Breast Reconstruction

The goal of breast reconstruction is to restore one or both breasts to near normal shape, appearance, symmetry and size following mastectomy, lumpectomy or congenital deformities. Breast reconstruction can be performed immediately after mastectomy (immediate reconstruction) or be delayed until a later date (delayed reconstruction). Breast reconstruction generally falls into two categories: implant-based reconstruction or flap reconstruction. Implant reconstruction relies on tissue expanders and/or implants to help form a new breast mound. Flap (or autologous) reconstruction uses the patient’s own tissue from another part of the body to form a new breast. If only one breast is affected, it alone may be reconstructed. In addition, a breast lift, breast reduction or breast augmentation may be recommended for the opposite breast to improve symmetry of the size, shape and position of both breasts.

Breast reconstruction is a highly individualized procedure.  There are a number of factors that should be taken into consideration when choosing which option is best:

• Type of mastectomy: Includes a lumpectomy (partial mastectomy) simple (total) mastectomy, or modified radical mastectomy. A skin sparing mastectomy removes the nipple areolar complex while preserving the breast skin. A nipple sparing mastectomy preserves both the breast skin and nipple areola complex. Your breast surgeon or plastic surgeon will be able to provide you further details.
• Cancer treatments: These include local treatments (radiation) or systemic treatments (chemotherapy, hormone therapy).
• Patient factors: Reconstructive options are influenced by the patient’s health status (smoking status, diabetes, etc), starting breast size and shape, and body habitus.

It is important to have realistic expectations of what breast reconstruction can achieve. A reconstructed breast will not have the same sensation or feel the same as your breasts before reconstruction. An important goal is to minimize the incisions, however, visible incision lines will always be present on the breast, whether from reconstruction or mastectomy. Certain surgical techniques will leave incision lines at the donor site (area where tissue is taken from).

There are many different reconstruction techniques available, including implant reconstruction, flap reconstruction, or a combination of implant and flap reconstruction. In general, implant reconstruction will create a more round and ‘implant-like’ breast, because the breast shape and size depends on the implant that is placed.  Implant-based breast reconstruction may be possible if the mastectomy or radiation therapy has left sufficient tissue of good quality on the chest wall to cover and support a breast implant. For patients with insufficient tissue on the chest wall, radiation changes, or for those who don’t desire implants, breast reconstruction may require a flap reconstruction (also known as autologous reconstruction). Flap surgery creates a breast that is shaped by your tissue (skin, fat, muscle) and the size of the reconstructed breast(s) will depend on the patient’s body habitus. The most common method of tissue reconstruction uses lower abdominal skin and fat to create a breast shape. Another common method uses the back skin, fat and muscle to replace damaged radiated skin/muscle and also uses an implant to provide more breast volume.

One-stage breast reconstruction with implants can only be performed at the same time as the mastectomy.  An implant is placed either on top (pre-pectoral reconstruction) or under the pectoralis muscle. Acellular dermal matrix (ADM) is used as an internal sling to support and cover some of the implant. ADM is a type of surgical mesh that is developed from human skin, in which the cells are removed and the support structure is left in place.   Drains will be placed at the time of surgery and will be removed anywhere from 1-2 weeks after surgery.

With pre-pectoral implant reconstruction, an implant covered with ADM is placed on top of the muscle. Benefits include a faster recovedrey time because the muscle in the chest has not been elevated. The breast implant itself is not influenced by the contraction of the muscle (animation deformity).  Complications, while rare, may include skin loss, excess bleeding, infection, malposition of the implant so that asymmetry occurs, wrinkling or rippling of the implant, possible fluid collection underneath the implant and/or unfavorable scarring. This procedure may also require secondary autologous fat transfer to eliminate upper pole wrinkling and rippling over time, which will occur over secondary procedures.

Sub-pectoral implant reconstruction is performed by elevating the chest muscle. Acellular dermal matrix (ADM) is placed at the bottom of the breast or inframammary crease and along the bottom edge of the chest muscle. The breast implant will then be placed under the ADM and your own muscle. Benefits of this technique is that the muscle that covers the implant will provide an additional layer of coverage, compared to a pre-pectoral technique, which may help decrease upper pole wrinkling. Complications, while rare, may include skin loss, excess bleeding, infection, malposition of the breast implant so that asymmetry occurs, wrinkling or rippling of the implant, possible fluid collection underneath the implant and/or prosthesis deflation.

This surgery involves a first surgery that places a temporary implant under the pectoralis muscle called a tissue expander.  Salt water is placed into the tissue expander during surgery to partially inflate it. Additional tissue expansion then occurs weekly in the office. The volume of the final tissue expanders depends on the patient’s preference for size, as well as the capacity of the tissue expander. Once the final tissue expansion is complete, there will be a time of passive expansion where little to no volume is added to the tissue expander in order to allow for muscle and skin to stretch and relax. The length of time will vary from patient to patient, but is around 3-6 months, depending if radiation is needed. Once this is completed, a second outpatient procedure will remove the tissue expander and place the permanent breast prosthesis. Complications, while rare, may include skin loss, exposure of the expander, excess bleeding, infection, malposition of the implant so that asymmetry occurs, wrinkling or rippling of the implant, possible fluid collection underneath the implant, pain at the injection site, muscle spasms with expansion and/or unfavorable scarring.

The surgical process for saline breast tissue expanders and breast expanders following mastectomy are the same. Expanders with saline have been used for decades but recently, a new type of expander using air, which allows for more patient control, have been introduced. Expanders have some of the same complication rates and risks as the other types of breast reconstruction, which include infection, seroma, hematoma, extrusion and/or expander deflation.

The expander is placed into a submuscular or subcutaneous space with no external filling ability. The expander will fill with compressed air contained within the expander itself. The patient will do self-controlled expander fills utilizing an external automatic activation device at home and will achieve similar results to the standard saline filled tissue expansion devices. It will be necessary to monitor the incisions and progress on your own and contact the physician if you feel there is something wrong. The advantage of the expander it that it may decrease doctor visits and decrease total expansion time.

Breast Reconstruction Surgery is generally performed as an outpatient procedure and you will be able to go home after the procedure to relax and recover. In general, most women recover well over the first week, and we provide you with all the medication and supplies to help you through this process. When thinking about time off work, or away from social commitments, 2 weeks can be a safer window of down time. Heavy lifting and strenuous exercise should be avoided for 4 weeks. Dr. Ho will see you in the office over the recovery period to review all of the important information with you and ensure you are doing well.