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After breast cancer with a biopsy or mastectomy, some women may wish to have breast reconstruction to restore the natural breast mound. The procedure can be performed at the same time as a mastectomy, or later on.
What is Breast Reconstruction?
Breast reconstruction is a surgical procedure typically done to recreate the breast mound after it is removed (mastectomy) which is typically done in patients diagnosed with breast cancer. Breast reconstruction can be implant based, autologous tissue based, or a combination of both. The reconstructive technique that is right for you will depend on a number of factors including your body type, how much of the breast was removed, skin elasticity, and your personal goals for the procedure. Your options will be gone over in more detail during your initial consultation with Dr. Newman.
Who is a Good Candidate for Breast Reconstruction?
Candidates for breast reconstruction are those that wish to restore the natural appearance of the breast after biopsy or mastectomy. The breast reconstruction procedure can help patients feel whole again and cope with the emotional stress of breast cancer. Those with enough remaining breast tissue and good skin elasticity might be good for breast reconstruction with implants. However, those with not enough breast tissue or skin elasticity to support an implant can still benefit from reconstruction using their own tissue-based reconstruction.
The Breast Reconstruction Procedure
Breast reconstruction can be done at the time of mastectomy (immediate reconstruction) or done at a later date (delayed reconstruction). There is no benefit to delaying reconstruction unless the tissues are ischemic at the time of mastectomy or there is an active infection. Immediate reconstruction adds about an hour per breast surgical time above the time required for mastectomy. Your breast reconstruction procedure will involve one of the following techniques:
Implant Based Reconstruction
Implant based breast reconstruction involves placing a silicone implant in the location where the breast was originally located. Typically, the implant is silicone-filled, because skin flaps are thin after mastectomy and silicone feels more natural than saline while reducing the chances of rippling.
After a mastectomy, there is often a deficiency of skin to cover an implant, and a tissue expander will have to be placed. Tissue expanders are silicone implants that are empty but can be expanded gradually by injecting saline into the tissue expander in the office. This is done in preparation for a second surgery where the tissue expander is removed, and the permanent larger silicone implant is placed. The expansion is a painless process that takes between one and three months depending on the desired size.
In breast reconstruction, implants can be placed under the pectoralis chest muscle (submuscular) or on top of the pectoralis chest muscle (prepectoral). Until recently, most implant-based reconstructions were done using a submuscular technique. Many reconstructions are still done this way, but prepectoral breast reconstruction is a new technique offered by Dr. Newman. Prepectoral breast reconstruction is preferred by Dr. Newman when there is a possibility that the patient will be treated with radiation. Radiation causes muscle contraction and fibrosis which distorts and displaces an implant if the implant is under the muscle. By placing the implant on top of the muscle, the fibrosis and muscle contracture that occurs does not affect the implant and leads to a better cosmetic result. Prepectoral reconstruction eliminates animation deformity and typically causes less pain. Animation deformity is when an implant jumps from a contracting pectoralis muscle during daily activities. The reduction in pain is due to the fact that the muscle is not being stretched by an implant. Prepectoral breast reconstructions are more likely to need an additional surgery for fat grafting the upper pole of the breast to smooth the transition of chest to implant creating a more natural look. Implant based reconstructions typically take less than an hour per breast.
Autologous Tissue Based Reconstruction
Autologous, meaning from self, refers to using the patient’s own tissue. In autologous based reconstruction, tissue can be taken from the back, abdomen, or elsewhere and moved to the breast. Autologous reconstruction can be done without cutting the blood supply to tissue or by cutting the blood supply to tissue and reconnecting it to a new blood supply using microvascular techniques. When the blood supply to the tissue is not cut, it’s called a pedicled flap. When the blood supply to the tissue is cut and is connected to a new blood supply, the technique is called free tissue transfer or a free flap. A free flap can be done in conjunction with or without silicone implants.
Dr. Newman reserves autologous pedicled flap reconstruction for patients that smoke cigarettes or use nicotine or have had previous radiation that has damaged the tissue. Radiated tissue does not handle well or heal well. By providing non-radiated tissue to the area needing reconstruction, healing is improved.
I couldn’t say enough wonderful things about my experience with Dr. Newman and his staff. I am a breast cancer reconstruction patient and from my first consultation, he made me feel like I was in the best of hands. He put my mind at ease, was incredibly knowledgeable and spent a ton of time with me answering all of the questions that I had. I knew immediately that I wanted to be in his care. My surgeries went without a hitch and I am very pleased with my results. It is clear that he truly cares about his patients. I would highly recommend Dr. Newman to anyone looking for the best of care. – Elisa L.
Skin Sparing or Nipple Sparing
Two techniques used in mastectomy are skin sparing and nipple sparing. These are important to discuss when it comes to the reconstructive process. Skin sparing mastectomy involves removing the nipple and areola complex (NAC) and the least amount of skin with the breast tissue. The nipple is removed because breast tissue converges and enters the nipple which is a site for potential future breast cancer.
Nipple sparing mastectomy involves making an incision through which the breast is removed without removing the NAC. Without further consideration, nipple sparing would no doubt be choice of all women. But there are a few things that must be considered. First, the larger the breast, the greater the risk of ischemia (lacking in blood supply) because blood must travel through thin skin flaps after mastectomy. The larger the breast, the longer the distance blood travels through the thin flaps. So, large C and D cup breasts are at higher risk for nipple necrosis with nipple sparing mastectomy. Nipple necrosis can lead to infection of an implant which is a devastating ordeal requiring a 6-month period without a breast implant in that breast. Next, since nipple sparing mastectomy avoids removal of the skin. The position of the nipple is fixed and doesn’t have the option of being moved to improve cosmesis. Lastly, saving the NAC does confer a slight increase in risk for future breast cancer because the nipple has breast tissue in it. While mastectomy surgeons attempt to check for cancer by biopsying the nipple at the time of surgery, the biopsy is a random biopsy and does not guarantee no cancer exists.
Downtime and Recovery
The recovery process after breast reconstruction will vary depending on the techniques used. Flap reconstruction recovery can be slightly more challenging because two surgical sites will need to heal. After surgery, drains are placed in each breast to prevent fluid buildup and infection. Drains typically come out in 1 to 2 weeks after surgery. Patients can expect several weeks of activity restrictions including no lifting the arms over the head, lifting heavy objects, and other more strenuous exercise. The majority of swelling after breast reconstruction will begin to subside after the first month, however, some swelling can still linger for many more months. After three-four months, patients can consider nipple reconstruction or nipple tattooing if they wish.
To learn more about your breast reconstruction options, contact our office and schedule your consultation with board certified surgeon, Dr. Newman.
