Dr. Hainer will perform a detailed examination and discuss with you the various options available taking into consideration your individual case, expectations, and desires.
The removal of one or both breasts due to breast cancer or other disease is not only a physical loss but also a severe emotional one. A woman’s self-esteem, her sense of self, and her femininity are also lost. Reconstruction of the breast replaces not just the breast but everything else as well.
In many cases those feelings of loss can be avoided entirely by reconstructing the breast at the same time as the mastectomy itself. The patient is thereby spared the emotional upheaval of losing a breast, and instead awakens after her mastectomy with a newly created breast mound. It is not surprising therefore that breast reconstruction is one of the most rewarding of all plastic surgical procedures.
Post-mastectomy reconstruction is not a simple procedure. However, there are often many options to consider and the specific surgical technique depends on a myriad of factors.
Breast augmentation will not only bring you greater freedom with fashion, but will also improve your self-image and make you feel better about yourself. For many women, along with a new figure comes a new attitude and enhanced self-confidence.
As recently as 25 years ago, a woman who had a mastectomy had few options if she desired breast restoration. Today, with the development and refinement in surgical techniques to satisfy the requests of women seeking breast restoration, the results of reconstructive surgery have improved dramatically. The focus now is on breast preservation and avoidance of a mastectomy deformity. Historically, breast restoration has relied on the use of tissue expanders and breast implants, and this technique is still a part of the reconstructive armamentarium. Breasts can also be rebuilt using the patient’s own tissues whereby flaps of muscle and skin obtained from the abdomen, back, hips, or buttocks can be transferred to the chest to recreate the breast. The optimal timing of breast reconstruction is also a consideration whether immediate (at the same time as the mastectomy) or delayed. The particular approach must be selected with the individual woman’s needs and her specific cancer treatment in mind.
Implant Reconstruction: This technique is the simplest form of breast reconstruction available. Typically a tissue expander is placed below the pectoralis muscle of the chest wall and over the course of several weeks to months, is slowly filled or expanded with saline. Once the appropriate volume is attained, the expander is replaced during a second surgical procedure with a permanent breast implant, typically a silicone-filled implant.
If a skin-sparing mastectomy is utilized, often a permanent implant can be placed immediately following the mastectomy, avoiding the expander-implant exchange procedure. Tissue expanders and breast implants are available in several styles and shapes and can be either saline or silicone filled. Dr. Hainer will discuss the various options and issues regarding implant reconstruction during the initial consultation.
Tissue Flap Reconstruction: The use of flaps of muscle or skin and muscle to supplement the tissue remaining after a mastectomy represents a major advance in breast reconstruction. With the newest flap techniques, most women’s breasts can now be rebuilt with their own tissue and usually without a breast implant. Furthermore, because the donor sites are often areas of tissue excess such as the lower abdomen, patients can expect a full and natural breast that closely resembles the size and shape of their opposite breast. The two most common sources of tissue for breast reconstruction with the patient’s own tissue (autologous) are the lower abdominal wall and the back.
TRAM Flap: The transverse rectus abdominis musculocutaneous (TRAM) flap uses an island of skin and muscle from the lower abdomen to reconstruct the breast. Not only does this reconstruct the breast with soft, pliable tissue that acts and feels like native breast tissue, but the patient also receives a “tummy-tuck” as a bonus. TRAM flap reconstruction is major surgery and usually takes 3-6hrs in the operating room under general anesthesia. A hospital stay of 3-4 days post-operatively is also required. Usually 3 months after the TRAM flap procedure, a separate procedure restores the nipple-areolar complex under local or intravenous sedation anesthesia. Tattooing of the nipple and areola are performed as a last step to match the other breast.
Latissimus Dorsi (Back) Flap: A latissimus flap is most often used when the patient does not want a TRAM flap, or a TRAM flap cannot be performed or is too risky. With this procedure, skin and muscle or sometimes only muscle is transferred from a woman’s back around to the breast area to replace the skin and breast tissue removed during the mastectomy or partial mastectomy. The flap can also be used to cover an implant or expander and provide healthy tissue to the mastectomy site. The latissimus dorsi flap takes between 2-4hrs to perform, is done under general anesthesia and requires 2-4 days of hospitalization. As with all other reconstructive procedures, nipple reconstruction and tattooing is also required as the last phase.
TIMING OF BREAST RECONSTRUCTION
Before the decision for breast reconstruction can be made, the foremost consideration of the general surgeon and the patient is the proper management of the breast cancer. No aspect of treatment should be compromised. The choice between immediate reconstruction or a delayed procedure several months later must be made before her breast cancer treatment becomes even more complex. Fortunately, with the increased emphasis on informed consent, many women learn of the option of reconstruction from their general surgeons well before they have their cancer surgery and have the opportunity to contact a plastic surgeon to discuss reconstructive surgery as a component of the total treatment plan. The entire process becomes a close interplay between the patient, her general surgeon and the plastic surgeon. Such cooperation had led to major advances in technique and to more attractive reconstructed breasts usually with less scarring.
When presented with the options, most patients opt for immediate reconstruction to avoid experiencing breast loss and the pain and added time and cost of yet another major surgical procedure. Immediate reconstruction not only has many positive psychological benefits, but also provides for a quicker resolution of the mastectomy deformity and reduces the number of operations needed and the overall duration of hospitalization. Ultimately, the patient can resume her normal activities earlier and return to her routine activities of living.
AESTHETIC ISSUES: THE OTHER BREAST
Sometimes the size and shape of the remaining breast cannot be duplicated exactly with any technique. In these instances, when symmetry is difficult to attain, the patient may opt to consider additional surgery to achieve breasts that more closely resemble each other. These procedures may include breast reduction, breast lift, or even on occasionally breast enlargement.
In October of 1998, the federal government passed The Federal Breast Reconstruction Law that mandates insurance coverage for breast reconstruction procedures. The law covers not only the reconstruction of the diseased breast but also procedures necessary on the other breast to achieve symmetry. This mandate now entitles any woman to pursue breast reconstruction without the financial burdens.
The topic of breast cancer and breast reconstruction is a complex one. To help our patients, we provide on loan an excellent reference text entitled A Woman’s Decision: Breast Care, Treatment & Reconstruction (Quality Medical Home Health Library) by Karen Berger and, John Bostwick. Further information regarding breast reconstruction can be found in the LINKS section of this website.