Breast Reconstruction Surgeries
Most commonly this involves recreating the breast shape following a mastectomy on one or both sides. This is obviously a very involved topic that is best left to an hour long consultation so that the discussion can be tailored to both your medical and surgical history, as well as your body type, plans for a nipple-sparing vs, skin-sparing mastectomy, and need for additional treatments such as chemotherapy and especially radiation history. Briefly, there are four main options for breast reconstruction. The common theme for all of the reconstruction options is that they are staged procedures (almost always more than one) and that they all have both pros and cons:
- Tissue expander followed by an implant – In nearly all cases of a delayed reconstruction and many cases of immediate reconstruction, a tissue expander will be placed at the time of the initial reconstruction. This allows the skin to recover following the mastectomy, prior to stressing it further with the full volume of the implant. For larger reconstructions or when the nipple is removed, this also allows us to stretch the skin and underlying pectoralis muscle to better accommodate the implants. This tissue expander is a saline-filled device that we can access in the office to volumize with additional saline. Eventually it is replaced with a saline or (more commonly) a silicone implant. The timing for this second surgery varies greatly (4-15 months) depending on what, if any, additional breast cancer treatments will be needed.
- Direct-to-implant reconstruction – In some cases of modest reconstruction sizes with nipple-sparing mastectomy, or in cases of previous breast augmentation, we can skip the tissue expander portion of the reconstruction. We will certainly discuss details of this further at your consultation, but a number of factors need to work in your favor to be able to accomplish this — particularly good skin health following the mastectomy. Ultimately this is a decision we would finalize at the time of the operation.
- Latissimus flap – This is most commonly performed now to help correct post-radiation problems such as asymmetry, capsular contracture or infection. This procedure utilizes the latissimus muscle on your back and a small to medium portion of the skin overlying it. The muscle and skin are then rotated through a tunnel high in your armpit and brought around to replace a portion of the damaged radiated tissue on the breast. This will also require an initial tissue expander in order to have adequate volume for the breast reconstruction. Typically after 4-5 months, the tissue expander will be exchanged out for saline or silicone implant at a second surgery.
- TRAM or DIEP flap – This reconstruction option utilizes your lower abdominal tissue to recreate the breast mound. Clearly when you utilize this much tissue, the blood supply to it must be maintained (unlike a skin graft). The manner in which you maintain the blood supply to the tissue dictates which operation was performed. A TRAM flap will utilize a portion or all of the rectus abdominis muscle (one side of your 6-pack) for each side. This may be performed as a pedicled flap (the muscle is rotated), or free flap (the blood supply is detached and then re-attached onto the chest under a microscope). A DIEP flap will spare the rectus muscle and just utilize the blood vessel which is re-attached at the chest under a microscope.
Fat Grafting to Reconstructed Breasts – This is one of our favorite finishing touches for breast reconstruction. We will perform liposuction from one area of the body and process the fat we remove. This fat can then be re-injected over the implant or within a flap in order to smooth contours, help correct wrinkling, and sometimes even improve the overlying skin quality. Obviously, you need enough fat to donate from another area of the body, and we know not all of the fat sticks around where we place it. That said, this is a procedure we offer to nearly all of our reconstruction patients because it can make a large difference in the final result. It works beautifully for naturally volumizing faces too!