Breast reconstruction offers 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 breast surgery can restore breast mound again.
Typically breast is reconstructed using either breast 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.
Breast Expander/Implant Reconstruction
Breast expander is placed either immediately at the time of the mastectomy or later in a delayed fashion. After the initial healing, breast expander is slowly inflated during office visits. When the breast skin has been sufficiently stretched, an out-patient surgery replaces the breast expander with a permanent breast implant. The choice of saline versus silicone implant will be made after a thorough discussion regarding the benefits and risks of each device. Fat transfer has been an important recent addition which significantly enhances the cosmetic outcome. Nipple reconstruction, if desired, is performed at a later date once the breast mound becomes stable and satisfactory. Sometimes additional surgery is necessary on the other breast to better match the reconstructed breast.
Advantages: Shorter and less invasive surgeries with lesser recovery than autologous option.
Disadvantages: Implant related problems such as rupture and capsule formation. Typically poor outcome when breast radiation is involved.
- 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
Rectus Abdominus Myocutaneous Flap(TRAM)
TRAM represents a more complicated and the longer reconstructive procedure, requiring about 6-7 hours of surgery for each breast. Rectus abdominus muscle and the overlying fat/skin are detached and tunneled up to the chest. The flap is shaped to create a breast mound matching the opposite side.
Breast implants are not usually required. The tissue is generally adequate to match the size of the other breast. Large or pendulous opposite breast may require a simultaneous breast reduction/lift. 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 maybe placed over the area where the muscle was removed. This strengthens the abdominal wall closure and lessens the chance of a hernia development. Some contouring of the new breast mound may be necessary at a later surgery. Nipple reconstruction is done as an additional procedure.
Advantages: This provides the most natural looking and feeling breast reconstruction. Not needing breast implant avoids future implant related complications such as deflation or capsular contracture. The scar is hidden with clothing but undesirable keloid scar may occur.
Disadvantages: The more complicated and prolonged nature of the surgery increases overall risks associated with the surgery, especially if there are other accompanying medical problems, smoking, obesity, or age over 65. There is a risk of hernia or abdominal weakness resulting from removal of the rectus abdominus muscle. Abdominal strength is diminished.
Contrary to a popular belief, this is not a true tummy tuck as the scar is much higher on the abdomen.
- Deep venous thrombosis and possible pulmonary embolus.
- Poor circulation to the flap resulting in tissue death.
- Weakness or herniation of the abdominal wall.
- Mal-positioned umbilicus.
- Collection of fluid (seroma) under the skin requiring needle aspiration.
- Need for an artificial mesh to repair donor site.
The reconstruction of the nipple adds a very pleasing final touch to the breast. This is a simple outpatient procedure that may be done with local anesthesia with sedation. The goal of the surgery is to create a nipple by using local skin flaps. After satisfactory healing, nipple can be tattooed to improve the color match.
- Additional scarring
- Shrinkage of the of the nipple, common in thin patients
Breast reconstruction following mastectomy is a rewarding procedure to the patient in restoring the sense of wholeness after the traumatic loss. There are many options which sometimes can be overwhelming. A careful and thorough discussion will help guide each patient achieve her goals.