Breast Reconstruction

Breast reconstruction offers much hope for a woman losing her breast to cancer. Reconstruction can often be performed immediately after the mastectomy, so the woman does not have to leave with one breast. Depending on health conditions, however, a mastectomy patient may have to wait before undergoing reconstructive surgery. In either case, reconstructive surgery holds much promise that the post-operative breast can match the natural breast again.

The Breast Reconstruction Surgery

When reconstructive surgery is performed immediately following mastectomy, a breast mound is created in place of the breast that has been removed. This is done in the hospital under general anesthesia. Dr. Bray will work with your oncologist to ensure the best possible conditions for reconstruction.

Breast reconstruction usually involves more than one operation, and follow up procedures may be performed on an outpatient basis. Follow-up procedures may only require local anesthesia, and often involve a skin expander with a breast implant, and reconstruction of the nipple and areola. Sometimes surgery is the performed on the natural breast to match the reconstructed breast; however, this creates additional scars.

Once the breast mound is in place, your plastic surgeon may follow up with a skin expander and breast implant or flap reconstruction.

Skin Expander with Breast Implant

This is the simplest of breast reconstructions. Blood transfusions are not required, and there is minimal pain and a short recovery time. In this procedure, a tissue expander is placed under the skin. Once sutures are removed, saline is added weekly to the expander. This stretches the skin as it expands.

When the skin has been sufficiently stretched, the tissue expander is removed replaced by a permanent breast implant in a two-stage procedure. Nipple reconstruction, if desired, is a separate procedure.

Advantages: Simplest surgery and shortest recovery from surgery. This is the favored procedure for persons who have heath problems or contraindications to extensive surgery.

Disadvantages: Multiple trips to the office over several weeks or months to undergo expansion. Capsule formation or poor cosmesis due to thin skin.

Possible Complications:

• Loss of breast skin requiring removal of implant. If you have undergone radiation this procedure is not advisable as you are at increased risk for skin loss.
• Noticeable outlines of the implant due to capsule formation
• Hard texture due to capsule formation
• Thin breast skin

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.

Blood transfusions are not usually required. A breast implant can be placed under the flap if necessary to balance a difference in size. 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

This is the most complicated and the longest reconstructive procedure, involving about 4-5 hours of surgery. One of the rectus abdominus muscles is 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 and minimizes the chance of herniation of the bowel. Nipple reconstruction is done as a second procedure. Some contouring of the new breast mound may be necessary at the same time.

Advantages: This provides the most natural looking breast reconstruction with the added benefit of a “tummy tuck”. No implant is needed so capsule formation is not a risk. The scar is easily hidden with clothing.

Disadvantages: There is a risk of herniation of the bowel resulting from moving the rectus abdominus muscle. Abdominal strength is diminished. This is the longest procedure and has the greatest risk for requiring a blood transfusion.

Possible Complications:

• Inadequate tissue requiring the use of a breast implant
• 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.
• Infection, in particular of the mesh requiring surgery for removal.

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. An average time for this is about 1-2 hours. The goal of the surgery is to create a nipple that has the appearance of the nipple of the opposite breast. Skin is taken from the inner part of the upper thigh or from behind the ear. These areas tend to have a darker pigment, which will provide a better contrast to the breast tissue. As a second procedure the healed nipple can be tattooed to improve the color match of the opposite breast.

Possible complications:

• Excessive scarring
• Shrinkage of the projecting part of the nipple
• Infection of the donor site or the newly created nipple
• Blood clot under the nipple, which may result in loss of all or part of the new 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 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.