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If you are considering breast reconstruction in Southern California including Beverly Hills, Santa Monica and Long Beach from a Board Certified Female Plastic Surgeon continue reading ...

Breast Reconstruction: What Can Be Done?

If a woman is a good candidate for reconstruction, she can usually expect a breast mound that will fill a bra cup to her desired volume, along with a nipple and areola, if desired. The opposite breast can be made to match by augmentation, reduction or lifting. These procedures are covered by insurance, as mandated by law. In addition, significant breast symmetry as a result of lumpectomy/radiation or multiple biopsies can be corrected with reconstructive surgery.

The word "can" is used because breast reconstruction is a matter of choice. Some women choose to wear a breast prosthesis with their bra. Others may choose reconstruction, which is not limited to one's age. The overall health condition and status of the cancer are the issues that determine feasibility.

Consultation with a plastic surgeon prior to mastectomy is part of a comprehensive breast care center program. The patient should be fully informed of her options for immediate versus delayed breast reconstruction. The technique(s) recommended are based upon her anatomy, medical background and anticipated future cancer treatments.

Decision-making in breast reconstruction begins with the simple question of whether breast reconstruction will be part of the woman's recovery process.

Some women know the answer immediately; others need days or weeks to decide.

Once the decision is made to go ahead with the procedure, the next question is which technique to select. In each case, the decision is based upon surgical preference and which technique will be better in the face of any anticipated treatments of chemotherapy and/or radiation therapy.

The two most common types of breast reconstruction are the tissue expander/implant technique and the transverse abdominus musculoctaneous (TRAM) flap. A third technique is the latissimus dorsi musculocutaneous flap with a breast implant. The table shown here summarizes and compares these techniques.

With the plastic surgeon's guidance, the most appropriate technique can be selected for breast reconstruction, taking into account the desires, health status and unique anatomy of the individual woman.

The expander/implant technique requires two stages. The first stage of this breast reconstruction is placement of the tissue expander below the pectoralis chest muscle. This procedure adds less than one hour to the mastectomy time with the same overnight hospital stay.

The second stage is the exchange of the tissue expander for the permanent saline or silicone gel filled breast implant. This stage requires general ane sthesia, but is usually less than one hour in duration unless a procedure on the opposite breast is added.

Breast implants are confirmed safe by multiple medical studies. Both saline and gel filled breast implants were released years ago by the Food and Drug Administration (FDA) to be used for breast reconstruction and for replacement of older or present gel implants.

The TRAM flap technique uses autogenous, or one's own tissue to create a breast mound. This surgery takes an average of five hours in addition to mastectomy completion with the average hospital stay of five days and an average recovery time of five weeks. The abdominal skin above the belly button is lifted off the abdominal fascia and sutured down to the pubic area skin with replantation of the belly button. The four to five week recovery period is necessary to straighten and strengthen the abdominal walls and muscles. Activity levels usually return to the normal, pre-operative status.
The latissimus dorsi flap with implant is usually used as a salvage

technique in the face of previous radiation or surgery. The flap consists of the latissimus muscle with an overlying skin paddle from the back. It usually requires a breast implant to obtain the desired breast shape and volume. The implant is placed below the latissimus muscle after the muscle is passed onto the chest wall through a tunnel at the base of the axilla (underarm). It is a useful reconstructive technique in the face of irradiated breast skin with deformity after lumpectomy and a lack of an adequate volume of abdominal fat.

Nipple areolar reconstruction can be performed at the time of the second stage reconstruction. Or, it can be done as a separate procedure as an outpatient under local anesthesia. The skin on the breast mound is the source of the nipple reconstruction with a full thickness skin graft, usually from the inner, upper thigh skin used for the areolar reconstruction. This skin is usually textured and pigmented resulting in a realistic appearing areola.

An extensive and detailed consultation with the plastic surgeon is mandatory for a patient to be truly informed and guided to make the best decision about breast reconstruction in conjunction with the treatment recommendations from the breast surgeon and oncologist

	Average Operating Time	Average Hospital Stay	Average Recovery Time	Characteristics
Expander/Implants	1-2 hours	1-2 days	2-3 weeks	Multi-stage No visible scars Muscle not impaired
Latissimus dorsi flap	2-4 hours	2-4 days	2-3 weeks	Implant Needed Scar on back Minimal weakness
TRAM flap	3-6 hours	3-6 days	4-8 weeks	No implant Scars on abdomen Possible abdominal weakness

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FREQUENTLY ASKED QUESTIONS:
Removal or deformity of a woman's breast following cancer treatment, injury or developmental abnormalities may severely impact one's body image and self-esteem. The removal of any body part, male or female can evoke a sense of loss. Breast reconstruction can be a great benefit in overcoming the emotional and physical consequences of a mastectomy or breast deformity.

How is breast reconstruction done? There are two general techniques of reconstruction. One technique uses a breast implant which is made of silicone and contains silicone gel, saline, or a combination of both. The second uses the patient's own skin, fat, and muscle to recreate the breast mound (flap reconstruction).

How is the implant method done? Following mastectomy the surgeon places a tissue expander beneath the skin and muscle. This is a balloon made of silicone which will gradually be inflated over several weeks or months with saline (salt water). This expander placement requires about one hour under general anesthesia and one or two days of hospitalization.

When the desired expansion is achieved , a second stage is required to remove the expander and replace it with the permanent implant. In some cases, a type of expander may be used which remains as the final implant. The second operation usually takes one or two hours and most often is performed as an outpatient or short hospital stay.

This technique is the simplest and shortest method of breast reconstruction, although it may ultimately take longer to achieve the final result. The recovery time for each stage is relatively short. On the other hand, it usually requires many office visits, additional surgeries and several months to complete the reconstruction. All of the possible complications of breast implants must be considered. (i.e. capsular contracture, wrinkles, infection, etc.) This method also has a high complication rate when the chest has had previous radiation therapy.

How are flap reconstructions done? Currently, the most common flap reconstruction is the TRAM (transverse rectus abdominus myocutaneous flap). This method uses the skin, fat, and muscle of the abdomen to reform the breast. The muscle "carries" the blood supply to the overlying skin and fat. The abdomen is repaired much the way a cosmetic "tummy-tuck" is performed. On occasion, two muscles of the abdomen can be used to "carry" larger amounts of skin. Another variation removes the "tissue" completely, transplanting the skin and fat to the chest using "microvascular" techniques to establish circulation. When the abdominal area is scarred from other surgeries or too thin to create a breast, tissue from the buttock or thigh can be transplanted to the chest using microsurgery. These operations generally require more than four hours but essentially create the breast mound in one operation. The hospitalization is usually four to seven days.

TRAM abdominal closure usually includes a synthetic mesh placed in the abdominal wall to add strength and prevent hernias or weakness where the muscle is removed. Blood transfusions may be required and autodonation (autologous blood) of the patient's own blood or donor directed blood is recommended when time allows. Smokers must stop smoking four weeks before and after surgery to reduce possible circulation problems and complications.

Although this operation can provide a very natural appearing breast, the patient must accept the longer surgery and recovery time, as well as the additional scars where the flap is taken from (donor site)

What is the Latissimus Flap? This is a flap of skin, fat and muscle (latissimus dorsi) from the back which can be molded into the form and shape of a modest breast (A/B cup) without the use of an implant. Much of the previous discussion applies to this technique as well. The scar on the back is transverse or oblique and attempted to be kept within the brassiere or clothing lines. There may also be some contour deformity where the fat is taken from. Commonly, the flap is used with an implant to create a larger breast in one stage.

Are other operations required? To achieve symmetry, many women choose to alter the other breast either by enlargement, reduction, or lift (mastopexy). Frequently, this can be done at the second stage (in the expander method or along with nipple areola reconstruction. These operations leave additional scars.

How is nipple areola reconstruction done? Generally, this operation is done several weeks to months after the breast is reconstructed. The nipple is created from local "flaps of skin and fat." The areola can be made from darker skin taken from the groin or by tattooing pigment into the skin. This is generally an outpatient operation and often is done with local anesthesia.

What are the potential risks of implants? Additional materials are enclosed which review this information in depth. Women who choose implants are required to participate in the FDA study which tracks and evaluates the outcome of participant's risks, benefits, and patient's responsibilities are outlined in separate consent forms for the study. Relevant information regarding saline implants can be provided in the information packets on Breast Augmentation.

What are the risks of surgery?

Initial

1. GENERAL RISKS of surgery include infection, pain, delayed wound healing, hematoma (a collection of blood at the surgical site), bleeding or reactions to anesthetic.

2. BLEEDING: When blood collects beneath the skin it causes excessive discoloration. Sometimes lumps which last many months may occur. If blood collection is discovered, it is usually removed by taking out a few stitches and squeezing the clot out, or inserting a needle and aspirating it. If bleeding continues, it is sometimes necessary to return to the operating room to stitch the bleeding vessels. This risk is increased in people who take aspirin or who bruise easily. Let your doctor know if this is the case. Do not use aspirin or aspirin-containing products for two weeks before and two weeks after surgery. (See list of medications that may increase bleeding. )

3. LOSS OF SKIN: The skin will sometimes lose its blood supply. When this happens, an area of skin will fail to survive and a number of weeks are needed for healing. Rarely, a skin graft may be needed to obtain healing. This risk is increased in smokers; therefore, you must stop smoking at least 4 weeks before and 4 weeks following surgery.

4. FLAP LOSS: Circulation problems can also effect the muscle and fat. On occasion, this can result in the loss of part of the flap or fat necrosis with subsequent areas for firmness. Rarely, complete loss of the flap occurs. Additional treatments such as hyperbaric oxygen therapy or emergent surgery may be required.

5. INFECTIONS: A significant wound infection requires antibiotic treatment and a longer stay in the hospital. Sometimes the wound must be opened to drain the infection and then the healing process is slowed.

6. SEROMA: On occasion, a clear yellowish fluid collects in the wound under the skin. It may require aspiration with a needle and syringe in the office. Aspirations may have to be repeated for several weeks.

7. NUMBNESS OR PAIN: Many little nerves are cut as part of the operative procedure. These must grow out again over a period of some months. Numbness of the abdominal skin will be noticed during this period. Sometimes the sensation does not return completely. Occasionally scar tissue forms around a healing nerve, causing pain. Usually this disappears within a period of several months.

8. UNSATISFACTORY SCARS: The scars are expected to be quite prominent and unsightly during the first 6-12 months after the operation. As the scars mature, they soften, become lighter in color and flatten out. An occasional patient forms excessive scar tissue and the maturing process is greatly delayed. Very rarely a patient will form a "keloid": the scar becomes larger and does not go away. If you have a history of true keloids, you should not have this operation.

9. ABDOMINAL WEAKNESS is generally prevented by the use of synthetic mesh, however on occasion, it is still a problem and uncommonly, a hernia may result.

10. NIPPLE CONTOUR problems such as lack of projection or over projection may occur and can require additional surgery for improvement.

11. AREOLAR COLOR: Asymmetry may require tattoo pigmentation for improvement.

12. BLOOD CLOTS IN THE LEGS OR LUNGS (Thrombosis and Pulmonary Embolism): Some people (particularly older people) tend to form blood clots in the legs after abdominal surgery, especially if their hips are in a flexed position. These blood clots can break off and go to the lungs. It is possible for such an event to be fatal. It is important for patients to get up out of bed and begin walking as early as possible after surgery to avoid this problem. Pneumatic compression stockings will also be used to help prevent this problem.

13. ATELECTASIS AND PNEUMONIA: Following a general anesthetic there is a tendency for the air sacs in the lungs to stick together. It is very important for patients to take deep breaths and to cough vigorously at frequent intervals after surgery to inflate the air sacs. Once in a while some air sacs will stay collapsed, causing patients to have a fever. The area in the lung which is affected can often be seen as a shadow on a chest x-ray which is called "atelectasis". Patients must then make every effort to breathe deeply, to cough frequently and to expand the air sacs, otherwise, pneumonia can result and hospitalization will be prolonged. This risk is increased in smokers or those patients with chronic lung disease.

14. CONTOUR IRREGULARITIES: Areas of depressions, waviness, "lumps" or asymmetries may occur. Some improve over time while others require additional surgery for improvement.

15. UMBILICUS (NAVEL) LOSS OR MALPOSITION: As with skin loss, poor circulation can result in partial or complete loss of the navel. Smoking within four weeks of surgery increases this risk. Furthermore, on occasion, the position of the navel may be higher or lower than desired or even slightly off midline position.

16. DEHISCENCE or separation of the incision occurs on occasions. This can result from excessive activity, trauma, infection, or tearing of the sutures and will delay healing.

17. IMPLANT COMPLICATIONS These are reviewed at length on the separate sheet title "Saline Implants: Potential Risks or contained in the "Gel-Implant FDA Study Consent". Initial this paragraph when you have reviewed this written material.

18. PHOTOGRAPHY: Photographing, filming, or videotaping of the treatment or procedure for educational or diagnostic use is a standard and required part of patient care.

19. NO GUARANTEE: The practice of medicine and surgery is not an exact science. Although good results are expected, there cannot be any guarantee, nor warranty, expressed or implied, by anyone as to the results that may be obtained.

20. COMPLICATIONS AND ADDITIONAL SURGERY: Any of these problems noted above may require additional surgery, hospitalization, and time away from work. If this occurs, there will be additional costs for surgical fees, supplies, anesthesia, etc., depending upon the required operation. Complications of cosmetic surgery generally will not be covered by medical insurance.

21. ANY FUTURE REVISIONAL SURGERY WILL INCUR ADDITIONAL COSTS TO BE PAID BY THE PATIENT.

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