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Breast Reconstruction
GOALS OF RECONSTRUCTION
In order to start thinking about what kind of reconstruction is the right choice for you, you need to understand what it is we as reconstructive surgeons are trying to do. First, skin is either recreated through expansion or replaced from another body donor site. Secondly, breast volume is restored either through the use of an implant, your own tissue or a combination of the two.
Another way to start thinking about your options is to consider prioritizing your goals. Some types of reconstructions may look symmetric in clothing, but do not have the look and feel of the opposite breast without this camouflage. Other types will have the look and feel, while others also will even tend to age symmetrically with the opposite breast.
TIMING
There are several things to remember. First, not choosing breast reconstruction at the time of mastectomy does not preclude you from having reconstruction at a later date though it will require an extra trip to the operating room. By the same token, breast reconstruction done now does not preclude further or different reconstructions chosen down the road.
NON-OPERATIVE OPTION
Please forgive me, but I must speak frankly and clinically in order to best inform you. I would encourage you to think for the future and determine your priorities regarding recreating the illusion of your breast. I see women coming back for delayed reconstruction (having had a mastectomy sometime prior) who complain they feel out of balance or that they are tired of always wearing a prosthesis, which appear to have certain limitations and annoyances that accompany them. Granted, I only see the delayed reconstruction patients who are dissatisfied with prosthesis, and there may be certainly many women that are quite satisfied whom I will never see.
IMPLANTS
Some patients desire only to rid themselves of the need for prosthesis and wish only to look and feel symmetric while in clothing. For this type of patient, an implant-only type of reconstruction may suffice. For those desiring a breast that looks symmetric while without clothing, may also choose nipple reconstruction. The saline implants that we have been using, unfortunately, do not feel or move like a natural breast. The new “low bleed” silicone implants have become increasingly popular for breast reconstruction and breast augmentation. These appear to be safer than older silicone implants and also move and feel more like natural breast tissue. A significant advantage to implant reconstruction is that these can be placed with no additional time in the hospital and at a minimal surgical risk.
AUTOLOGOUS RECONSTRUCTION (using your own tissue)
For women who desire the illusion of a breast that both looks symmetric without clothing and feels, moves and ages naturally, may choose to use their own tissue – usually from their abdomen or back area. This type of reconstruction requires one to four extra days in the hospital as well as a much longer surgical procedure. There are risks to this surgery, and not everyone is a candidate. An advantage to this approach is that it better avoids the need for future implant replacements as the implant life span is typically around ten years, and it provides a breast that tends to age more naturally with the opposite breast.
TUMMY TUCK RECONSTRUCTION
At Bangor Plastic and Hand Surgery, we offer a reconstruction from the abdomen that you may have heard about called the DIEP flap or “perforator” flap in which all the core muscled is spared and only tummy tuck tissue is used. This allows a quicker recovery than the traditional TRAM or muscle-sparing TRAM and may well protect against future hernia development. This operation is especially applicable for those that need both breasts reconstructed and have an adequate donor site. Bangor Plastic and Hand Surgery is the only practice north of Dana -Farber Cancer Institute that is performing this, which is important to know when working with insurance companies.
LATISSIMUS WITH IMMEDIATE NIPPLE RECONSTRUCTION
Another technique that works well for bilateral reconstructions is the Latissimus flap taken from the back. This is usually done with expanders and/or implants as the back does not usually carry enough fatty tissue to recreate the breast volume desired. An advantage of this choice at Bangor Plastic & Hand Surgery is the addition of immediate nipple reconstruction as the thickness and pliability of back skin lends itself to reliable and ample nipple recreation. When skin sparing mastectomy is an option patients wake with what appears to be breasts, though smaller, but with some volume and nipples already in place.
THE OPPOSITE BREAST
Breast lift, breast reduction and possibly breast augmentation to the opposite breast for the sake of symmetry is always an option and covered by insurance. Nipple reconstruction and nipple tattooing are chosen by many, but are not priorities to others. These two procedures are usually done last, completing the process which usually takes on the order of two to six months depending upon the type of reconstruction chosen.
UNSURE?
For patients that are unsure, often the best course of action is to have an expander placed at the time of the mastectomy to “hold the space” and prevent some of the scar formation. This does not require any longer stay in the hospital and allows you to have more time to recover emotionally and to decide if implant or your tissue is the most appropriate choice for permanent replacement. This is often the best choice if you are anxious to have your cancer surgery done and over as soon as possible.
I would now encourage you to look through this pamphlet put out by the American Society of Plastic Surgery Educational Foundation, which may help some of your questions. I fully expect you to have many that are unanswered or that require clarification. I really hope this information is of benefit to you. I am quite sure this process and appointment is something that you would have never chosen to have or that you might even dread, but my staff and I will work to make the experience as painless and dignified as possible.
We are anxious to meet you and develop a relationship and rapport that we share with so many other breast cancer patients. You may have spoken with Alicia, my receptionist, Danielle, my insurance coordinator, and our clinical coordinator, Jill - all of whom you will soon meet.
At this time we do not participate with insurance and ask that you contact your primary care physician for an out of network referral. Out of network benefits should be easily obtained, especially for reconstruction techniques not available elsewhere like the tummy tuck reconstruction (DIEP flap) or the Latissimus flap with immediate nipple reconstruction.
Please feel free to contact us should you have any issues regarding your appointment, and I will be anxious to hear if this information was of help to you.
FREQUENTLY ASKED QUESTIONS
How does/would the need for radiation affect my options?
Implants usually do not do well with radiation. Radiation is done best before transfer of tissue as the radiation can often cause shrinkage and hardening of the transferred tissue.
Why don’t you just place the implant and use an expander?
Usually the remaining breast skin needs time to heal without the volume (and pressure) of the fully reconstructed breast. Also it allows tailoring of the breast to the desired breast volume.
How long between expander placement and implant exchange?
Usually 3-6 months.
How does using my Latissimus muscle affect the use of my upper body?
Typically functional impairment is minimal unless you are a competitive swimmer, climber or paddler.
How does a skin sparing mastectomy (removal of only the nipple, areola, and breast mound) affect my options?
When biopsies are done with a needle or through an incision around the areola, or there is no invasive cancer, a skin sparing mastectomy is often performed. In this case the Latissimus with immediate nipple reconstruction or tummy tissue (DIEP flap) can be done limiting the scars to the hidden position around the areola. These techniques often give the best results without the horizontal scar needed (when a skin-sparing technique cannot /is not used) to close over an expander when no tissue is added to replace the nipple and areola.
How long does it take to get surgery scheduled?
For expander placements surgery is usually scheduled within two weeks from consultation. When using your own tissue two to four weeks are usually needed to coordinate a longer surgical day with your breast cancer surgeon.
