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.
Reconstruction may be performed either immediately at the time of mastectomy or delayed. Previously, immediate reconstruction was encouraged; but now, many surgeons 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 tumor, the patient's body type, her overall health, and need for chemotherapy or radiation.
Breast reconstruction usually involves more than one operation, and follow up procedures may be performed on an outpatient basis. 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; however, this creates additional scars.
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 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 in a two-stage procedure. Nipple reconstruction, if desired, is a separate procedure.
Advantages: This method is the simplest surgery and has the shortest recovery. It is the favored procedure for women who have heath problems or contraindications to extensive surgery. It can also give excellent results in women with a small opposite side breast or who require reconstruction on both sides.
Disadvantages: The patient must multiple trips to the office over several weeks or months 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 often not recommended.
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 4-7 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 do occur. Other problems include those associated with abdominoplasty surgery.
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 create a new breast mound. A breast implant can be placed under the flap if necessary to balance a difference in size. Increased breast size may also be obtained when combined with expansion reconstruction.
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 approximately three hours in the operating room and 2-5 day hospital stay. There is a significant scar across the back. There may be decreased strength in the back due to muscle loss. Complications associated with implants and with flaps as outlined above may occur.
Nipple Reconstruction
Nipple reconstruction adds an essential final touch to the new breast. It is performed when the reconstructed breast has reached a stable end result, usually at 3-6 months post operation. Nipple-areola formation is a simple outpatient procedure which requires 1-2 hours. Tissue on the reconstructed breast mound is cut and folded to form a cone shaped nipple. 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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After graduating medical school, Dr. Wigod completed eight years of formal General Surgery Residency and Plastic Surgery Fellowship training. His 16 years of higher education allows him to perform both Cosmetic and Reconstructive Plastic Surgery and to treat the whole patient without being limited to one body part or technique. Broad surgical training, large volume practice experience, and continuing education assist Dr. Wigod in his efforts to provide optimal care for his patients. Dr. Wigod has experience in all aspects of Plastic Surgery, but now specializes in Cosmetic Surgery of the Breast, Body and Face, as well as Breast Cancer Reconstruction.
