
- Avoid additional donor scarring and morbidity.
- Disadvantages include increased complication rate in patients with diabetes and history of breast radiation.
- Implant related issues include infection, capsular contracture (tightening of scar
tissue around the implant) and leak.
Reconstruction may involve direct to implant (single-stage) or a two-stage technique. The decision is predicated on multiple factors including breast size and assessment of risk factors.
Combination of Autologous and Implant Based
- Tissue from your abdomen or the back is used to reconstruct the breast.
- In most cases, avoids the necessity of using an expander or implant.
- Preferred type of reconstruction when there is a history of irradiation of the breast.
- Disadvantages include a longer recovery period, additional scarring, longer surgery and requires hospitalization.
- Most cases involve using the latissimus dorsi muscle from the back and transferred to the breast. An island of skin is also brought with the muscle. A tissue expander and an implant are used for reconstruction due to the lack of sufficient volume.
- In situations when there is a lack of abdominal tissue, this is the preferred flap.
- Recommended for the reconstruction of irradiated breasts.
The most common donor site is the abdomen. There are two techniques that are utilized specifically the TRAM (transverse rectus abdominis mucocutaneous) flap or the DIEP (deep inferior epigastric perforator) flap. The latter usually requires a surgeon with fellowship training in microsurgery. The main advantage of a free flap reconstruction such as the DIEP flap, is preservation of the rectus abdominis or six pack muscle. The blood vessels are disconnected from the abdomen and connected to the chest vessels, as seen below (right).
The latissimus muscle flap is supplied by blood vessels in the axilla (arm pit) which are left connected to the muscle as a pedicled flap.
The skin island is used is to bring healthy vascularized muscle and skin tissue that allows for the expansion of the reconstructed breast.
A tissue expander is used and placed over the pectoralis major muscle. The latissiums muscle is placed over the expander.
Hospital stay may range from 2 to 7 days
with a recovery period of approximately
6 to 8 weeks. Drains are placed in the
breast and the back and usually are
removed within 2 to 3 weeks.
Risks include flap necrosis, seroma (fluid) accumulation, shoulder weakness, and capsular contracture. Physical therapy may be ordered in order to improve muscle and shoulder recovery.
While recovery time can be quite significant in the short term, in the long term, satisfaction can be quite high, especially in patients who have had breast radiation. Patients with a history of breast radiation are at an increased risk for implant-related complications, therefore well-vascularized healthy tissue is needed with the expander in order to mitigate the risks associated with implant-based reconstruction alone.
The TRAM flap technique keeps the blood vessels connected and sacrifices the rectus muscle in order to preserve the blood supply to the flap.
This type of reconstruction is most commonly employed in settings such as a community hospital. As resources for microsurgical reconstruction may not be readily available.
Tissue based breast reconstruction specific complications include flap necrosis or failure and donor site complications.
Hospital stay may range from 4 to 7 days with a recovery period of approximately 6 to 8 weeks. An abdominal binder is used during the postoperative period. Drains are placed in the breast and the abdomen and usually are removed within 2 to 3 weeks.
While recovery time can be quite significant in the short term, in the long term, satisfaction can be quite high, especially in patients who have had breast radiation. Patients with a history of breast radiation are at an increased risk for implant-related complications, therefore tissue-based reconstruction is recommended.
In the two-stage approach, the tissue expander, as seen above, is placed under or above the pectoralis muscle (prepectoral). Cadaveric skin is used to wrap or secure the expander under the muscle. As seen below, a prepectoral reconstruction with coverage of an expander with the cadaveric skin is demonstrated.
Over several weeks, the expander is
slowly filled with saline until the final desired volume is reached. Approximately six weeks after the final expansion (six months if treated with radiation), the exchange is performed with the placement of the final implant.
Recovery after the initial surgery is approximately 4-6 weeks. Drains are placed and usually removed between 2 to 3 weeks after surgery.
Oncoplastic Breast Reconstruction
- The concept of oncoplastic breast reconstruction is to reshape the breast after lumpectomy that would otherwise cause a significant deformity if this technique is not employed. On the left diagram, the various techniques of soft tissue rearrangement are demonstrated.
- Candidates are patients with large breasts and with tumors that do not encompass a large portion of the breast.
- Symmetry is achieved with contralateral reduction and/or lift.
- Recovery is almost identical to a breast reduction with a return to regular activities between 4 to 6 weeks.
- Most patients take 1 to 2 weeks off of work.
- Recovery is similar to breast reduction surgery.
- Approximately 6 weeks after surgery, radiation therapy, if indicated, is initiated.