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Breast Reconstruction Breast surgery


Breast Reconstruction Breast surgery

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									                                       Breast Reconstruction
What is Breast Reconstruction?
Breast reconstruction is plastic surgery done to create a breast after mastectomy. It is used to restore a positive body
image and allow you to look and feel as comfortable as possible. New medical techniques have made it possible for
surgeons to create a breast that comes close in shape and appearance to a natural breast. There are different methods
used for breast reconstruction surgery. Reconstruction can be done at the same time as the mastectomy or later.

Breast reconstruction is a process that involves several surgeries and may produce some temporary physical
discomfort such as pain, swelling, and numbness. The decision to have breast reconstruction is a personal one, and at
first these decisions may seem overwhelming. This handout, along with your plastic surgeon’s advice, can help you
decide which option is best for you. The handout will give you a basic understanding of the procedures available,
how they are done and what results you can expect.

Will you be able to have Breast Reconstruction?
The decision to have breast reconstruction or not is made by the patient following consultation with the surgical
oncologist and plastic surgeon. The following factors influence the decision:
           • tumor size
           • tumor location
           • breast size
           • body fat distribution
           • medical history (diabetes, high blood pressure, obesity, smoking)

Timing of Surgery
When should your breast reconstruction be performed? Breast reconstruction can be done at the same time as
mastectomy (immediate reconstruction) or on a delayed schedule, weeks or even years following the surgery. The
best timing depends on many things: the patient’s wishes, the stage of breast cancer, medical history, social and
emotional factors, and the need for post-operative radiation.

Advantages of Immediate Reconstruction
One possible advantage of immediate reconstruction is that women who have this procedure may suffer less stress
and may feel less disfigured when waking up after their mastectomy.

And, when reconstruction is performed during the same surgery as the mastectomy, the cancer surgeon and the
plastic surgeon can work together to produce the best possible result.

Disadvantages of Immediate Reconstruction
There are many good reasons to wait. Many women feel overwhelmed by their cancer diagnosis, and trying to decide
if and when to have reconstruction adds to this. Others do not want to have any more surgery than is absolutely
necessary. Still others may have medical reasons to wait. Some patients may be advised by their surgeon to wait if
they have a very aggressive cancer because they may need to start radiation therapy as soon as possible. Women with
health problems such as high blood pressure, obesity, or smoking may also be advised to wait.

Radiation Affects All Types of Reconstruction
More women with breast cancer are now being treated with post-operative radiation. Radiation has strong effects on
skin and underlying tissue which can affect the reconstruction. It can cause scarring and fibrosis of the surrounding
tissues. This affects all types of reconstruction.

Overview of Surgical Options
In general, the breast can be made from either autologous tissue (your own tissue) or an implant. With autologous
reconstruction the breast is made from areas of the patient’s body where there is “excess” tissue such as the abdomen,
the back, the buttocks or even the thigh. The tissue is then moved to the mastectomy area and shaped to form a new

Another option is to create a breast by using a saline (salt water) filled implant. This is done in 2 stages. First a tissue
expander (a balloon-like device) is placed under the skin flaps from the mastectomy. The expander is then slowly
filled with saline through an injection port under the skin. Your plastic surgeon will determine how often the saline
will be added, usually between 2 to 4 times a month for about 3 or 4 months. The expander grows with the injections
and increases the size of the skin envelope that can contain a permanent breast implant.

Types of Implants
A breast implant is a silicone shell filled with either silicone gel or saline. Silicone-filled implants are only available
to women who are participating in approved studies. If you are getting implants your doctor will recommend which
type of implant should be used.

Reconstruction with Tissue Expanders and Implants
This is the most common technique of breast reconstruction. Following the mastectomy, the plastic surgeon inserts a
tissue expander under the skin and chest muscle. A valve in the expander allows the surgeon or nurse to inject a
saline solution and slowly fill the expander over a time period of weeks to months. After the skin over the breast has
been fully stretched to allow for placement of the permanent breast implant, the expander is removed and a second
surgery is done to place a permanent implant. This is called an implant exchange.

In rare cases a woman will not require skin expansion. In these cases the implant can be placed at the time of the
mastectomy and left in place as the final implant. Following expansion, the nipple and the areola (the darker area
around the nipple) can be reconstructed.

The ideal patient for tissue expander reconstruction is a thin woman with very little sagging of the other breast who
will not require postoperative radiation therapy. A history of radiation therapy to the breast can make tissue
expansion an unwise choice, since irradiated skin and muscle may not allow for enough expansion.

Reconstruction with Your Own Tissue (Autologous Tissue)
Breast reconstruction with your own tissues is an excellent option for women who wish to avoid the use of implants.
A number of possible donor sites are available for breast reconstruction. These donor sites include the abdomen, the
buttock area, the thigh and the back.

In general, these procedures are more complicated than breast reconstruction with tissue expanders and implants.
Once completed, however, this type of reconstruction makes you feel more natural and tends to require less upkeep
as you age.

Transverse Rectus Abdominus Myocutaneous (TRAM) Flap surgery is an operation where excess skin and
fat around the abdomen is used to reconstruct the missing breast. This tissue is moved based on blood vessels
that run through the rectus abdominus muscle (the “six pack” muscles on the front of the abdomen).

TRAM flaps can be performed right away or many years after the mastectomy. 2 basic methods are used to
perform the TRAM flap:

    •   Pedicled TRAM flap reconstruction

         The TRAM flap is kept attached to the rectus muscle and tunneled under the skin of the upper
        abdomen into the breast. The blood vessels therefore remain attached at all times.

    •   Free TRAM flap reconstruction

        The tissue is removed and brought up to the breast, where the artery and the vein need to be
        reconnected using microsurgery. The TRAM flap is usually connected to the blood vessels under the
        arm. Sometimes it is not possible to use the vessels under the arm. In those cases, vessels under the
        sternum are used instead to reconnect the TRAM flap.

TRAM flaps can be used to reconstruct both breasts if necessary. After surgery the breast feels much more
like the remaining natural breast, and the abdomen will be much slimmer and flatter (as in a tummy tuck).
However, there are scars on the abdomen and the recovery period is longer. Most patients recover from a
TRAM flap operation in 4-6 weeks.

Small revisions to the TRAM flap will usually be needed to create a better match with the remaining natural
breast as well as to create a nipple and areola. These revisions are usually performed 3 months after the first

Other Flaps
In some cases a woman does not have enough extra fat and tissue on her abdomen. In these cases tissue can
be used from other parts of the body. Your plastic surgeon can talk about these options with you during your

Reconstruction with your own tissue and implants
Sometimes a combination of techniques is needed for reconstruction. This usually happens when the patient
has already had radiation treatment. In these cases an expander and implants are generally not a good choice
because the scarring will likely prevent a visually pleasing result. In such cases and others, an implant, along
with back muscle and skin (the latissimus dorsi) can be used to complete the breast. Reconstruction will be
performed as a pedicled flap and the circulation is therefore maintained intact.

                        Implant and Tissue Reconstruction Techniques Comparison

Concerns                             Implant/Expander                    Tissue Reconstruction
Surgery (numbers)                    2-3 operations                      2 operations
General anesthesia                   Yes                                 Yes
Hospitalization                      2-3 days                            4-6 days
Recovery period                      2-3 weeks                           4-6 weeks
Office visits post-op                Multiple for expansion              Few
Scars                                Mastectomy scar only                Mastectomy and donor site scar
Appearance                           No natural sag, may be firm         Natural shape and soft to touch
Opposite breast                      More changes usually needed         Fewer changes usually needed
Problems                             • Breast can become hard            • Abdominal weakness
                                     • Infection                         • Partial flap loss
                                     • Does not sag with aging           • Longer operative time
                                                                         • Not recommended in obese

Nipple and Areola Reconstruction
After the breast mound is made, many women choose to have the nipple and the areola reconstructed at a later
date. This can be done as early as three months after the first surgery or years later. Usually it will be
performed after any adjunctive treatment (chemotherapy or radiation) is finished. There are many techniques
available for nipple reconstruction. Most involve using local breast tissue to create a small mound about the
same size as the other nipple. An areola can be created using a tattoo treatment to dye the skin, or by
performing a skin graft. This procedure takes approximately 1 hour and can usually be done with local
anesthesia. The tattoo treatment is very quick and is usually done as an office procedure. The skin graft,
however, has better texture match to the other breast’s areola than the tattoo.

Breast Reconstruction is an excellent choice for most women who undergo mastectomy. A consultation with
a plastic surgeon will help you decide which option is best for you.



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