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Breast Reconstruction

Procedures Offered:

Post-Mastectomy Radiation Therapy affects the procedural options available to you.

Expanders and Implants

This procedure typically involves at least two surgeries, but has the fewest scars and is the least invasive of all of the options.

A tissue expander is a balloon placed at the time of the mastectomy and adds about 1 hour of extra surgery time. This procedure usually entails one and sometimes two days in the hospital. Recovery times vary, but typically is in the 2-3 week range.

During weekly office visits over 2-3 months and starting about 2 weeks after placement, the expander is slowly filled with salt water until the desired size is reached. When chemotherapy (if necessary) is completed, the expander is removed and the permanent implant placed. This takes about 1 hour and is done on an outpatient basis.

After healing from the second surgery, a nipple can be created in the operating room in a pain free manner with skin taken locally from the reconstructed breast. A tattoo is added later in the office for the areola color.

Expander and implant surgery is best suited to women who are small breasted and slender. It will appeal to woman who are looking for symmetry in clothing. Over the years the appearance will change little, while the unaffected breast will have normal aging changes.

Expander and implant surgery is not as well suited for larger breasted women, recipients of radiation therapy, women who want symmetry out of clothing, or for those who would have difficulty with repeated office visits. Yet it may stay still be the best choice for beginning the reconstruction process.

Your surgeon may discuss the use of processed human skin as part of your implant reconstruction. One stage reconstructions are sometimes possible.

Risk of infection is always a possibility and this typically leads to failure of the procedure with need for removal of the expander. The risk is approximately 1 in 25.

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Abdominal Flap Breast Reconstruction / Free TRAM / DIEP Flap

This option is sometimes called a 'tummy tuck' breast reconstruction. Skin and fat between the navel and pelvic bone are used to create a mound of tissue to replace the removed breast. The result is a flatter stomach and a breast mound reconstruction made of your own tissue. The goal of this procedure is to create a breast mound symmetric with your opposite breast that is as natural and lasting as possible.

Microsurgery is often used to help in the movement of tissue from the abdomen to the chest. These are called "free flaps", because the tissue is free and disconnected from the body for a brief time. Depending on the anatomy of the blood vessels to the tissue, sometimes all of the lower rectus abdominis muscle is harvested with the skin and fat. This is called a "free TRAM flap". If only a portion of the muscle is needed, it is a "muscle sparing free TRAM flap", and if no muscle is taken from the abdomen, it is called a "DIEP" flap or "SIEA" flap. There may be a tradeoff between the reliability of the flap and the recovery of the abdomen from surgery. About 1 in 25 times the vessels clot off resulting in partial or total loss of the flap. The disrupted circulation can also result in small areas where the transferred fat dies and becomes firm. These can be removed or improved with surgery at a later time.

Because the flap is taken from the abdomen there is a resulting long hip to hip scar near the underwear line, which will partially fade over time. The surgery can cause some weakness in the abdominal muscles because part of one muscle is often taken with the flap; the exact amount needed cannot be determined until the time of surgery and depends on the woman's individual blood vessel anatomy.

Women in good health who have had children, have generous lower abdominal tissue and fat, and wish for breast symmetry out of clothing are good candidates for this procedure. Smokers and obese women may have a more complicated postoperative healing process.

This procedure takes at least 4-5 hours and requires 3-5 days in the hospital, with the first night in intensive care to moniter the transferred flap. A blood transfusion is occasionally necessary. Drains will be placed during the surgery and left for 5-7 days (these prevent fluid from collecting in the breast and abdominal area which complicates the healing process).

You should plan on at least 6-8 weeks of postoperative recovery time.

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Latissimus Flap Breast Reconstruction

This option utilizes skin and muscle from the back which is tunneled just under the axilla to create a breast mound. Because the back has less fatty tissue than the abdomen, an implant is usually necessary to achieve the desired breast size. The blood supply to this tissue is left intact so failure of the flap is rare. This is a useful procedure for women who have large breasts but do not have sufficient abdominal tissue, have wound healing problems, previous infections of the chest, or have had prior radiation therapy of the chest.

This procedure takes about 3 hours and requires 2-3 days in the hospital. Drains stay in the back for 1 to 3 weeks to prevent fluid collections there. Besides the scar on the breast, there is also a long scar on the mid-back region of the affected side. This scar is placed in a natural fold line that many women have to improve the quality of the scar. Recovery for this procedure is in the 3-4 week range.

For a larger breast size, an expander (rather than a permanent implant) is placed at the time of surgery under the latissimus flap and necessitates extra office visits to fill the expander. A second surgery to replace the expander with a permanent implant is then performed.

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Bilateral Breast Reconstruction

Bilateral refers to breast reconstructions on both sides. For various reasons, patients decide to undergo bilateral mastectomies. Some of these patients request bilateral breast reconstructions.

Important Concepts For These Patients

Bilateral breast reconstruction with expanders and implants is still a multi-step procedure with numerous office visits. Operating on both sides is not much more involved than operating on just one side. It is still a 60-90 minute procedure that occurs after the mastectomies. A second operation in the OR is needed to remove the exapnder, make adjustments, and to place the permanent expander. The second surgery is done as an outpatient, typically 3 months after the placement of the expanders, or after chemotherapy and/or radiation therapy have been completed.

The implants, because they are both round, achieve some added symmetry for the patient. A patient will continue to have weekly office expansions until she feels that the size of the expanders is appropriate for her build, her clothes, and her expectations. The final size depends upon the patient's expectations for how she will look in clothes.

If the patient has already had radiation to her chest or if there is some wound healing issue, the patient may elect to have an expander on one side, and a latissimus flap for the other side. Rarely, both side latissimus flaps are performed, especially for women who have had bilateral chest radiation for Hodgkin's disease in the distant past.

For the patient with abundant abdominal tissue, a bilateral breast reconstruction with free flaps is an option. In comparison to the use of expanders and implants, this is a much more involved procedure, lasting 8-10 hours in length for the mastectomies and the reconstructions. As for any free flap, there is a risk of the small blood vessels clotting off, and the loss of the flap. The recovery from this procedure is fairly long, because parts of both stomach (rectus) muscles must be used to help dissect out the blood vessels to the flaps. Mesh is often needed to reconstruct the abdominal wall and to help prevent a bulge or a hernia. Half of the lower abdominal tissue is used to make one breast, and half is used for the other. The size of the breast reconstruction then depends on the amount of abdominal skin and fat available. In general, the reconstructed breast mounds are a bit smaller than the patient's cup size before surgery.

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How Radiation Therapy Affects Breast Reconstruction Surgical Options

Radiation is delivered to women with breast cancer to help prevent the return of the cancer on the chest. There are studies that imply a small improvement in overall cancer cure rates when radiation is added to surgery for breast cancer.

Radiation is specialized energy delivered to the breast or chest, and it causes a very precise and selective "burn" to the tissues. The tissues become red often during treatment, and rarely wounds develop. The tissues then go on to heal from the radiation treatment. Some people show absolutely no ill effects from the treatment, while in others the tissue and skin is contracted, firm, and discolored.

One important concept is that a history of radiation therapy causes unpredictable healing when surgery is needed on the radiated tissues, even multiple years after the radiation.

Another important concept is that radiation makes breast reconstruction more difficult, and probably with overall poorer cosmetic outcomes.

A final important issue is the effects of radiation are unpredictable, and so plastic surgeons tend to not want to do complex flaps for breast reconstruction before radiation therapy. Plastic surgeons tend to perform flaps after radiation therapy has been delivered to the tissues.

Three Scenarios In Which Patients and Plastic Surgeons
Must Discuss Radiation Therapy

  1. Patients with newly diagnosed breast cancer, who will receive
    radiation therapy after the mastectomy.

    Women with large breast tumors and women with more than three positive lymph nodes often are treated with radiation after the mastectomy. When there is a high suspicion on the part of the breast cancer surgeon that radiation will be needed after the mastectomy, this should be communicated with the plastic surgeon.

    In general, there are two main ways to achieve a breast reconstruction for Scenario A. The reconstruction can be performed after the mastectomy and radiation has been completed. This is the same as Scenario C, below. Alternatively, a tissue expander is placed at the time of the mastectomy, and the tissues expanded before the radiation. The radiation therapists at Northwestern believe it is totally acceptable to radiate the tissues with the expander in place. After radiation therapy is completed and the tissues have all healed (several months later), the patient can undergo the definitive breast reconstruction. That can be a simple implant exchange, the latissimus flap, or the TRAM flap. Immediate breast reconstruction with a tissue expander preserves all of the options available for women who will undergo post-mastectomy radiation therapy. While implant reconstructions under radiated skin often are firmer and with more capsular contraction than for non-radiated patients, this option is simple and suffices for many patients.

  2. Patients with a previous lumpectomy and radiation therapy.

    Women with a recurrence after breast cancer treatment are not candidates typically for expander/implant reconstructions, because the radiated skin does not expand well and the expanders often become infected. Scenario A with implants is possible, because the tissue is expanded before the radiation is delivered. Patients in Scenario B are recommended to have either the latissimus or the tram flap breast reconstructions. Both of these flaps are non-radiated, and the non-radiated flap tissue helps with healing. The choice to use the back or the abdomen depends on patient choice and the surgeon's evaluation of the amount of abdominal tissue for a TRAM flap.

  3. Patients who already have had mastectomies and radiation,
    and now want a breast reconstruction.

    For the same reasons outlined in Scenario B, patients in Scenario C are counseled to undergo one of the flap reconstructions for breast reconstruction.

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