Breast Reconstruction Sacramento
Breast reconstruction is available to any woman undergoing treatment for breast cancer. Most commonly, it is performed after a mastectomy (complete removal of the breast). But sometimes reconstruction can be performed as part of a lumpectomy procedure (removal of only the cancerous tissue of the breast).
Reconstruction can be performed at the same time as the cancer treatment (immediate reconstruction), or after the patient has recovered from the cancer surgery (delayed reconstruction).
After a diagnosis of breast cancer, most women want to have the cancer removed as quickly as possible. Fortunately, breast cancer tends to be very slow-growing, so most women have time to consider their options. Women should listen carefully to their surgeon regarding options for lumpectomy or mastectomy, and make decisions based on what feels best and provides the best chance at cure. All women have the option of consulting with a plastic surgeon prior to the cancer surgery in order to understand what the reconstructive opportunities are as well.
After the mastectomy is performed, the plastic surgeon will initiate the reconstruction. This can involve various choices, depending on the anatomy of the patient and her desires.
Placement of a tissue expander: If the patient has relatively small breasts, or if the amount of skin to be removed in the mastectomy is significant, then a tissue expander allows the plastic surgeon to create a appropriately-sized skin envelope for the ultimate permanent implant. Tissue expansion does not just stretch the skin. The pressure created by the expander actually causes new skin to grow, much like your belly grows when you are pregnant. Tissue expanders are deflated balloons, with a built-in port. The expander is placed under the remaining breast skin (usually under the pectoral muscle as well). It may remain empty at first (if the skin envelope is tight) or filled with a small amount of saline solution. The mastectomy incision is then closed.
After the wound has healed a bit, additional saline is added to the expander during visits to the plastic surgeon’s office. The amount of saline added depends on the anatomy and comfort level of the patient. Saline is usually added weekly until the volume is such that the skin envelope is adequate and the patient’s ultimate size is deemed satisfactory.
A second surgery is then performed to remove the tissue expander and replace it with a permanent breast implant. The final implant can be filled with either silicone or saline. Silicone implants tend to feel a bit more natural, since silicone feels more like not-quite-set gelatin. Saline, being water with salt, is a bit firmer, more “feel-able” and wrinklier. Once the implant is in place, nipple reconstruction may be done as well.
The placement of the tissue expander at the time of the mastectomy adds about one hour to the procedure. Most patients stay overnight in the hospital, and go home the next day. There is usually a drain in place, which draws out any weeping blood or lymph fluid. This drain is removed when the fluid volume diminishes, usually in just a few days but up to 4 weeks later.
The second surgery, usually performed about 3-4 months later, is done on an outpatient basis. The recuperation is relatively easy, as the exchange process is fairly simple. Drains are usually not necessary. The reconstructed nipple is protected by a bandage that is changed daily for about two weeks. After the reconstruction is completed, the patient is followed annually to check the implant, touch up the nipple color, evaluate symmetry, etc.
Some women choose to have a bilateral mastectomy. If that is the case, then the same procedure is performed on the opposite breast. There is usually good symmetry between the two sides, although both reconstructed breasts have less feeling than before (the sensory nerves are removed with the mastectomy).
Additional procedures may be necessary over time, if there is a problem with the implant, if the aging process changes the overlying skin significantly, or if the nipple reconstruction flattens out over time.
Some women choose to keep the opposite breast. In some cases, women have an opposite breast which is fairly easy to match. Some women, however, have an opposite breast which is either too big, too small, or too droopy. In that case, surgery may be recommended for the opposite breast to improve its size or shape, in order to achieve better symmetry. Opposite breast surgery for symmetry is a mandated benefit of health insurance plans. If opposite breast surgery is performed at the time the tissue expander is exchanged, there will be some discomfort on that breast for a few days. Recuperation usually requires 2-3 weeks.
Some women have breast anatomy that allows the permanent implant to be placed at the same time as the mastectomy. This technique usually requires the use of acellular dermal matrix, human dermal skin scaffolding. This product allows the surgeon to enlarge the subpectoral muscle pocket so that it can immediately accept an appropriately-sized implant. This technique usually adds about 1 ½ hours to the mastectomy procedure, overnight hospitalization, and 2-4 weeks recuperation.
Nipple reconstruction is then performed 2-3 months later, once the implant reconstruction has had a chance to settle. If only the nipple reconstruction is necessary, this can often be performed in the plastic surgeon’s office with local anesthesia. If opposite breast surgery is necessary, nipple reconstruction may be performed at the same time, under sedation or general anesthesia, in an operating room.
A projecting nipple and the surrounding colored areola are made by creating small flaps of skin, sewing the flaps together to make the nipple, and coloring the area with tattoo. This takes about 30 minutes to perform. Sutures are in place for 1-2 weeks. These nipples do tend to flatten over time, and the tattoo tends to fade, so the nipple/areolar reconstruction may need to be “touched up” over time. This is usually a fairly simple procedure.
What about chemotherapy?
If a woman requires chemotherapy after her mastectomy, then the reconstructive process needs to be tailored to suit those needs. Sometimes the expansion visits have to be delayed, so the expansion may take a bit longer. The exchange surgery has to wait until the chemotherapy is completed, so the patient may have the expander in place for a few months longer. This is usually not a problem.
What about radiation therapy?
Some women are also recommended to have radiation treatment to the breast area. Radiation is usually performed once the chemotherapy is completed. Radiation usually requires 5-6 weeks of treatments. I recommend women take a leukotriene inhibitor medication while undergoing radiation, to try and mitigate the risk of developing a tight scar around the tissue expander or implant. After radiation is completed, my patients will have in-office cold laser treatments weekly for about 4 weeks, again to reduce inflammation and speed healing of the radiated skin. Once the radiation is completed, most plastic surgeons recommend waiting at least 4-6 months before performing the exchange procedure. Radiated skin is damaged, and the risks of wound healing difficulties, infection, and poor scarring are higher.
Some women prefer to use their own tissue to recreate the breast. Sometimes if the cancer is easy to remove with a lumpectomy, the remaining breast tissue can be re-fashioned with a breast reduction or breast lift procedure. This can result in a cancer-free breast which is cosmetically appealing. This re-fashioned breast may then undergo radiation treatment, if recommended. Radiation can cause the breast tissue to shrink a bit, and may change the texture of the skin.
If a woman undergoing a mastectomy desires autologous reconstruction the most common donor-area is the lower abdomen. The skin and fat from the bellybutton to the pubis is used to recreate the breast. This tissue can either remain attached to a blood supply carried in the abdominal muscles (TRAM flap) or the blood supply can be recreated microsurgically (DIEP, SIEP flaps). This kind of reconstruction usually adds a few hours to the mastectomy surgery, and the patient stays in the hospital a few days. Microsurgical reconstruction needs to be performed in centers that do the procedure frequently and well, so the risk of failure is minimal.
All of the procedures so far described can be performed after the mastectomy wound has healed. Some women prefer to delay the reconstruction because they don’t want to complicate or delay the cancer treatment. Some women prefer to complete all the cancer treatments, like chemotherapy and radiation, before they embark on reconstruction.
In a delayed reconstruction, there is usually a need for more skin, so it is usually not possible for a direct-to-implant reconstruction. Tissue expansion or autologous reconstruction is necessary to gain adequate skin for the breast. If tissue expansion is possible, then the surgeries are usually outpatient. Autologous reconstruction still requires hospitalization for a few days.
If the woman has had radiation to the breast skin, an autologous reconstruction may be necessary to improve the blood supply of the area. In addition to abdominal flaps, a common flap used after radiation is the latissimus dorsi. The LD is a muscle of the back that can be swung around to the front of the chest to provide skin and nourishing muscle to the radiated breast area. A tissue expander or direct-implant can be placed under the LD to provide the breast volume. This surgery is done in the hospital, with overnight hospitalization.
Some women who choose lumpectomy and radiation as treatment for their breast cancer are disappointed afterwards. The treated breast may be misshapen or smaller than the opposite breasts. Fat transfer can be a way to fill in post-lumpectomy contour defects. Fat is harvested from other areas (abdomen, buttocks, etc.) and injected into the defect. This may take more than one treatment, and complete correction may not be possible. Sometimes the opposite breast can be adjusted with a lift or small reduction in order to achieve symmetry.
Sometimes the lumpectomy breast can undergo breast-lifting to reposition the nipple, correct contours, etc. but again caution must be taken as the radiated skin has a higher risk of problems after surgery.
Ask to consult with a Plastic Surgeon:
Every woman is unique, and reconstructive options vary based on diagnosis, treatment necessary for the cancer, anatomy of the breast, and patient desires.
You should consult with a plastic surgeon regarding your particular options, and you can together make decisions regarding your breast treatment.