BREAST RECONSTRUCTIVE

Cancer Reconstruction

Breast cancer requiring a mastectomy can be devastating to a woman's physical and emotional health. Studies have shown that breast reconstruction may significantly improve the cancer patient's body image and improve her quality of life. The natural breast may never be exactly replicated, but it can be closely approximated. Realistic patients are usually very happy with their results. Federal law requires that insurance companies cover breast reconstruction and matching procedures for the opposite breast. Breast reconstruction has not been shown to increase breast cancer recurrence incidence.

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Reconstruction may be performed either immediately at the time of mastectomy or delayed. Previously, immediate reconstruction was encouraged; but now, many surgeons, including Dr. Wigod, prefer delayed reconstruction. There are advantages to each, so this is a decision to be made by the patient, cancer surgeon, and reconstructive surgeon.

The breast may be reconstructed by using breast implants (expander reconstruction) versus the patient's own tissue (autogolous reconstruction) versus a combination of the two. Which technique would be most appropriate is sometimes a complicated decision which must be made by the patient and surgeon. Both method and timing may be impacted by the extent of cancer, the patient's body type, her overall health, and need for chemotherapy or radiation.

Breast reconstruction usually involves more than one operation. Expect the process to last 6 to 12 months. Sometimes surgery, such as reduction or mastopexy, is the performed on the opposite breast to match the reconstructed breast. Some patients elect to have bilateral (both sides) mastectomy to minimize their future cancer risks and to maximize their symmetry.

Tissue Expander with Breast Implant

A tissue expander (deflated silicone rubber shaped balloon with filling port) is placed under the skin and muscle of the mastectomy site. Saline is added in the operating room and then weekly in the office to the expander. This device stretches the skin and muscle as it expands. When the skin has been sufficiently stretched, the tissue expander is removed replaced by a permanent breast implant. Nipple reconstruction, is frequently performed at the same time, limiting the reconstruction to just two procedures.

Advantages: This method is the simplest surgery, may usually be performed as an outpatient, and has the shortest recovery. It can give excellent results in women with a small opposite side breast or who require reconstruction on both sides. It is also a favored procedure for women who have heath problems or contraindications to extensive surgery.

Disadvantages: The patient must make multiple trips to the office over several weeks or to undergo expansion. A second procedure must then be performed to exchange the expander for the permanent breast implant. The implant may not match the opposite breast well, even if matching procedures are performed. The implant may have thin tissue coverage and there may be deforming or painful scarring around the implant (contractures). If the chest has been irradiated, expander reconstruction is best accompanied by a latissiumus flap (see below).

Latissimus Dorsi Myocutaneous Flap

The latissimus dorsi is a large sheet like muscle which covers the mid to lower back. This muscle and its overlying skin may be transferred from the back to the chest to help create a new breast mound. Most frequently, Dr. Wigod latissimus flap rotation with expander reconstruction in patients who have had radiation.

Advantages: This is usually a very reliable procedure and provides a good environment for an implant. The chances of capsule formation around the implant are reduced. It is a good choice for patients who have had radiation, but are not candidates for a TRAM flap. Shoulder mobility is not affected. Recovery is easier than for a TRAM flap.

Disadvantages: Operation requires an additional three hours in the operating room to whatever other reconstruction is planned and 2-4 day hospital stay. There is a significant scar across the back. There may be decreased strength in the back due to muscle loss, but most patients find that this does not limit their activities of daily living. The tissue flap may die secondary to poor oxygen supply or blood drainage. Total loss is very uncommon, but small areas of loss may occur.

Trans Rectus Abdominus Myocutaneous (TRAM) Flap

This is the most complicated and the longest autogolous reconstructive procedure, involving at least 5 hours of surgery. Good candidates for operation should have some extra fat on their abdomens, but not be obese. They should also be in good physical condition and not smoke.

The abdominal tissue between the umbilicus and pubis which would normally be removed as part of an abdominoplasty is mobilized for movement, except for its attachment to one of the underlying rectus muscles. A tunnel is then made between the abdomen and mastectomy site. The mobilized tissue is rotated up and into the defect to form a new breast mound. The rectus muscle leash acts like giant blood vessels to supply and drain blood from the new breast. The abdominal wound is then closed with synthetic mesh as in a hernia repair and the skin closed a in an abdominoplasty.

Advantages: 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.

Disadvantages: This is the longest procedure and patient will usually require a 4-6 day stay in the hospital. Recovery at home takes additional weeks. Abdominal strength is diminished and there is a risk of bowel herniation if the mesh repair breaks down. If the mesh becomes infected, it must be removed. The tissue flap may die secondary to poor oxygen supply or blood drainage. Total loss is very uncommon, but small areas of loss may occur. Other problems include those associated with abdominoplasty surgery.

Dr. Wigod offers this reconstruction to selected patients and usually only for one side. He currently feels that bilateral abdominal tissue reconstructions are best performed with free flap techniques which have limited availability, usually at university medical centers.

Nipple Reconstruction

Nipple reconstruction adds an essential final touch to the new breast. It is usually performed at the time of implant exchange with expander reconstructions or at 3-6 months post TRAM reconstruction. Nipple-areola formation is an outpatient procedure which requires 1-2 hours. Tissue on the reconstructed breast mound is cut and folded to form a cone shaped nipple ( Skate Flap technique). Skin is taken from the inner part of the upper thigh to make an areola. This area tends to have a darker pigment for the areola which will provide a better contrast to the breast tissue. The tissue donor site is usually well hidden and tolerated. Many excellent surgeons use tattoo techniques, but Dr. Wigod believes the grafting technique delivers the best results.

After the operation a cotton bolster holds the skin graft in place for a week and is then removed. The operative site must remain dry until removal. The nipple at first will have too much projection, but then will contract to an appropriate height. The grafted areola will darken and usually hold its color. The result is very good for most patients, but an exact copy of the opposite nipple cannot be produced. Problems may include poor skin graft take, donor site healing difficulties, or excessive loss of nipple height.

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Breast Reduction (Reduction Mammaplasty)

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Breast reduction, or reduction mammoplasty, is indicated for women with health problems and/or extreme self-consciousness associated with very large, heavy breasts. The goal is to give the woman a more attractive contour with smaller, better-shaped breasts in proportion with the rest of her body. She will then benefit from decreased health problems associated with large breasts and an improved self-image.

The most common medical problem associated with very large breasts include back, neck, and shoulder pain caused by the excessive weight. Appropriate candidates may also have skin irritation, shoulder grooving, poor posture, and interference with normal daily activities such as exercise. Excessive breast size may also lead to a decreased sense of attractiveness and self-confidence.

Breast Reduction is often covered by insurance. Please check your policy as some plans specifically exclude coverage for this surgery, no matter how medically necessary. Insurers require a certain volume of tissue be removed to qualify. This quantity is usually related to the patients height and weight (body surface area), but is high enough to exclude patients who are seeking predominately cosmetic benefits. After an examination, Dr. Wigod will be able to better estimate if you are likely to qualify for insurance coverage. The office will then submit a letter and await approval before proceeding.

The Procedure

Breast reduction is done under general anesthesia on an outpatient or inpatient basis. The operation lasts 3-4 hours. Fat, glandular tissue, and skin is removed from the breasts to makes them smaller, lighter, and firmer. The size of the areola, the darker skin surrounding the nipple, is also usually reduced.

Incisions are made around the nipple-areola complex and extend vertically below the nipple and in the fold under the breast. Using the superior-medical pedicle or inferior pedicle technique, the nipple-areola complex is then moved upward to the desired location and the breast tissue rearranged for closure. Care is taken to maintain the nerve and blood supply to the nipple. Dr. Wigod uses pedcile techniques in most patients. Liposuction may be added in select patients to remove excess fat from the armpit. Liposuction only for breast reduction is not recommended by Dr. Wigod as he feels the technique either removes insufficient tissue to give relief or removes enough an leaves a poor cosmetic result due to ptosis and poor shape.

In some instances, such as extremely large breasts or in patients who cannot tolerate a longer operation, the nipple may be removed as a skin graft and then sutured into the appropriate new location. This nipple grafting method is safer in that damage to the nipple during movement is minimized, and the operation may be performed in less time. The breast may actually have better shape, but erotic sensation to the nipple is lost.

Drains are placed and exited under the armpits. The wounds are closed in an upside down "T" shape with a combination of absorbable and removable sutures. Afterward, the breasts are placed in a surgical bra or binder.

Post-Operative Information

You will usually be discharged the same day, but may be scheduled for an overnight stay depending on your pain level, overall health, and other factors.

Your wounds will be dressed with gauze and a breast binder. Dressings should be changed daily or when significantly soiled. You do not require dressings once you have no more drainage from your wound, but you should have a clean soft cotton garment in contact with the wound which is washed or changed daily. During the first 3 weeks after the operation, you should wear a breast binder or loose sports bra. During the second 3 weeks, you may wear a regular soft bra without underwire. After 6 weeks, you may wear an underwire bra for short periods and progress to longer periods over the next month.

Your skin will be closed by a combination of visible and deep sutures. You may have some oozing which is not unusual. If you have a pedicle technique, you will be able to see your nipples and may wash your breasts in a shower 24-48 hours after the operation. If you have the nipple grafting technique, you will have what looks like a package tied over your nipples and should keep this dry for one week at which time the bolster (package) will be removed. In the meantime, you may sponge bathe. Your sutures will be removed at 2 weeks post-op.

You will have a rubber tube, called a drain, exiting from each breast. They are there to allow controlled drainage from the wound and to decrease pain. These tubes may be removed from one to several days after the operation. The drains should be emptied every 8 hours and the drainage tracked in milliliters (cc's). Your recovery nurse will instruct you. You may shower with the drains in. If a drain is accidentally removed, it is not an emergency as it will not be reinserted. Notify Dr. Wigod during the next business day.

You will be provided a narcotic for pain. You may start taking ibuprofen 48 hours after the operation. Do not use ice or heat on your breasts unless specifically discussed with Dr. Wigod. Your pain should improve rapidly during the first few postoperative days and then resolve more slowly. Pain should limit your activity and you should avoid heavy lifting and sweating for about 3 weeks.
Your breasts will feel swollen for 2 to 4 weeks. Gradually they will "settle" into a more rounded shape. Your breasts will continue to change with time as the operation does not stop the natural aging process. Dr. Wigod makes every effort possible to create symmetry. Since approximately 90% of women are asymmetric pre-operatively and since tissue removal during the operation is very subjective, exact symmetry cannot be guaranteed and should not be expected.

Small scabs or limited wound opening with drainage is not unusual, particularly at the center of the inverted "T" where tension is greatest and blood supply is least. Although Dr. Wigod will make your scars as inconspicuous as possible, permanent scarring is inevitable. Smokers are more likely to experience poor healing and wider scars. The scars will be red and raised in the months following the surgery, but they should improve and become less obvious with time. Most clothing and bathing suits will cover the scars.

The breast is a functional organ, and every effort is made to maintain that function by using pedicle techniques. The ability to breast feed after the operation cannot be guaranteed. Most patients will have minimal long term change in their nipple sensation, and some may even have slight improvement. Many patients, however, do have temporary decreased nipple sensation. A few patients may experience a permanent loss of feeling in their nipples or breasts. Rarely, the nipple and areola may lose their blood supply and the tissue will die. The nipple and areola can usually be rebuilt, however, using reconstruction techniques.

Other problems may occur such as delayed healing, fat necrosis, blood clots, infection, and need for further surgery. Overall, the operation is very successful and patients are usually satisfied with their results.

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