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Breast Reconstruction Overview


Overview

Few operations in plastic surgery require the technical expertise as well as the personal compassion as breast reconstruction. When consulting with a plastic surgeon it is imperative to form a bond with him or her. Breast cancer and mastectomy are very emotional. It is a very difficult time for the patient. Often, the patient feels like she is in a fog and nothing seems real. But the consequences are very real. It is important to take all the patient's issues into consideration when planning what is best for the patient as a whole.

Sometimes, it is best to wait for a while and reconstruct in the future. In general, however, it is best to have the reconstruction performed at the same time as the mastectomy. This allows the woman to feel complete right after the mastectomy. Facing breast cancer is very difficult. It is easier from a psychological point of view to feel and see that things are getting back to normal. Another significant advantage is that the patient has to undergo anesthesia only once .

Another fundamental decision the patient must make with the help of the plastic surgeon is whether or not she wants her breast reconstructed with an implant or with her own natural tissue. The own natural tissue usually means performing a TRAM flap reconstruction using abdominal muscle and fat. This has the additional benefit of having a tummy-tuck done at the same time. This is helpful to the patient’s state of mind. She feels that, even though she just lost something very dear to her, she gained something in return. Not every woman is a good candidate for a TRAM flap. Poor candidates include patients with: significant obesity, heavy smoking habit, certain abdominal scars, previous abdominoplasty, significant lung or heart disease and brittle diabetes. Another choice for reconstruction with natural tissue is using fat and muscle from the back. This is known as a latissimus dorsi flap. It can be used with or without an implant.

Another option, which does not involve using the patient's own a natural tissue, is to use a tissue expander. It is done by placing an implant under the pectoralis muscle, usually at the time of mastectomy, and then expanding it to the desired size over the next 3 months. The expansion is done during regular office visits and is relatively painless. Once the expanders are filled to the desired size they are usually removed and replaced with a permanent implant. This is a quick outpatient procedure. It is often an excellent choice if both breasts are removed and are being reconstructed simultaneously. Implant reconstruction, however, does not create as normal appearing breasts as your own tissue does. If both breasts are being reconstructed, this is not as much of a problem because at least there is a very good symmetry. If only one breast is being reconstructed this is more of a problem, especially if the breasts have some sag to them; most do beyond the age of 30. Here, patients own tissue produces a more natural result.

To simplify things, the most important question a patient needs to answer is whether she wants to use an implant or her own natural tissue. It is a question she needs to work out with her plastic surgeon. If she decides to have an implant, she can always have reconstruction with her own tissue down the road if she changes her mind.

It should be mentioned that breast reconstruction, no matter which type is decided upon, does not affect the recurrence of the breast cancer, nor does it interfere with the radiation or chemotherapy, if it is necessary.

Benefits

The benefits of breast reconstruction in the patient with the diagnosis of breast cancer are immeasurable. It provides the patient with a sense of wholeness during a time where she feels like she has very little control. The entire reconstruction process can be looked at as a process of getting the patient back to normalcy.

Are you a good candidate?

Most women, if they are reasonably healthy, are good candidates for at least implant breast reconstruction, because implant insertion requires less additional operating time to perform. If you are in poor health, then either implant or nothing at all would be your choice. If, however, you are not in poor health, you have a choice. At this point, the question becomes: Are you a good candidate for reconstruction with your own tissue?

In hands of most doctors, the most natural appearing and feeling breasts are obtained when your own tissues are used. This is not to say that implant reconstruction cannot provide a good result. The reality is that nothing feels more natural than your own tissue. Also, your own tissue will sag somewhat over time just like a normal breast does. Some patients have commented that implants used for augmentation provide very attractive breasts so why can't they provide very attractive reconstructed breasts? This is a very good question. The answer is that even on a woman with very small breasts an implant used for augmentation still has SOME breast tissue to act as padding and to hide the implant. With a mastectomy, the point of the operation is to remove ALL the breast tissue to adequately treat the cancer. Therefore, an implant under a reconstructed breast has only skin and a muscle to cover it. There is no fat and no breast tissue.

Aside from having poor health, there are some other factors that may make breast reconstruction with your own tissue unwise. These include being markedly overweight, prior abdominal surgery, very little abdominal fat, diabetes, and smoking. All these must be discussed during your consultation with a plastic surgeon.

Possible complications

When outlining complications, it is important to distinguish the complications unique to implant reconstruction, and those unique to reconstruction with your own tissue.

Possible complications unique to implant reconstruction are: possible implant failure (i.e. rupture), malposition of implant, capsular contraction (hardening of the tissues around the implant), visible rippling of the implant, extrusion of the implant, and increased risk of infection, because the implant is a foreign body.

Possible complications unique to reconstruction with your own tissue include: loss of part, or all of the transferred tissues, abdominal hernia formation, unfavorable abdominal scar, unfavorable naval reconstruction, unfavorable abdominal contour and unfavorable breast shape.

Possible complications seen with any major abdominal or breast surgery include: infection, wound healing problems, fluid or blood collection and blood clot formation. Blood clot formation within the deep veins of the leg can break off and travel to the lung causing a pulmonary embolism. A pulmonary embolism can be life-threatening.

Do's and Dont's prior to surgery

  • Medications. Certain medications thin blood and should not be taken within 3 weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should discontinued. Your doctor will go over this more thoroughly prior to the procedure.

  • Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask your doctor for something to help you sleep.

  • Smoking. You must not smoke within 3 weeks before and after surgery. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood of infection, wound healing problems, and scar formation. It also affects your airway, what makes anesthesia much more difficult.

  • Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. It is OK to take medications with a sip of water. Please discuss all medications with your doctor and the anesthesiologist.

  • Washing. It is a important to wash the entire surgical area thoroughly the night before and the morning of surgery. This includes cleaning crevices such as the naval and any folds in an effort to prevent infection.

  • State of mind. Remember, state of mind is critical. It affects not only your attitude but your immune system and your overall ability to heal. Excessive worrying can actually be detrimental and you should discuss this with your doctor prior to surgery so that something can be prescribed to make sure you remain calm.

Anesthesia

The anesthesiologist will discuss with you what type of anesthesia is best for you. He/she will take into consideration your medical history, the procedure, and your personal wishes.

General anesthesia is the only option available for breast reconstruction surgery.

After the procedure

The length of the mastectomy and reconstruction is variable. If reconstruction is done with an implant, the entire procedure usually lasts around 4 to 5. If a TRAM flap is used for reconstruction, the entire procedure usually will take from 6 to 8 hours. There are many variables that can change the length of the surgery.

Immediately. Immediately after the procedure you will wake up in a recovery room, where nurses will be monitoring you. Around an hour postoperatively you can have friends and family visit you. You will have dressings and a surgical bra on. If you have had a TRAM reconstruction you will also have dressings around your abdomen and you will be in a flexed forward position. You will be able to talk but, understandably, you will probably feel somewhat tired. Most likely you will have drains coming out of the surgical wounds to prevent fluid collections. Approximately 2 hours after the operation you will be transferred to the nursing floor.

The remainder of the post operative course is markedly different between the implant reconstruction and a TRAM flap reconstruction. The TRAM flap reconstruction is a much more involved surgery and usually requires a hospital stay between 4 and 6 days. This is compared to an implant reconstruction hospital stay which is normally between 2 and 3 days.

With an implant reconstruction you will possibly be up and walking the evening of surgery and certainly the next day. You are discouraged from doing active exercise with your arms, as this may cause implant malposition and/or bleeding. The drains are removed usually on the second or third day after the operation.

Normally you go home 2 or 3 days after the operation and are encouraged to walk around slowly. Stairs for the first week are discouraged. You may shower on the second post-operative day by just standing in the shower and letting the water gently roll over you. After the shower, you should apply bacitracin, surgical gauze, and put on your surgical bra.

With TRAM flap reconstruction recovery is much slower. You will remain in bed the evening after surgery but will be encouraged to deep breath and drink fluids. The next day you will be encouraged to walk around in a flexed forward position with the help of a nurse. You will not be able to shower until about day 3 or 4. Depending on how quickly you will be able to get around on your own, you will usually go home 4 to 6 days after the operation. Normally the drains from your breast area will be removed on day 3 and the ones from your abdomen will probably remain until about 10 days after the operation.

When you go home you will still be walking in a flexed forward position. You will be able to shower and do your own dressing changes. Post operative medications and other protocol will be modified as necessary by your doctor with your recommendations.

Typically, it takes about 4 weeks until you will be able to get around normally without being too active. It will take about 3 months before you are able to actively flex your stomach muscles. Keep in mind, because one of the stomach muscles was used to re-create the breast, you may never regain stomach strength similar to what you had before the operation.

Nipple reconstruction and/or breast revision is performed 3 months later. It is not uncommon to perform a breast lift on the other breast in order to obtain symmetry. This will be discussed after the TRAM flap. Nipple reconstruction and breast revision are relatively small procedures and done with very little, or no pain. They are performed as an outpatient procedures and have almost no downtime. Breast-lifting of the other breast for symmetry is also an outpatient procedure but has a about one week downtime period.