Breast Reconstruction

Why Reconstruct Breasts?

Breast rebuilding is achieved through several plastic surgery techniques that attempt to restore a breast to near normal shape, appearance and size following mastectomy:

Reconstruction of the breast(s) is a physically and emotionally rewarding procedure for a woman who has lost a breast due to cancer or other condition.

The creation of a new breast can dramatically improve your self-image, self-confidence and quality of life. However, it is important to remember that although surgery can give you a relatively natural-looking breast, a reconstructed breast will never look or feel exactly the same as the breast that was removed.

Candidates for Reconstruction

Breast reconstruction is a highly individualized procedure. You should do it for yourself, not to fulfill someone else’s desires or to try to fit any sort of ideal image.

All patients with breast cancer should be informed about the options involving rebuilding of the breast. Your Breast Surgeon, Oncologist, and Plastic Surgeon will work together do decide if you are a good candidate for reconstruction.

Generally speaking, you are a good candidate for reconstruction if:

  1. You do not have any medical conditions that would impair would healing
  2. You have realistic goals and expectations in regards to the results of your reconstructed breast

Consultation with Your Reconstructive Surgeon

During your initial consultation with your reconstructive plastic surgeon, you will be asked numerous questions about your health, diagnosis, lifestyle, and desires.

Having breast(s) rebuilt is highly variable and individualized to each patient.
Factors that will need to be considered in deciding which reconstruction option works best for you include:

  • Size and shape of your breasts
  • Unilateral or bilateral reconstruction
  • Need to perform lift or reduction on healthy side for symmetry
  • Need for radiation
  • Need for chemotherapy
  • Your body size
  • Lifestyle
  • Medical conditions
  • Prior surgeries

Once all of these factors have been reviewed, your reconstructive surgeon will discuss the different options of breast reforming and timing of the procedure.

Preparing for surgery

Before undergoing surgery, you may be asked to:

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

Special instructions you receive will cover:

  • What to do on the day of surgery and where to go
  • The use of anesthesia during your proper reformation of the breast
  • Post-operative care and follow-up

If your breast reforming is performed on an outpatient basis, be sure to arrange for someone to drive you to and from surgery and to stay with you for at least the first night following surgery.

Reconstruction Options

During your initial consultation with the plastic surgeon, you will be informed of the different options of reconstructing your breast. The two main types of reconstruction are either implant based reconstruction or autologous based reconstruction (ie: Flap).

Implant Based Reconstruction

Implant-based reconstruction is a popular procedure that provides adequate cosmetic outcome without having to use tissue from another part of the body. Implant based reconstruction is most often a staged procedure, the first stage with be the placement of a tissue expander at the time of the mastectomy and the second stage will be the exchange of the expander for a permanent implant.

In some cases the implant can be placed directly at the time of the surgery which is called “single staged direct implant”  This option will be decided between you and your surgeon before the mastectomy to determine if you are a good candidate for this type of reconstruction.

Staged Reconstruction with Tissue expanders

Following mastectomy, your reconstructive surgeon will insert a tissue expander in a pocket formed under the muscle and remaining skin on your chest wall. The expansion process will take place at your plastic surgeons office. More saline solution is gradually added to the tissue expander during outpatient clinic visits, stretching the muscle and skin to the desired size. Often the skin is stretched slightly more than needed because it has a natural tendency to shrink when the tissue expander is removed.

The amount of saline needed for each expansion may vary depending on the tightness of the skin. The number of expansions required depends on how much fluid was placed at the time initial placement of the tissue expander and the quality of the skin. Through the use of AlloDerm® as part of the breast formation process, our surgeons can frequently place a larger volume of saline during the initial expander placement. This in turn may affect the total duration of treatment, as the less the expander needs to be adjusted, the less time may be required to reach the fully expanded volume. The entire process usually takes 2-3 months, but may take longer if you need other cancer treatments, such as chemotherapy or radiation.

Once the "pocket" has reached the desired size, the expander is left in place, stretching your skin for approximately 3 to 5 weeks more. Surgery is then scheduled to remove the tissue expander and replace it with a permanent implant, which is an outpatient surgical procedure. The permanent implant will either be filled with saline or silicone and will be much softer than the tissue expander. Your reconstructive surgeon can discuss the various types of available breast implants. This two-stage approach is currently the most common method of implant based reconstruction.

Single Staged Direct Implant

Single staged direct implant approach allows the possibility of placing a breast implant immediately at the time of the mastectomy. In most cases, this direct-to-implant approach requires the use of a dermal matrix such as AlloDerm®, allowing immediate results in a potentially single-stage. Our practice is among the few practices in South Florida that offer single staged direct implant reconstruction.

Patients who have adequate breast skin remaining following mastectomy may be candidates for direct-to-implant breast  reformation. The determining factor for who is a good candidate for single stage is whether the remaining skin, typically in conjunction with the use of a dermal matrix such as AlloDerm®, can accommodate the volume of the breast implant. For patients that are good candidates, single staged direct implant reconstruction allows our surgeons to place a breast implant immediately, avoiding the use of a tissue expander. This “single stage” approach can potentially allow patients to awaken from their mastectomy with a well-defined breast shape.

In the single staged direct implant reconstruction, the implant is placed behind the pectoralis major muscle immediately after mastectomy. To provide additional soft tissue support and to prevent the implant from bottoming out over time, AlloDerm® is secured to the chest wall along the lower and outer folds of the breast. Over a period of several months, the breast implant will settle into place and at that point the reconstruction is complete. If the patient decides that she would like to further change or improve her reconstructed breast shape, secondary procedures may still be desired to improve symmetry, breast size or breast contour. Also, unless the initial mastectomy was done using a nipple-sparing approach, most women will proceed with reconstruction of the nipple areola.

Advantages of Implant Reconstruction

  • Decreased length of surgery and down time
  • No scars on other parts of body
  • Satisfactory shape in clothing

Disadvantages of Implant Reconstruction

  • Will require frequent office visits for the tissue expansion process
  • Most often a two-staged procedure: tissue expander followed by exchange for permanent implant
  • Hard to achieve nipple projection with nipple reconstruction, due to thinner skin
  • Difficult to achieve symmetrical shape with the natural breast
  • May need to replace or revise implants down  the road
  • For unilateral reconstructed breasts, the implant alone will not create a natural droopy appearing breast and may appear fuller in the upper half compared with a natural breast.

Latissimus Dorsi Flap

The Latissimus Dorsi flap is harvested from the upper middle back using a horizontal incision that often can be hidden in the area behind the bra strap. The LD flap which is composed of a paddle of skin, soft tissue and muscle is elevated and brought around to the chest wall to reconstruct the breast. The thoracodorsal artery is the main source of blood supply for the LD flap, and these vessels are left attached. Although the LD muscle is removed and transferred to the chest, there are generally minimal if any significant physical limitations after this procedure.

In select patients, the LD flap can provide sufficient tissue for a small breast rebuilding without having to place an underlying implant. In most women undergoing LD flap reconstruction, a breast implant or tissue expander is placed under the flap in order to provide sufficient volume. Breast restoration with an LD flap can be done at the same time as the mastectomy or as a delayed procedure after the patient has healed already healed from the mastectomy. This flap sometimes is termed the “Lifeboat” flap which can be used to salvage a previously failed breast repair in cases of implant loss due to infection or radiation. 

Advantages of LD flap reconstruction

  • Decreased length of surgery and down time compared with abdominal tissue transfer
  • Natural looking and natural feeling breast
  • Excellent flap for salvage of faiiled breast alteration

Disadvantages of LD flap recontruction

  • Most often not enough volume to reconstruct an entire breast
  • Most often a two-staged procedure: latissimus flap with tissue expander followed by exchange for permanent implant
  • If performed with implants, may need to replace or revise implants down  the road
  • Patients who are very athletic may notice some weakness in shoulder extension and adduction

Autologous Tissue Reconstruction

The main alternative to implant-based reconstruction is using your own tissue to reconstruct the breast. Autologous reconstruction (sometimes called autogenous reconstruction) uses tissue -- skin, fat, and sometimes muscle -- from another place on your body to form a breast shape. The tissue (called a "flap") usually comes from the belly, the back, the inner thighs, or the buttocks to create the reconstructed breast. The most common donor site for this tissue is the abdomen, but there are several other choices.  

Breast repair using tissue from someplace else on your body is popular because it usually lasts a lifetime. Implants normally have to be replaced after 10 or 20 years. Also, the tissue on your belly, buttocks, and upper inner thighs is very similar to breast tissue, makes a good substitute, and feels very natural. But as with implant reconstruction, the new breast will have little, if any, sensation.

The use of abdominal tissue for reforming is named the Transverse Rectus Abdominis Myocutaneous (TRAM) flap. Originally, this tissue was used as a pedicled flap (pTRAM). This means that the blood vessels that supply the abdominal tissue are not separated from the body. Rather, the tissue stays connected and is moved to the chest through a tunnel underneath the skin. This method is the most common form of autologous reconstruction. Risks of this procedure include bulging of the abdomen, hernia, and fat necrosis of the flap (firm areas in the breast).

An alternative to a pedicled TRAM is a free TRAM (fTRAM). In this procedure, the same abdominal tissue is utilized as the pTRAM; however, the skin, fat, blood vessels, and possibly a small piece of abdominal muscle are completely removed from the body. The blood vessels are then reattached to blood vessels in the chest, and the skin and fat is used to reconstruct the breast mound. The benefits of a fTRAM over a pTRAM include a more robust blood supply, less donor site morbidity of the abdomen, and potentially a better aesthetic outcome.

To decrease the risk of bulge, hernia, or abdominal weakness following breast shape alteration, the Deep Inferior Epigastric artery Perforator (DIEP) flap was developed. This flap also uses the tissue of the lower abdomen, but it does not use any of the abdominal wall muscles. We aim to perform a DIEP flap when ever possible, but cannot promise that all the muscle will be spared. If muscle is harvested, it is usually only the size of a postage stamp. The decision of a fTRAM versus a DIEP flap can only be made in the operating room based on an individual patient’s anatomy.

Advantages of Autologous Reconstruction

  • Reconstructed breast will feel more natural
  • Better symmetry with other healthy breast
  • No risks associated with implants
  • Easier to achieve better nipple reconstruction
  • Better option in the setting of radiation

Disadvantages of Autologous Reconstruction

  • Longer operation
  • Longer recovery
  • Need for scar on other part of body
Things to know about autologous reconstruction:

The physical effects of each type of autologous reconstruction are highly individual to your body, your range of motion, your physical strength, and your normal day-to-day activities.

  • Remember that while you’re healing from surgery, there will be at least two areas of the body that are healing at the same time – your reconstructed breast(s) and the donor tissue site(s), depending on whether one or both breasts are being reconstructed at the same time. Some women may also have a sentinel node biopsy or axillary node dissection at the same time, which means an additional incision.
  • If you gain or lose weight, the size of an autologous tissue reconstruction can change along with the rest of your body.
  • Autologous reconstructions tolerate radiation therapy better than implants alone do. If radiation is part of your treatment plan, make sure to discuss this with your plastic surgeon.

As in all procedures, autologous reforming has its advantages and disadvantages. Advantages include the fact that it is your own tissue, and therefore, the risk of infection is much less than implant reconstruction. Because it is your own tissue, it does not deflate and does not need to be replaced in the future. Finally, your abdomen will be flatter, similar to a “tummy tuck.” 

The disadvantages and risks of autologous tissue reconstruction are that the procedure is longer. Surgery for a unilateral (one-sided) reconstruction is four to six hours (including the mastectomy). A bilateral (both sides) reconstruction can take seven to ten hours. Since the tissues used to reconstruct the breast need blood flow to survive, there is always the risk that there could be a problem with this blood flow. 

If this occurs, it requires a return visit to the operating room to evaluate the flap and attempt to salvage it and to provide a successful breast reforming. While the risk is low (approximately 1 to 4 percent), there is always the possibility that partial or total flap failure will occur. There will be scars on your abdomen as well as your breast(s), and there is the risk of a bulge or hernia on the abdomen. Is it important to remember that reconstruction is a process and is rarely completed in one operation. Typically, four months after the initial operation, revisions are performed to improve the contour of the reconstructed breast.

If only one breast was treated, the other breast may need a lift, reduction, or augmentation to improve the balance and appearance between both breasts. In addition, nipple areolar reconstruction may be performed if the nipple was removed at the time of mastectomy.

Reconstruction Recovery Time

Following your surgery for flap techniques and/or the insertion of an implant, gauze or bandages will be applied to your incisions.

An elastic bandage or support bra will minimize swelling and support the reconstructed breast. A small, thin tube may be temporarily placed under the skin to drain any excess blood or fluid.

A pain pump may also be used to reduce the need for narcotics. You will be given specific instructions that may include: How to care for your surgical site(s) following surgery, medications to apply or take orally to aid healing and reduce the risk of infection, specific concerns to look for at the surgical site or in your general health, and when to follow up with your plastic surgeon.
Be sure to ask your plastic surgeon specific questions about what you can expect during your individual recovery period.

  • Where will I be taken after my surgery is complete?
  • What medication will I be given or prescribed after surgery?
  • Will I have dressings/bandages after surgery?
  • When will they be removed?
  • Will there be drains? For how long?
  • When can I bathe or shower?
  • When can I resume normal activity and exercise?
  • When do I return for follow-up care?

Healing will continue for several weeks as swelling decreases and breast shape and position improve. Continue to follow your plastic surgeon’s instructions and attend follow-up visits as scheduled.

Results and outlook

The final results of reconstruction surgery following mastectomy can help lessen the physical and emotional impact of mastectomy. Over time, some breast sensation may return, and scar lines will improve, although they’ll never disappear completely. There are trade-offs, but most women feel these are small compared to the large improvement in their quality of life and the ability to look and feel whole. Careful monitoring of breast health through self-exam, mammography and other diagnostic techniques is essential to your long-term health.