Breast Reconstruction Procedures for Mastectomy Patients
Breast reconstruction offers much hope for a woman losing her breast to cancer. Reconstruction can often be performed immediately after the mastectomy, so the woman does not have to live with one breast. Depending on health conditions, however, a mastectomy patient may have to wait before undergoing reconstructive surgery. In either case, reconstructive surgery holds much promise that the post-operative breast can match the natural breast again.
Through the advocacy of the American Society of Plastic Surgeons (ASPS) and breast cancer support groups, insurance companies are now required by law to provide coverage for breast reconstruction and related procedures to adjust the opposite breast. Pre-authorization may still be required.
Emotional Impact
This is an emotional time and an intense surgery. Dr. Sommerhaug, recommends that his patients participate in individual or group breast cancer sessions. He works closely with several counselors, including one who is a breast cancer survivor, former registered nurse and now a certified therapist. He also has former patients who are willing to be in contact with his new patients for support and questions. There are several support groups and resources for breast cancer patients. We encourage you and your family to be involved in these. Dr. Sommerhaug’s nurse practitioner will provide you with the information, if requested.
Please see these other resources:
American Society of Plastic Surgeons: www.plasticsurgery.org
Susan B. Komen Foundation: www.komen.org
Consultation:
Please bring a family member to every one of your appointments to help absorb the amount of information.
The consultation is the first step to learning how this surgery can work for you. It is designed to educate you about your individual options. This will include:
- A discussion of your goals and an evaluation of your individual case.
- The options available.
- The likely outcomes and any risks or potential complications.
- The course of treatment recommended by your plastic surgeon, general surgeon and oncologist as a team.
Overall health and personal outlook will greatly impact the outcome of breast reconstruction surgery. The success of your surgery, safety and overall satisfaction requires that you:
- Honestly share your expectations.
- Incorporate the physicians realistic outcomes.
- Fully disclose health history, current medications, vitamins and herbal supplements, alcohol intake, tobacco and drugs.
- Commit to precisely following all of your plastic surgeon’s instructions.
By making the decision to consult with a plastic surgeon and following all the instructions given, you are taking an important step in helping assure your safety.
The Surgery
Breast reconstruction can be physically and emotionally rewarding. The result of breast reconstruction can be relatively natural looking in appearance; however, a reconstructed breast will never look or feel exactly the same as a natural breast.
Breast reconstruction involved several surgeries performed in multiple stages. It is very important that a woman feels ready for the emotional adjustment involved. It takes women some time to accept losing a breast and the results of breast reconstruction. It is a very intense time both physically and emotionally to undergo breast reconstruction. While breast reconstruction can effectively build a woman’s breast, the results are highly variable. The surgeon must work with tissue that has been exposed to radiation or chemotherapy. The tissue is changed after exposure to these procedures. A reconstructed breast will not have the same sensation and feel as the breast it replaces.. Visible scars will always be present on the breast, whether from reconstruction or the mastectomy. In addition, if a flap technique is required, there will be incision lines at the donor site.
Stages of Reconstruction May Include:
- Flap techniques to reposition the woman’s own muscle, fat and skin to create or cover a breast mound.
- Tissue expanders placed to stretch the skin in order to provide a pocket for a breast implant. There may be several stages to this.
- Surgical placement of a breast implant and breast lift on opposing breast if requested.
- Grafting to create a nipple and areola.
- Tattoo procedure to color the nipple and areola.
- Follow-up surgery to correct asymmetry.
When reconstructive surgery is performed immediately following mastectomy, a breast mound is created in place of the breast that has been removed. This is done in the hospital under general anesthesia. Dr. Sommerhaug will work with your oncologist and general surgeon to ensure the best possible conditions for reconstruction. If you are a smoker, you must stop smoking prior to this surgery.
Breast reconstruction involves more than one operation, and follow-up procedures may be performed on an outpatient basis. The surgery will require general anesthesia. Follow-up procedures may only require local anesthesia, and often involve a skin expander with a breast implant. A later surgery will consist of the reconstruction of the nipple and areola. Dr. Sommerhaug works with a permanent make-up artist, who will color the areola and nipple to closely match the natural color, if this is so desired by the patient. Sometimes surgery is performed on the natural breast to match the reconstructed breast; however, this creates additional scars.
Once the breast mound is in place, your plastic surgeon may follow up with a skin expander and use a flap reconstruction.
Skin Expander with Breast Implant
This is the simplest of breast reconstructions. In this procedure, a tissue expander is placed under the skin. Once sutures are removed, saline is added weekly to the expander. This stretches the skin as it expands.
When the skin has been sufficiently stretched, the tissue expander is removed and replaced by a permanent breast implant in a two-stage procedure. Nipple reconstruction, if desired, is a separate procedure.
Breast reconstruction is not a simple surgery, but this is the simplest surgery and has the shortest recovery time. This is the favored procedure for persons who have heath problems or contraindications to extensive surgery.
Multiple trips to the office over several weeks or months to undergo expansion. Capsule formation or poor cosmetic outcome, due to thin skin.
Breast reconstruction is a highly individualized surgery. Techniques offer varying advantages. Choosing the appropriate treatment requires careful consideration by both patient and surgeon. Things to consider are patients anatomy, patient- surgeon preference, desired realistic outcomes and resources available.
Flap techniques are necessary when there is little tissue or muscle remaining after a mastectomy. Incision lines appear on both the donor and reconstructed sites and a lengthy recover follows. There is also a remote chance of partial or full loss of the flap due to poor healing.
Possible Complications:
- Loss of breast skin requiring removal of implant. If you have undergone radiation this procedure is not advisable as you are at increased risk for skin loss.
- Noticeable outlines of the implant due to capsule formation.
- Hard texture due to capsule formation.
- Thin breast skin.
Latissimus Dorsi Myocutaneous Flap
This surgery involves moving the latissimus dorsi muscle and overlying skin from the back to the chest to create a new breast mound. The incision is usually made along the bra line so the scar will be concealed.
Blood transfusions are not usually required. A breast implant can be placed under the flap if necessary to balance a difference in size. Nipple reconstruction is done later.
This is a very reliable procedure, which provides a good environment for an implant. The chances of capsule formation around the implant are reduced.
Scar across the back. There may be decreased strength in the back due to muscle loss. Capsule formation may occur and result in the need for additional surgery.
Possible Complications:
- Circulation problems with the flap.
- Formation of capsule around the implant.
- Symptoms from loss of shoulder muscle, such as decreased strength.
- Loss of back skin requiring skin grafting.
- Collection of fluid (seroma) under incision requiring needle aspiration.
Rectus Abdominus Myocutaneous Flap
This is the most complicated and the longest reconstructive procedure, involving about 4-5 hours of surgery. One of the rectus abdominus muscles is tunneled along with the overlying skin up to the chest. The breast mound is created to match the opposite site. A blood transfusion may be required. You may donate your own blood prior to surgery to be re-infused during the surgery.
Breast implants are not usually required. The tissue is generally adequate to match the size of the opposing breast. If the opposite breast is large or pendulous it can be decreased in size by a simultaneous breast reduction. Patients wishing to have this procedure must stop smoking six weeks prior to and six weeks following surgery. Failure to comply may result in death of the flap. A synthetic mesh is placed over the area where the muscle is moved. This strengthens the abdominal wall and minimizes the chance of herniation of the bowel. Nipple reconstruction is done as a second procedure. Some contouring of the new breast mound may be necessary at the same time.
This provides the most natural looking breast reconstruction with the added benefit of a “tummy tuck”. No implant is needed so capsule formation is not a risk. The scar is easily hidden with clothing.
There is a risk of herniation of the bowel resulting from moving the rectus abdominus muscle. Abdominal strength is diminished. This is the longest procedure and has the greatest risk for requiring a blood transfusion.
Possible Complications:
- Inadequate tissue requiring the use of a breast implant.
- Poor circulation to the flap resulting in tissue loss.
- Weakness or herniation of the abdominal wall.
- Placement of the umbilicus off center.
- Collection of fluid (seroma) under the skin requiring needle aspiration.
- Infection, in particular of the mesh requiring surgery for removal.
Nipple Reconstruction
The reconstruction of a nipple adds a very pleasing final touch to the breast. This is a simple outpatient procedure that may be done with local anesthesia. An average time for this is about 1-2 hours. The goal of the surgery is to create a nipple that has the appearance of the nipple of the opposite breast. Skin is taken from the inner part of the upper thigh or from behind the ear. These areas tend to have a darker pigment, which will provide a better contrast to the breast tissue. As a second procedure the healed nipple can be tattooed to improve the color match of the opposite breast.
Possible Complications:
- Excessive scarring.
- Shrinkage of the projecting part of the nipple.
- Infection of the donor site or the newly created nipple.
- Blood clot under the nipple, which may result in loss of all or part of the new nipple.
Reconstruction of the breast following mastectomy is a very rewarding procedure to both the patient and the surgeon. Many women describe a feeling of once again being whole. There are many materials available regarding breast reconstruction. There are support groups available where one can meet women who have gone through these procedures. Ask us for references, books and support groups in your area. Take advantage of these invaluable resources.