Breast Reconstruction

Breast reconstruction offers much hope for a woman losing her breast to cancer. Reconstruction can often be performed immediately at the  time of the mastectomy However in certain circumstances, a delayed reconstruction performed at a later date may offer advantages. In either case, reconstructive surgery holds much promise that the post-operative breast can restore breast mounds again.

The Surgery

Typically breast is reconstructed  using either expander or autologous tissue. Many factors are considered  in picking the best option for each patient.  Dr. Chun will discuss various reconstructive options at the initial consultation.

When the skin has been sufficiently stretched, an out-patient surgery replaces the tissue expander with a permanent breast implant. Nipple reconstruction, if desired, is performed at a later date once the breast mounds become stable and satisfactory. Sometimes surgery is necessary on the other breast to better match the reconstructed breast.

Advantages: Less surgery and shorter recovery.

Disadvantages: Implant related problems such as rupture and capsule formation. Unsatisfactory outcome due to extremely thin tissue. Typically poor outcome when breast radiation is involved.

Possible Complications:

• Loss of breast skin requiring additional surgery.
  
• Noticeable outlines of the implant due to thin soft tissue coverage. 
• Firmness and tightness  due to capsule formation

Latissimus Dorsi Myocutaneous Flap

This surgery involves moving the latissimus dorsi muscle and overlying skin from the back to the chest to create a new breast mound. The incision is usually made along the bra line so the scar will be concealed.

A breast implant is usually placed under the flap. Nipple reconstruction is done later.

Advantages: This is a very reliable procedure, which provides a good environment for an implant. The chances of capsule formation around the implant are reduced.

Disadvantages: Scar across the back. There may be decreased strength in the back due to muscle loss. Capsule formation may occur and result in the need for additional surgery.

Possible Complications:

• Circulation problems with the flap
• Formation of capsule around the implant
• Symptoms from loss of shoulder muscle, such as decreased strength
• Loss of back skin requiring skin grafting
• Collection of fluid (seroma) under incision requiring needle aspiration

Rectus Abdominus Myocutaneous Flap(TRAM)

This is a more complicated and the longer reconstructive procedure, involving about 6-7 hours of surgery for one breast. Rectus abdominus muscle is detached and tunneled along with the overlying skin up to the chest. The breast mound is created to match the opposite site. A blood transfusion may be required. You may donate your own blood prior to surgery to be re-infused during the surgery.

Breast implants are not usually required. The tissue is generally adequate to match the size of the opposing breast. If the opposite breast is large or pendulous it can be decreased in size by a simultaneous breast reduction. Patients wishing to have this procedure must stop smoking six weeks prior to and six weeks following surgery. Failure to comply may result in death of the flap. A synthetic mesh is placed over the area where the muscle is moved. This strengthens the abdominal wall closure and lessens the chance of hernia development.  Some contouring of the new breast mound may be necessary at a alter surgery. Nipple reconstruction is done as an additional procedure.

Advantages: This provides the most natural looking breast reconstruction.  No implant is needed so capsule formation is not a risk. The scar is  hidden with clothing but may form keloid scar.

Disadvantages: The more complicated and prolonged nature of the surgery increases overall risks associated withe surgery, especially if there are other accompanying medical problems. There is a risk of hernia or abdominal weakness  resulting from moving the rectus abdominus muscle. Abdominal strength is diminished.

Contrary to a popular belief, this is not a true “tummy tuck” as the scar is generally much higher on the abdomen.

Possible Complications:

• Deep venous thrombosis and possibly pulmonary embolus.
  
• Poor circulation to the flap resulting in tissue loss
• Weakness or herniation of the abdominal wall.
• Placement of the umbilicus off center
• Collection of fluid (seroma) under the skin requiring needle aspiration.
• Need for an artificial mesh to repair donor site.

Nipple Reconstruction

The reconstruction of a nipple adds a very pleasing final touch to the breast. This is a simple outpatient procedure that may be done with local anesthesia.  The goal of the surgery is to create a nipple by using local skin flaps.  When properly healed,  nipple can be tattooed to improve the color match to the opposite breast.

Possible complications:

• Additional scarring
• Shrinkage of the projecting part of the nipple
• Infection of the donor site or the newly created nipple

Reconstruction of the breast following mastectomy is a very rewarding procedure to both the patient and the surgeon. Many women describe a feeling of once again being whole. There are many materials available  options regarding breast reconstruction. There are support groups available where one can meet women who have gone through these procedures. Ask us for references, books and support groups in your area. Take advantage of these invaluable resources.