Breast Reconstruction St. Petersburg
Breast reconstruction is a surgery typically done to recreate a breast after a the breast is removed (mastectomy) which is typically done in patients diagnosed with breast cancer. Breast reconstruction can be implant base, autologous tissue based, or a combination of both. The majority of community based breast reconstructions are implant based while breast reconstructions done in teaching institutions or academic centers may be either implant or autologous tissue based. Implant based reconstructions typically take less than an hour per breast while autologous tissue reconstructions take between 8 and 12 hours.
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. Saline implants feel harder and tend to have more rippling. Rippling occurs when ripples can be seen through the skin from contours of the filled implant.
After 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. 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.
Autologous Tissue Based Reconstruction
Autologous, meaning from self, refers to using tissue from the patient. 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 free flap. A free flap can be done in conjunction with or with silicone implants. Free flaps take 8 to 12 hours but may avoid needing an implant. It’s fraught with technical challenges that lead to the risk of flap failure where the flap needs an emergent revision for lack of blood supply or failure when the flap dies. Free flap surgeries typically require more revision surgeries compared to implant based surgeries. Because free flaps require specialized monitoring equipment and staff to monitor the viability and health of the flap after surgery, they are typically only done in an academic setting and not community hospitals.
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.
Skin Sparing or Nipple Sparing
Two techniques used in mastectomy are skin sparing and nipple sparing. These are important to discuss when discussing breast reconstruction because they impact 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 holiday without a breast implant in that breast. Next, since nipple sparing mastectomy avoids removal of skin, the position of the nipple is fixed and doesn’t have the option being moved to improve cosmesis. If it sags too low before the surgery, it will always be too low. 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.
What to Expect
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 active infection. Immediate reconstruction adds about an hour per breast surgical time above the time required for mastectomy. Cadaver skin is always used in implant base reconstruction to avoid capsule contracture. Drains are placed in each breast to prevent fluid build up and infection. Drains typically come out in 1 to 2 weeks after surgery. If tissue expanders are placed, in office expansion begins 3 weeks after surgery and can take from 1 to 3 months of weekly visits to complete. Once the desired size is achieved, a 4 week rest begins before a short trip to the operating room allows removal of the expander and placement of the permanent implant. 3 to 4 months later, patients can have nipple reconstruction, nipple tattoo, or simply go without nipples. All are viable options.