Larry Weinstein, MD, F.A.C.S.
Chester Plastic Surgery
Top Plastic surgery Doctors in New York Metro Area

Breast Reconstruction

Breast Reconstruction is one od the main procedures of my practice. Having trained at Sloan- Kettering Memorial I am fully aquainted with all current techniques of Breast and Nipple reconstruction. I was the assistant surgeon in the first tissue expander uased at Sloan - Ketteirng for breast reconstruction. This technique has helped avoid major surgery in thousands of patients. I use both TRAM flaps and tissue expander implant for breast reconstruction.
Ideal candidate for Tissue expander breast implant are thin patient's with low body mass, small nonptotic -saggy-  breasts, active lifestyle patients and  nonradiated tissue bed.

Breast reconstruction is surgery to rebuild a breast's shape after a mastectomy. It cannot give a woman back her breast - a reconstructed breast does not have natural sensations. However, the surgery offers a result that looks like a breast. Most women who had breast reconstruction are glad they did.

In breast reconstruction, a surgeon forms a breast mound by using an implant or tissues from the belly, back or buttocks. Implants are silicone sacs filled with salt water or silicone gel. The type of reconstruction you get depends on your body type, age and cancer treatment.

Breast reconstruction takes more than one surgery. Extra steps may include:

  • Adding a nipple
  • Changing the shape or size of the reconstructed breast
  • Operating on the opposite breast for a better match

NIH: National Cancer Institute

New choices in breast cancer surgery and reconstruction

Each year more than 254,000 American women face breast cancer. Today, the emotional and physical results are very different from what they were in the past. Much more is now known about breast cancer and its treatment. New kinds of treatment as well as improved reconstructive surgery mean that women who have breast cancer today have better choices.

Today, more women with breast cancer choose surgery that removes only part of the breast tissue. This may be called breast conservation surgery, lumpectomy, or segmental mastectomy. But some women have a mastectomy, which means the entire breast is removed. Many women who have a mastectomy choose reconstructive surgery to rebuild the shape and look of the breast.

If you are thinking about having reconstructive surgery, it is a good idea to talk about it with your surgeon and a plastic surgeon experienced in breast reconstruction before your mastectomy. This lets the surgical teams plan the treatment that is best for you, even if you want to wait and have reconstructive surgery later.

Why have breast reconstruction?

Women choose breast reconstruction for many reasons:

  • To make their breasts look balanced when they are wearing a bra
  • To permanently regain their breast shape
  • So they don't have to use a form that fits inside the bra (an external prosthesis)

You will be able to see the difference between the reconstructed breast and the remaining breast when you are nude. But when you are wearing a bra, the breasts should be alike enough in size and shape that you will feel comfortable about how you look in most types of clothes.

Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery. Also, you may not be happy with how your breast looks and feels after surgery. You and those close to you must know the facts about what to expect from reconstruction.

There are often many options to think about as you and your doctors talk about what is best for you. The reconstruction process often means one or more operations. Talk about the benefits and risks of reconstruction with your doctors before the surgery is planned. Give yourself plenty of time to make the best decision for you. You should decide to have breast reconstruction only after you are fully informed.

Immediate or delayed breast reconstruction

Immediate breast reconstruction is done at the same time as the mastectomy. An advantage to this is that the chest tissues are not damaged by radiation therapy or scarring. This often means that the final result looks better. Also, immediate reconstruction means less surgery.

After the first surgery, there still may be a number of steps that are needed to complete the immediate reconstruction process. If you are planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take.

Delayed breast reconstruction means that the rebuilding is started later. This may be a better choice for some women who need radiation to the chest area after the mastectomy. Radiation therapy given after breast reconstruction surgery can cause problems.

Decisions about reconstructive surgery also depend on many personal factors such as:

  • Your overall health
  • The stage of your breast cancer
  • The size of your natural breast
  • The amount of tissue available (for example, very thin women may not have enough extra body tissue to make flap grafts)
  • Whether you want reconstructive surgery on both breasts
  • Your insurance coverage for the unaffected breast and related costs
  • The type of procedure you are thinking about
  • The size of implant or reconstructed breast
  • Your desire to match the look of the other breast

Other important things to think about

  • Some women do not want to think about reconstruction while coping with a diagnosis of cancer. If this is the case, you may choose to wait until after your breast cancer surgery to decide about reconstruction.
  • You may not want to have any more surgery than needed.
  • Scarring is a natural outcome of any surgery, but cell death (called necrosis) of the breast skin, the flap, or transplanted fat can happen. Immediate reconstruction may be more likely to result in necrosis. If this happens, more surgery is needed to fix the problem and can deform the new breast shape.
  • Not all surgery is a total success, and you may not like the way it looks.
  • You may be concerned if you tend to bleed or scar.
  • Healing may be affected by previous surgery, chemotherapy, radiation, smoking, alcohol use, diabetes, some medicines, and other factors.
  • Would you prefer to have reconstruction before or after you complete your cancer treatment?
  • Breast reconstruction restores the shape, but not feeling, in the breast. With time, the skin on the reconstructed breast can become more sensitive, but it will not feel the same as it did before your mastectomy.
  • Surgeons may suggest you wait for one reason or another, especially if you smoke or have other health problems. Many surgeons say that you must quit smoking at least 2 months before reconstructive surgery to allow for better healing. You may not be able to have reconstruction at all if you are obese, too thin, or have blood circulation problems.
  • The surgeon may recommend surgery to reshape the remaining breast to match the reconstructed breast. This could include reducing or enlarging the size of the breast, or even surgically lifting the breast.
  • Knowing your reconstruction options before surgery can help you prepare for a mastectomy with a more realistic outlook for the future.

Types of breast reconstruction

Several types of operations can be done to reconstruct your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. (A tissue flap is a section of your own skin, fat, and muscle which is moved from your tummy, back, or other area of your body to the chest area.)

Implant procedures

The most common implant is a saline-filled implant. It is a silicone shell filled with salt water (sterile saline). Silicone gel-filled implants are another option for breast reconstruction. They are not used as often as they were in the past because of concerns that silicone leakage might cause immune system diseases. But most of the recent studies show that silicone implants do not increase the risk of immune system problems. Also, alternative breast implants that have different shells and are filled with different materials are being studied, but you can only get them in clinical trials.

One-stage immediate breast reconstruction may be done at the same time as mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant where the breast tissue was removed to form the breast contour.

Two-stage reconstruction or two-stage delayed reconstruction is done if your skin and chest wall tissues are tight and flat. An implanted tissue expander, which is like a balloon, is put under the skin and chest muscle. Through a tiny valve under the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over time (about 4 to 6 months). After the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant. Some expanders are left in place as the final implant.

The two-stage reconstruction is sometimes called delayed-immediate reconstruction because it allows options. If the surgical biopsies show that radiation is needed, the next steps may be delayed until after radiation treatment is complete. If radiation is not needed, the surgeon can start right away with the tissue expander and second surgery.

There are some important factors for you to keep in mind if you are thinking about having implants:

  • Implants may not last a lifetime. You may need more surgery to replace them later.
  • You can have problems with breast implants. They can break (rupture) or cause infection or pain. Scar tissue may form around the implant (capsular contracture), or you may not like the way the implant looks.

Tissue flap procedures

These procedures use tissue from your tummy, back, thighs, or buttocks to rebuild the breast. The 2 most common types of tissue flap surgeries are the TRAM flap (or transverse rectus abdominis muscle flap), which uses tissue from the tummy area, and the latissimus dorsi flap, which uses tissue from the upper back.

These operations leave 2 surgical sites and scars -- one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but they will never go away completely. There can also be problems at the donor sites, such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue's blood supply, flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers.

In general, flap procedures behave more like the rest of your body tissue. For instance, they may enlarge or shrink as you gain or lose weight. There is also no worry about replacement or rupture.

TRAM (transverse rectus abdominis muscle) flap

The TRAM flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). The tissue from this area alone is often enough to shape the breast, and an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower belly, or a "tummy tuck."

There are 2 types of TRAM flaps:

  • A pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area.
  • In a free flap, the surgeon cuts the flap of skin, fat, blood vessels, and muscle for the implant free from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer than a pedicle flap. The free flap is not done as often as the pedicle flap, but some doctors think that it can result in a more natural shape.

Two diagrams showing TRAM flap incisions.  First diagram shows muscle used; skin and fatty tissue for flap taken from abdomen.  Second diagram shows transplanted skin, fat, and muscle for reconstructed breast; closed abdominal incision.Diagram detailing the tissue used to rebuild the breast shape: blood vessels, muscle, skin, and fat.

    TRAM flap incisions The tissue used to rebuild the breast shape

Latissimus dorsi flap

The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.

Diagrams of latissimus dorsi flap. First diagram shows skin used for flap and latissimus dorsi muscle on back.  Second diagram shows breast implant under muscles, latissimus dorsi flap in place on breast, and closed incision on back.

    Latissimus dorsi flap

DIEP (deep inferior epigastric artery perforator) flap

A newer type of flap procedure, the DIEP flap, uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This results in less skin and fat in the lower belly (abdomen), or a "tummy tuck." This method uses a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels. The procedure takes longer than the TRAM pedicle flap discussed above.

Diagram showing donor tissue site on abdomen for DIEP flap. Diagram showing reconstructed breast using DIEP flap, and closed incision on abdomen.

Donor tissue site for DIEP flap After DIEP flap

Gluteal free flap

The gluteal free flap or SGAP (superior gluteal artery perforator) flap is longer more involved type of surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It is an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons. The method is much like the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest area. A microscope (microsurgery) is needed to connect the tiny vessels.

Method of tissue support instead of Flap

These surgeries move sections of tissue to new places, or add fairly heavy implants, and some tissues need support to keep them in place as they heal. Doctors use synthetic mesh and other methods for this. More recently, doctors are trying a new product made of donated human skin (AlloDerm®, an allograft). It is regulated by the U.S. Food and Drug Administration (FDA) as a human tissue used for transplant. But it has had the human cells removed (is acellular), which reduces any risk that it carries diseases or the body will reject it. It is used to extend and support natural tissues and help them grow and heal. In breast reconstruction it may be used with expanders and implants.

After breast reconstruction surgery

What to expect

You are likely to feel tired and sore for a week or 2 after implants, and longer after flap procedures. Your doctor can give you medicines to control pain and other discomfort.

Depending on the type of surgery, you should go home from the hospital in 1 to 6 days. You may be discharged with a drain in place. The drain is an open tube that is left in place to remove extra fluid from the surgery site while it heals. Follow your doctor’s instructions on wound and drain care. Also be sure to ask what kind of support garments you should wear. If you have any concerns or questions, call your doctor.

Getting back to normal

You should be up and around in 6 to 8 weeks. If implants are used without flaps, your recovery time may be shorter. Some things to keep in mind:

  • Reconstruction does not restore normal feeling to your breast, but some feeling may return.
  • It may take up to about 8 weeks for bruising and swelling to go away. Try to be patient as you wait to see the final result.
  • It may take as long as 1 to 2 years for tissues to heal and scars to fade, but the scars never totally go away.
  • Ask when you can go back to wearing regular bras. Underwires and lace may not be comfortable.
  • Follow your surgeon's advice on when to begin stretching exercises and normal activities. As a rule, you'll want to avoid any overhead lifting, strenuous sports, and sex for 4 to 6 weeks after reconstruction.
  • Women who have reconstruction months or years after a mastectomy may go through a period of emotional readjustment once they have their breast reconstructed. Just as it takes time to get used to the loss of a breast, you may feel anxious and confused as you begin to think of the reconstructed breast as your own. Talking with other women who have had breast reconstruction might be helpful. Talking with a mental health professional may also help you sort out these feelings. It's estimated that more that one million reconstructive procedures are performed by plastic surgeons every year. Reconstructive surgery helps patients of all ages and types - whether it's a child with a birth defect, a young adult injured in an accident, or an older adult with a problem caused by aging.

The goals of reconstructive surgery differ from those of cosmetic surgery. Reconstructive surgery is performed on abnormal structures of the body, caused by birth defects, developmental abnormalities, trauma or injury, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.

Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.

Although no amount of surgery can achieve "perfection," modern treatment options allow plastic surgeons to achieve improvements in form and function thought to be impossible 10 years ago.

This will give you a basic understanding of some commonly-used techniques in reconstructive surgery. It won't answer all of your questions, since each problem is unique and a great deal depends on your individual circumstances. Please be sure to ask your doctor to explain anything you don't understand. Also, ask for information that specifically details the procedure you are considering for yourself or your child.

Who has reconstructive surgery

There are two basic categories of patients: those who have congenital deformities, otherwise known as birth defects, and those with developmental deformities, acquired as a result of accident, infection, disease, or in some cases, aging.

Some common examples of congenital abnormalities are birthmarks; cleft-lip and palate deformities; hand deformities such as syndactyly (webbed fingers), or extra or absent fingers; and abnormal breast development.

Burn wounds, lacerations, growths, and aging problems are considered acquired deformities. In some cases, patients may find that a procedure commonly thought to be aesthetic in nature may be performed to achieve a reconstructive goal. For example, some older adults with redundant or drooping eyelid skin blocking their field of vision might have eyelid surgery. Or an adult whose face has an asymmetrical look because of paralysis might have a balancing facelift. Although appearance is enhanced, the main goal of the surgery is to restore function.

Large, sagging breasts are one example of a deformity that develops as a result of genetics, hormonal changes, or disease. Breast reduction, or reduction mammaplasty, is the reconstructive procedure designed to give a woman smaller, more comfortable breasts in proportion with the rest of her body.

In another case, a young child might have reconstructive otoplasty (outer-ear surgery) to correct overly-large or deformed ears. Usually, health insurance policies will consider the cost of reconstructive surgery a covered expense. Check with your carrier to make sure you're covered and to see if there are any limitations on the type of surgery you're planning. Work with your doctor to get pre-authorization from the insurer for the procedure.

All surgery carries some uncertainty and risk

When reconstructive surgery is performed by a qualified plastic surgeon, complications are infrequent and usually minor. However, individuals vary greatly in their anatomy and healing ability and the outcome is never completely predictable.

As with any surgery, complications can occur. These may include infection; excessive bleeding, such as hematomas (pooling of blood beneath the skin); significant bruising and wound-healing difficulties; and problems related to anesthesia and surgery.

There are a number of factors that may increase the risk of complications in healing. In general, a patient is considered to be a higher risk if he is a smoker; has a connective-tissue disease; has areas of damaged skin from radiation therapy; has decreased circulation to the surgical area; has HIV or an impaired immune system; or has poor nutrition. If you regularly take aspirin or some other medication that affects blood clotting, it's likely that you'll be asked to stop a week or two before surgery.

Planning your surgery

In evaluating your condition, a plastic surgeon will be guided by a se t of rules known as the reconstructive ladder. The least-complex types of treatments-such as simple wound closure-are at the lower part of the ladder. Any highly complex procedure-like micro-surgery to reattach severed limbs-would occupy one of the ladder's highest rungs. A plastic surgeon will almost always begin at the bottom of the reconstructive ladder in deciding how to approach a patient's treatment, favoring the most direct, least-complex way of achieving the desired result.

The size, nature and extent of the injury or deformity will determine what treatment option is chosen and how quickly the surgery will be performed. Reconstructive surgery frequently demands complex planning and may require a number of procedures done in stages.

Because it's not always possible to predict how growth will affect outcome, a growing child may have to plan for regular follow-up visits on a long-term basis to allow additional surgery as the child matures.

Everyone heals at a different rate-and plastic surgeons cannot pinpoint an exact "back-to-normal" date following surgery. They can, however, give you a general idea of when you can expect to notice improvement.

Plastic and Reconstructive Surgery:
July 2009 - Volume 124 - Issue 1 - pp 43-52
doi: 10.1097/PRS.0b013e31818b9005
Breast: Special Topics

Postmastectomy Reconstruction: An Approach to Patient Selection

Disa, Joseph J. M.D.; McCarthy, Colleen M. M.D., M.S.; Mehrara, Babak J. M.D.; Pusic, Andrea L. M.D., M.H.S.; Hu, Qunying Y. M.D.; Cordeiro, Peter G. M.D.

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Summary: The overriding goal of reconstructive breast surgery is to satisfy the patient with respect to her own self-image and expectations. Ultimately, individualized selection of a reconstructive technique for each patient will be a predominant factor in achieving a reconstructive success. The authors reviewed their institutional experience with postmastectomy reconstruction over the past 2 years and discuss indications, contraindications, advantages, and disadvantages of autogenous tissue and prosthetic breast reconstruction.

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