Breast reconstruction surgery can be as important as the vital component of removing the malignancy. The reconstruction procedure accelerates both the emotional and physical healing process necessary for a complete recovery from the loss of the breast. By recreating the natural contour of the breast through either a prosthesis or use of one’s own body tissue, the staged reconstruction process can literally make the patient look and feel ‘normal’ again.
As stated, each patient has unique characteristics so it is important for her to consult with her team of physicians to formulate a seamless and coordinated game plan of treatment. Physicians typically include her family physician or OB/GYN, general surgeon, plastic/reconstructive surgeon, and oncologist (if chemotherapy and/or radiation are necessary). These physicians will stay in contact with one another to monitor the patient’s progress and needs. It is also important that the patient become quickly educated regarding the journey upon which she is about to embark. A strong system of family and friends is vital to ensure an accelerated recovery period for the breast cancer patient. This team of caregivers will truly make a difference.
Timing of your reconstruction
Timing of one’s initial surgery, again, depends upon the patient’s specific situation. She may begin the reconstruction process at the time of her mastectomy (immediate) or weeks to years later (delayed).
Immediate reconstruction offers the advantage of going ahead with the first stage of reconstruction at the time of the mastectomy, thereby allowing the patient to awaken from the surgery with her ‘first stage’ completed.
Some patients may either need or want to wait, or delay their reconstruction process until other treatments, like radiation or chemotherapy, are completed. This waiting period may also provide the patient with much needed reflection time.
Reconstruction choices
There are two basic approaches to the first stage of breast reconstruction. The chosen approach will depend upon the individual patient’s situation. The new breast will either be created by the use of a prosthesis (breast implant) or the patient’s own tissues (tissue flap). An implant is a fluid-filled breast form, which will be surgically implanted under the chest tissues to create a new breast. A tissue flap is a section of skin, fat and muscle which is removed from either the stomach, back or other area, and transferred to the chest area. It is then shaped into a new breast.
Reconstruction using breast implants
The most common approach used is that of using breast implants. Since 1960, approximately 1-2 million women have used implants either for reconstruction following mastectomy, or for breast size enhancement. Implants offer a shorter recuperative time and cause less trauma and stress to the body as compared to the tissue flap approach. The implant itself consists of a silicone gel shell filled with either silicone gel or saline (salt water). The silicone gel-filled implants are available on a limited basis in the U.S. but saline-filled are available on an unlimited basis. The patient should first become comfortable with the data available regarding the use of silicone materials. Your plastic surgeon will have these educational materials available for study.
Stage One: Tissue Expansion
Because the mastectomy procedure requires the removal of both skin and breast tissue, the remaining chest tissue is left flat and tight. For the patient’s body to be able to accommodate a permanent breast implant of desired size, the placement of a temporary tissue expander must first be employed. This may be done during the immediate reconstruction procedure or later if the patient has delayed reconstruction.
The tissue expander itself is a silicone rubber, balloon-like device inserted into the body deflated. It is then periodically inflated with sterile saline fluid through a filling port. Over time, as the tissue expander begins to stretch, a new breast shaped pocket is created to hold the permanent implant. This periodic expansion process usually begins about three weeks following the initial tissue expander placement and continues for six to ten weeks. The patient usually experiences some pressure and discomfort following the expansion which subsides as her tissue expands.
Stage Two: Breast Implant Placement
The second surgery occurs once the tissue expander has served its purpose of adequately creating the desired breast size and shape to hold a permanent implant. This outpatient procedure includes the removal of the tissue expander and placement of permanent implant. The type of implant used will be evaluated with your plastic surgeon. A variety of sizes, shapes and textures are available to suit specific patient needs.
Stage Three: Nipple Areola Reconstruction
Since the nipple is typically removed during mastectomy to ensure the absence of cancer cells, it too, must be reconstructed. About three to six weeks following the permanent implant placement surgery, this third outpatient surgery is performed. Either a small skin graft or part of the nipple from the opposite breast is used. The areola (dark circle around the nipple) may be reconstructed with a skin graft or by tattooing the area to match the areola of the opposite breast.
Stage Four: Tattooing
The final stage of breast reconstruction involves tattooing the nipple areola to match the opposite side’s natural color. This tattooing procedure is typically done in the plastic surgeon’s office under localized anesthetic.
Reconstruction using tissue flaps
The breast may also be reconstructed by surgically removing a section of skin, fat and muscle from one part of the body and repositioning it to the chest area. This approach is often used when the patient has undergone radiation treatment which has resulted in damaged tissue not suitable for expansion. It is also used when extra tissue coverage is needed over the breast implant. The tissue may be taken from the abdomen, upper back, upper hip or buttocks. The reconstructed breast may then be created from the tissue flap alone or from the flap plus a breast implant.
The tissue flap may either be left attached to the blood supply and moved to the breast area through a tunnel under the skin (a pedicled flap), or it may be removed completely and reattached to the breast area by microsurgical techniques (a free flap).
Either flap technique is considered a major surgery, which requires a multi-day hospital stay. This procedure is more extensive than the mastectomy and requires good health and strong emotional motivation. A patient who is overweight, smokes and has circulatory problems may not be a good candidate for this procedure.
The most common flaps are the TRAM (transverse rectus abdominus myocutaneous) flap, from the abdomen, and the Latissimus dorsi flap, taken from the upper back.
The TRAM flap (pedicle or free) removes a section of tissue from the abdomen and moves it to the chest to reconstruct the breast. It is sometimes referred to as the “tummy tuck” reconstruction since it may leave the stomach area flatter. This procedure takes about six hours and may require a blood transfusion. Hospital stay is two to five days with a six to eight week recuperation period.
The Latissimus dorsi flap makes use of thinner and smaller tissue from the back area. Due to the type of tissue used here, an implant may be used under the flap to provide more volume and shape to the reconstructed breast. This procedure takes two to four hours with a two to three day hospital stay. Recuperation period is two to three weeks.
Once the patient undergoes the flap procedure, she resumes the above mentioned stages of reconstruction (stages three and four).
Other fine tuning
If the patient is addressing reconstruction in only one breast (unilateral), the plastic surgeon may have difficulty in exactly matching the remaining breast. This is especially true if the patient has large breasts or sagging breasts from aging or child bearing.
Oklahoma law ensures the right of breast cancer patients to have symmetrically balanced breasts. This means that, after having undergone reconstruction surgery, the remaining breast may be altered to match the reconstructed side. This creation of symmetry may be accomplished by means of a mastopexy (breast lift), reduction mammaplasty, or augmentation mammaplasty (enlargement).
FAT GRAFTING *
Recently introduced as an effective tool to enhance the visible results of breast reconstruction, a woman’s own fat cells serve as a remarkable resource in reconstructive breast surgery.
*refer to FAT GRAFTING IN COSMETIC & RECONSTRUCTIVE BREAST SURGERY article on Dr. Love’s website for more details.
Conclusion
As earlier noted, the patient’s overall game plan must be charted at the beginning of this reconstruction process to ensure her the best results. Entering into the process can be very frightening for the patient. But, with thoughtful and educated planning, the patient and her support team of physicians, family and friends can move confidently and positively through this rebuilding process. We are very fortunate to have such techniques available to us today from early detection tools like mammograms, to the ability to literally rebuild the human form. A patient should always feel that she can ask as many questions as needed of her physicians. She is playing a major role in her own rebuilding and recovery.
: rebuilding your life following breast cancer