Breast Reconstruction
Procedure: Breast Reconstruction
Surgery Length: 1-8 hours depending on technique chosen
Anesthesia: General with local
Where: Outpatient Hospital/Inpatient Hospital
Recovery: 1-6 weeks depending on technique, Collection of fluid which resolves with drains or needle aspiration, wrinkling of skin when implant is removed secondary to infection (Resolved when patient is re-implanted), numbness in the surgical site
Back to work: 2-8 weeks depending on technique
Full activities: 2-8 weeks depending on technique
Risks: Scaring, Leaking or deflated expander (rare), Infection, Bleeding, Capsule formation around implant, firmness of implant, Asymmetry of breast, Hernia (in abdominal procedure for flaps), Injury to overlying skin w/partial or complete loss of flaps or skin grafts
Technique: This involves either the immediate or delayed reconstruction of a deformity on the chest wall following a mastectomy for either benign or in most cases malignant disease. The techniques involved in reconstruction include the use of straight forward implants such as used for a breast augmentation and/or the use of tissue expanders to stretch existing tissue and subsequent placement of a permanent implant. Breast reconstruction may also entail the use of tissue from elsewhere in the body forming flaps to recreate a breast. This would include the tummy tuck procedure or TRAM (Transverse Rectus Abdominus Myocutaneous) flap utilized to reconstruct one or both breasts, and/or the latissimus muscle flap used from the back to do similar such reconstruction.
Reconstruction of the breast has been performed for over one hundred years. The techniques have improved to the point that immediate reconstruction is becoming common at the time of the mastectomy. Any suspicious breast lump detected either from mammograms (breast x-ray) or other clinical findings merit a breast biopsy. If a cancer is discovered, several courses of therapy can be instituted but need not be performed immediately. The breast lump can be evaluated with a frozen section (immediate results are often available) or a permanent section (one to several days required). One can proceed with a lumpectomy on the sit of the original biopsy, removing the remaining tissue, sampling some lymph nodes in the armpits and preserving the remainder of the breast.
Following this lumpectomy and lymph node sampling, radiation of the breast would be required in order to definitely treat possible residual breast cancer. However, that radiotherapeutic alternative may be difficult for patients who have large breasts. These patients may have problems of discomfort and numbness of the breast as well as hardness of breast tissue. The pros and cons of this mode of therapy are best discussed with a qualified radiotherapist. Statistically, the cure rate for breast cancer is equal for the first five years using surgery alone versus lumpectomy-radiation. However, in one study at ten or more years the lumpectomy-radiation group shows a greater incidence of tumor reoccurrence in the treated breast than is seen in the surgical group. For this reason many physicians prefer radiation for older or infirm patients. Also, small breasted patients can have poor results following lumpectomy and radiation. The missing breast tissue and the shrinkage from radiation can cause a marked asymmetry with the opposite breast. Attempts at restoring a cosmetic result after radiation are poor owing to the extensive scarring and compromised blood supply to the irradiated skin and breast tissue. Implant/Expander reconstruction to an irradiated is not feasible as the chest wall muscle and skin will not stretch with expansion. In these cases tissue it is imperative to bring in tissue with its own blood supply, i.e. flaps from the back or abdomen.
Another option for a positive breast lump would be to perform a standard mastectomy for the removal of the breast and all of the lymph nodes of the armpit. This could be followed with a reconstructive effort, either at the time of the mastectomy or at a later date. Most often, immediate reconstruction is done with a permanent expander placed under the muscles of the chest where the breast had been. The expander has a small tube with an injection port attached to the end. When placed under the chest muscle the tubing and port will point toward the armpit. After the incisions have healed, salt water is instilled into the expander over a number of weeks to gradually stretch the muscle and skin to create a breast mound.
The intent of the reconstructive operation is to recreate an internal breast mound. Otherwise, following a mastectomy, external breast mound prosthesis is your only alternative. These external prostheses are quite heavy and easily dislodged. They are cumbersome for patients performing any physical activity and make it difficult to fit clothing. Many patients also complain of being lopsided with the loss of one breast and do not feel balanced with the external prosthesis.
The improved aesthetics from a reconstructed breast mound would be another matter to consider. Even with the finest of reconstruction and with a multitude of stages employed, one cannot totally replicate a normal breast in both its feel and appearance. Reconstruction will certainly improve the contour of your chest wall, improve your ability to fit into clothes and to improve yourself in athletic activities.
There is a multitude of ways to reconstruct a breast. The simplest is to implant a silicone/saline implant beneath the pectoralis muscle. This muscle is usually left on the anterior chest wall following a mastectomy. A pocket under the overlying skin alone is usually not satisfactory for a silicone/saline implant. There tends to be scar formation and hardness around the residual breast skin when the implant is placed under the skin alone. With a permanent implant placed under the muscle, there are some limitations to the size of the implant owing to the tension of the muscles and their attachment to the chest wall. This problem can be improved by having the pocket under the muscle expanded over several weeks using a breast expander as previously mentioned. This is the second option to the straight forward silicone/saline implantation. The expander is filled with salt water from a reservoir which will expand the overlying muscles and skin to the appropriate size in a matter of weeks. Although rare to happen, the expander prosthesis may leak requiring replacement. This can be done as an outpatient procedure under general or local anesthesia.
In some cases the expandable implant can be permanently left behind and over-inflated during the course of the postoperative period. After partly deflating the over-inflated expander, the new breast becomes soft and sags slightly like a normal breast. This permanent implant/expander can have its small filling reservoir removed under local anesthesia after removing what excess fluid may have been instilled. Initial inflation usually begins two or three weeks after the operation and continues for as long a period as is required on a weekly basis. Usually the fill-up period lasts from six to twelve weeks. The ideal approach is to have only one operation with such a permanent expandable prosthesis. Insertion can be performed at the time of the mastectomy or at a later date. In rare cases, as mentioned, it has been noted that these “permanent” expandable prostheses may leak, deflate, and require removal and replacement with a permanent implant.
Another alternative for breast reconstruction is the use of the Latissimus dorsi myocutaneous flap. The Latissimus dorsi muscle is on each side of the posterior chest at the mid to low back area. The operation entails cutting out an ellipse of back skin left attached to muscle. The muscle and skin are then turned in an anterior direction to cover the missing muscle and skin tissue on the anterior chest wall. Beneath this skin/muscle flap a silicone/saline implant is often inserted to reconstruct a breast mound. The subsequent defect on the back is closed as a straight line and is usually well hidden in the bra strap area.
Another mode of reconstruction is a tummy tuck technique combined with the skin, fat, and a muscle island harvested from the lower abdomen (TRAM). An island of skin and fat is removed from below the belly button and is tunneled underneath the abdominal wall with an abdominal muscle. This muscle, skin, and fat island is turned into the anterior chest area. Some feel that there are advantages using this technique since there may be enough fat in the skin island that a silicone/saline implant is not necessary. Many surgeons, however, have discovered that some supplementation with a implant is required in order to provide adequate contour to the reconstructed breast. The donor defect in the lower abdomen is closed as a transverse straight line usually just below the belly button. This is similar to the incision that is usually employed when performing and abdominoplasty (tummy tuck procedure). This latter procedure is not totally innocuous and carries with it side effects which will be discussed later.
All of these procedures carry with them the immediate problem of wound infection and bleeding. This is in part obviated by placing the patients on antibiotic therapy as well as paying strict attention to bleeding at the time of surgery. When both infection and bleeding occur, a patient may subsequently require culture for infections and be treated for that infection with another antibiotic. Abscess collections (collections of infected fluid) may require draining. If an implant or expander becomes infected it will require removal and replacement six to twelve months later. Some wrinkling of the skin may occur with the absence of the implant or expander. Bleeding may require return to the operating room to control additional bleeding sites. When time allows, patients are requested to donate their own blood for transfusion at the time of their operation. Their blood is either banked in a frozen or fresh refrigerated state over a period of weeks and months. Transfusing your own blood obviates the problems of hepatitis and other serious diseases that are now contracted through blood donation. Designated blood donors can also be arranged. We also ask that patients not take Vitamin E or aspirin products prior to surgery as they decrease the blood’s ability to clot.
Scarring is a problem with any surgical maneuver. The scar on the back from the Latissimus dorsi technique is a linear scar which can spread with time and motion. The width and thickness of the scar depends upon the patient. This may require a revision and it may require injection with cortisone. Scars on the abdomen or chest may also require such revision and cortisone injections. Scar tissue around the implants may result in capsule formation or sometimes a hard misshaped breast. This may require another surgical procedure (open capsulotomy) to soften the feel and improve positioning of the implant. Sometimes these implant capsules remain permanently hard. The breast may remain asymmetrical as compared to the opposite breast and occasionally the implant will require removal following a rejection process by the body.
In the more extensive procedures, namely the Latissimus dorsi flap procedure, as well as the abdominal flap procedure, undermining of the skin tissue in large areas will cause a collection of fluid which is partially obviated with the suction drains. However, fluid may accumulate as a persistent problem in the ensuing weeks after aspiration with needle and syringe. This problem clears on its own but may take some time.
The use of the Latissimus dorsi myocutaneous flap does not necessarily limit the motion of the arm. Some patients do note, if they are strong swimmers, that their may be some weakness of their breast stroke. Otherwise most patients can continue their ordinary activity without suffering loss of the neither muscle nor significant physical deformity to the back area other than the scar. On the other hand, in the abdominal (tummy tuck) procedure the Rectus Abdominus muscle is utilized to move the skin/fat island to the chest wall reconstruction site. This muscle loss lends to some weakness of the abdominal wall. With this there can be a chance of abdominal herniation and subsequent need for repair of the hernia with either local or synthetic tissue.
Similarly, all of these described techniques can cause injury to the overlying skin with partial or complete loss. In these events, further flaps or even skin grafts may be required. Owing to nicotine decreasing the blood supply to the skin, we demand patients to refrain from smoking or chewing Nicoret gum prior to surgery and for one week later. Diabetic and obese patients also have poor blood supply and we tend to use the more conservative procedures on these patients.
In all of these procedures there will be numbness in the areas operated on as the nerves have been cut in the immediate vicinity of dissection.
Breast reconstruction can be performed at the time of mastectomy or later. Immediate reconstruction saves another general anesthetic, another hospitalization, and added expenses. In most methods of reconstruction (particularly the expander techniques), little is added to the operative time. Also, fresh local tissues are much easier to work with as compared to staged reconstruction in the midst of scar tissue as well as muscle and skin which have shrunk.
In order to obtain symmetry with the reconstructed breast, the opposite normal breast is not usually touched until the original reconstruction is complete. The one usually must address the opposite breast with a breast reduction, mastopexy (breast lift), or augmentation with an implant. A subcutaneous mastectomy is sometimes recommended for the opposite breast if there is a suspicious finding with mammograms or clinical exam of a precancerous condition.
The nipple is reconstructed after completion of the formation of the new breast mound. The nipple reconstruction is performed with a variety of techniques. The techniques are performed under heavy sedation and local anesthesia. Occasionally the nipple-areola complex is preserved on the mastectomized breast or it is removed and “banked” as a skin graft in the groin. Later, following reconstruction of the final breast mound, the nipple is returned to the reconstructed breast. In cases where the nipple is sacrificed with the breast, a nipple can be made using parts of the opposite nipple-areola or from skin grafts from the groin. All these techniques may require silicone or cartilage grafts to provide improved nipple projection.
