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Breast Reconstruction

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What Is Breast Reconstruction?

The goal of breast reconstruction is to restore a natural, realistic breast with adequate volume and shape and an aesthetically pleasing contour.

Breast reconstruction surgery is intended to recreate the natural form of the breast after tissue was removed due to cancer or disease. This may involve using breast implants or your own tissue to restore the size and shape of the breasts, and can often be performed at the time of a mastectomy (or other treatment) or later in a delayed procedure. Our plastic surgeons, Dr. Neil J. Zemmel and Dr. Karishma Reddy, are highly experienced in performing a variety of breast reconstruction techniques, and they take great pride in helping women on their journey to feeling like themselves again.

Our Approach on Breast Reconstruction

The goal of breast reconstruction is to restore a natural, realistic breast with adequate volume and shape and an aesthetically pleasing contour.

Being diagnosed with breast cancer begins a journey of making many informed decisions that deeply affect your body and mind. Using knowledge as a guide for your journey allows you to become an advocate for your own well-being. As reconstructive plastic surgeons, Dr. Zemmel and Dr. Reddy present patients with the tools and information to build their knowledge as they embark on their journey. This page serves as an instrument of knowledge for past, current, and future breast cancer patients of Richmond Aesthetic Surgery as they make informed decisions about breast reconstruction. Remember, our surgeons will be there throughout this journey to guide, lead, or assist you with whatever you may need to succeed.

Reconstruction of a breast that has been removed due to cancer or other disease is one of the most rewarding surgical procedures our surgeons perform at Richmond Aesthetic Surgery. Recent advances in surgical techniques have made it possible for Dr. Zemmel and Dr. Reddy to create a breast close in form and appearance to a natural breast. Frequently, reconstruction is possible immediately following breast removal (mastectomy), so patients awake from surgery with a reconstructed breast in place and are spared the experience of living without a breast. There are many options to consider as you and your surgeon explore what treatment course is best for you.

This information will give you a basic understanding of breast reconstruction — when it is possible, how and when it is performed, and what the journey entails. It will explain the pre-surgical plan, the surgical operation, and the post-surgical course, as well as the results you can expect. However, it cannot answer all of your questions since a lot depends on your individual circumstances. Please be sure to ask your surgeon if there is anything you do not understand about the procedures or what you can expect.

From the entire team at Richmond Aesthetic Surgery, we wish you the best of luck as well as good health and well-being during your journey.

Sincerely,


Neil J. Zemmel, MD, FACS*

 

I required bilateral mastectomies because of breast cancer. Dr. Z’s caring, guidance, and advice gave me results I never dreamed of! I am happier now with my body (at 55) than I was in my 30’s! I am SO glad I listened and took his advice. His concern and expertise are unmatched!

elizabeth chapman

June 11, 2012

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Should I Get Breast Reconstruction?

Any patient who undergoes removal of a part of the breast (lumpectomy or breast conservation therapy), the whole breast (mastectomy), or preventive removal of the breast (prophylactic mastectomy) is eligible for breast reconstruction. New medical devices and plastic surgery techniques allow Dr. Zemmel and Dr. Reddy to recreate a breast at the time of mastectomy or sometime later and to correct contour abnormalities of the breasts after breast conservation treatment. The best candidates, however, are women who are in good health, do not smoke, and whose cancer, as far as can be determined, will be or has been removed by surgery.

Many options are available for breast reconstruction. Your surgeon will recommend the best options for you based on your body size, shape, medical issues, personal values, personal preference, cancer, and need for chemotherapy or radiation. As you consider the options recommended by your surgeon at Richmond Aesthetic Surgery, ask yourself the following questions:

Use the answers to these questions to help you choose which option you feel most comfortable with.

How Can I Prepare for Breast Reconstruction?

You can begin talking about reconstruction as soon as you are diagnosed with cancer, or when you find out that you are genetically predisposed to cancer. Our surgeons will work to develop a strategy to help put you in the best possible condition for reconstruction.

After evaluation, your surgeon will explain which reconstruction options are most appropriate for your age, health, anatomy, body type, and goals. Be sure to discuss your expectations openly. Post-mastectomy reconstruction can improve your appearance and renew your self-confidence — but keep in mind that the desired result is an improvement and not perfection.

Once you have scheduled a surgery date, your doctor will provide you with specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain medications or vitamins. Your doctor will also give you information regarding blood work and tests needed prior to surgery, and will have you receive a CT scan prior to any free-tissue breast reconstruction.

Immediate vs. Delayed Breast Reconstruction

Breast reconstruction can be done at the time of your mastectomy (immediate) or weeks, months, or even years later (delayed). The decision to have immediate or delayed reconstruction depends on many factors that Dr. Zemmel and Dr. Reddy take into consideration:

“When this happens to you, you do not want to wait weeks for questions. I was very pleased that I could get an appointment with Richmond Aesthetic Surgery within days.”

– Bethann

Many choose to have delayed reconstruction based on these factors. Some women are not comfortable weighing all of their options during a time of extreme emotional stress when coping with the diagnosis of breast cancer. Some patients may be advised to wait because of other health conditions. Also, those with metastatic or inflammatory breast cancers may be advised to delay breast reconstruction. Your surgeon will discuss the advantages and disadvantages with you during your initial visit.

What Are My Breast Reconstruction Options After Mastectomy?

There are a number of ways to perform breast reconstruction after mastectomy. Dr. Zemmel and Dr. Reddy divide them into three general categories:

During your consultation, the pros and cons of each will be discussed with you, including the unique benefits and risks based on your situation. Your surgeon will also help you understand what to expect after your breast reconstruction process, which will likely require multiple surgeries. Together, you and your surgeon will choose the best option for you based on your body shape, past surgeries, current health, breast cancer treatments, and personal preferences.

Breast Reconstruction with Implants

Breast implants can be used to restore the shape and volume of the natural breast tissue that is removed during cancer treatment, such as mastectomy. Our surgeons offer both saline and silicone breast implants for reconstruction, each coming in different shapes and sizes. Dr. Zemmel or Dr. Reddy will go over the benefits and risks of your options, helping you determine which breast implant is ideal for your needs and preferences.

If you choose to receive silicone breast implants, you will need to undergo an MRI every other year, starting three years after your reconstructive surgery, due to the risk of leaks going undetected. Saline implants, however, are more noticeable when there is a leak, which is why you will not need to undergo additional monitoring. Other complications associated with implants include infection, which occurs in less than 1% of cases at our practice, as well as capsular contracture, which is characterized by hardening of the scar tissue surrounding the implant. Capsular contracture happens in about 2-5% of cases and can constrict the breast implant, making it feel hard and look deformed. If you are undergoing radiation therapy, this increases your risk of capsular contracture, as radiation damages the surrounding tissues.

Remember, implants are not lifetime devices and must be replaced like any other manufactured part. You should expect to replace your implants at least once in your lifetime. There is no mandatory scheduled maintenance, but the average patient replaces her implants around 10 to 15 years after surgery. A breast implant exchange procedure is usually simple with very little downtime. It requires no new incisions and is an outpatient operation.

Breast Reconstruction with Your Own Tissue

Autologous tissue reconstruction, or flap reconstruction, involves using your own tissue from another part of your body to rebuild your breast. The tissue from your back, abdomen, thighs, or buttocks may be used. Sometimes, the tissue can stay connected to its own blood supply and just be rotated to reconstruct the breast, known as a pedicled flap. Other times, the tissue is disconnected from your body and its own blood supply and is reconnected to a new blood supply in the chest, known as a “free” flap. Free flaps typically do not require the sacrifice of a muscle in order to bring blood flow to the flap.

Regardless of which flap technique your surgeon performs, this type of reconstruction is more complex than implant-based reconstruction. Scars will be left at both the tissue donor site and reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the reconstructed breast is made entirely with your own tissue, the results are more permanent, natural, and there are no concerns about implant-related complications. In some cases, you will have the added benefit of an improved body contour where the donor tissue was taken.

You will be required to stay in the hospital for 3 or 4 nights. During this stay, your surgeon and the nurses will monitor your flap to make sure the blood flow to the transplanted tissue is adequate. The color, temperature, and pulse of the skin will be checked. Two devices will be used to monitor your flaps. One listens to your blood flow through the flap (Doppler), while the other measures oxygen levels (ViOptix). If your flap has blood supply issues, your surgeon may have to take you back to the operating room to assess and correct the problem. This happens in less than 10% of patients. In approximately 2% of all patients, the flap may fail, and another method for your breast reconstruction will be offered.

You will also have 3 or 4 drain tubes placed depending on if one or both breasts are reconstructed. In most circumstances, these drains will remain in for about 10 to 14 days. The recovery time for flap reconstruction is approximately 4 weeks. You will likely be sore and bruised for 10 to 14 days. You should feel better each day, and our surgeons will make sure you are as comfortable as possible. You will have follow-up appointments with your surgeon at least once per week for the first month. It is very normal to feel fatigued in the few weeks following surgery.

What Are the Different Types of Flap Reconstruction?

The name of the flap for your autologous breast reconstruction denotes the area from which the tissue is taken (donor site). Common types of autologous reconstructions include:

These surgeries require the skills of a microvascular-trained plastic surgeon. This is a complex technique that requires using a microscope to reconnect blood vessels. Dr. Zemmel and Dr. Reddy offer these exciting new techniques.

Abdominal Wall Tissue (TRAM, DIEP, & SIEA Flaps)

An abdominal flap reconstruction may involve four layers of tissue taken from the abdomen:

The rectus abdominis muscle receives its blood supply from two blood vessels: the superior epigastric artery and vein, and the deep inferior epigastric artery and vein (DIEP). These vessels enter the body of the rectus muscle and branch within the muscle itself. The muscle then sends small blood vessels to the skin surface. Additional redundant vessels are located closer to the skin surface. These are called the superficial inferior epigastric artery and vein (SIEA).

Advances in surgical techniques have allowed surgeons to lessen the amount of muscle and fascia that is used for abdominal wall flaps. Now, Dr. Zemmel and Dr. Reddy avoid taking any muscle or fascia by using the small blood vessels emanating from the muscle to the skin, called perforators. These perforators may come from the deep inferior epigastric vessels (DIEP) or from the more superficial source called the superficial inferior epigastric artery and vein (SIEA). Both the DIEP and SIEA are muscle sparing and use no muscle with the abdominal wall tissue, lowering the chance of hernia formation or abdominal wall bulge.

The amount of tissue and blood supply used to create your new breast determines the name of the breast flap. Your surgeon will help decide which type of flap is best for you.

TRAM Flap

The TRAM (Transverse Rectus Abdominis) flap consists of skin, fatty tissue, and the rectus muscle itself. The TRAM flap is usually rotated on its remaining blood supply (pedicled) or disconnected from its own blood supply and reconnected to the blood in the chest (free flap). Since this flap involves removing your muscle, and sometimes your fascia, there is a small risk of hernia or weakness of the abdominal wall.

The pedicled TRAM flap operation is a safe, reliable procedure and has been offered for over 30 years. Your surgeon will examine you carefully to determine whether you are a candidate for a soft tissue reconstruction. They may offer you the options of either a pedicled TRAM flap or a DIEP or Free TRAM flap.

A free muscle-sparing TRAM flap is made up of belly skin, fat, and a very tiny part of the rectus muscle. This flap is disconnected from its own blood supply and then reconnected to the blood supply in the chest. If a large amount of muscle has to be taken because of the anatomy of your abdominal wall, then your surgeon may have to reinforce it with a supportive layer of mesh to prevent hernia formation.

DIEP Flap

A DIEP (Deep Inferior Epigastric Perforator) flap is made up of belly skin and fat ONLY. The flap is disconnected from its own blood supply and then reconnected to the blood supply in the chest using the deep inferior epigastric artery and vein and its perforators. This is the most common procedure performed by our Richmond plastic surgeons. Not only does the fat and skin removed at the time of surgery reconstruct a supple, naturally appearing breast, but it also provides for a “tummy tuck” effect.

There are a number of benefits of DIEP flaps over traditional pedicled TRAM flaps. They include:

Breast Recon DIEP 1Breast Recon DIEP 2

SIEA Flap

A free SIEA (Superficial Inferior Epigastric Artery) flap is made of belly skin and fat ONLY. The flap is disconnected from its own blood supply and then reconnected to the blood supply in the chest using the superficial inferior epigastric artery and vein and its perforators. Since the superficial epigastric artery and vein are very small, and only exist in about 30% of patients, few can have this flap.

Buttocks Tissue (SGAP & IGAP Flaps)

SGAP (Superior Gluteal Artery Perforator) and IGAP (Inferior Gluteal Artery Perforator) flap reconstruction is reserved for patients who do not have enough skin and tissue on the belly, have had previous belly surgery to preclude a DIEP, do not want implants, and have enough buttocks tissue to recreate a breast. These flaps are made of skin and fat from the buttocks. Their blood supply is disconnected from the buttocks and then reconnected to the internal mammary artery and vein in the chest. You will have a scar hidden in the bikini line and slight indent around the donor site area from where the tissue is taken. The SGAP and IGAP flaps provide for a natural-looking and moderate-volume breast.

Thigh Tissue (TUG Flap)

The TUG (Transverse Upper Gracilis) flap is made up of skin, fat and muscle from the thigh. The gracilis muscle that is taken is considered “expendable,” and patients do not report any weakness of the leg after surgery. The TUG is usually done for patients who do not have adequate skin in the buttocks or belly. It is a small-sized flap and thus can only be used for those who do not require a large-volume breast reconstruction. The incisions from the TUG are hidden in the groin area. This area is warm, moist, and dark, and it undergoes a lot of motion while sitting, standing, or using the bathroom which makes it a higher risk for poor healing and infection.

Back Tissue (Latissimus Dorsi & T-DAP Flaps)

The latissimus dorsi flap from your back is made up of skin, fat, and muscle (latissimus dorsi muscle). The T-DAP (Thoracodorsal Artery Perforator) flap is made up from skin and fat ONLY. Both the latissimus dorsi and the T-DAP flaps remain attached to their blood supply and are rotated through the armpit to recreate the breast on the chest. The scar is often well-hidden in the bra strap on the back. Often, the flaps are not large enough to recreate a breast, and an implant will be required under the flap. People generally do not have a problem from missing the muscle in the back and continue their normal daily living. However, if you are a competitive rock climber, swimmer, or tennis player, you may be affected and show weakness.

How Long Does Breast Reconstruction Take?

The length of time for your breast reconstruction can vary depending on the number of surgeries you require and the need for other breast cancer treatments, such as radiation or chemotherapy. The reconstructive process generally takes 6 months to one year regardless of the type of reconstruction you choose, assuming no further cancer treatment is necessary. Some patients will require revisional surgeries to balance the reconstructed breast with the natural breast and recreate a nipple. The timeline to completion will vary for each patient, but a general guide is:

Single- vs. Two-Stage Breast Reconstruction

Within the implant-based reconstruction category, there are two possible methods of reconstructing the breast: two-stage reconstruction and single-stage reconstruction, also called direct-to-implant (DTI).

Two-Stage Breast Reconstruction

The first and most common technique, two-stage reconstruction, uses a device called a tissue expander followed by insertion of a prosthetic breast implant. This requires a minimum of two operations, and commonly a third is added to refine or “touch up” your result. Nipple reconstruction and fat grafting is usually performed at this third and final stage.

The first operation consists of mastectomy (removal of the breast, to be performed by the breast cancer surgeon) followed immediately by placement of a tissue expander with acellular dermal matrix (Alloderm). The purpose of the tissue expander is to stretch and mold the overlying soft tissue, skin, and muscle, and the goal of Alloderm is to create a stable pocket for your implant to permanently reside. This stretching and molding involves injections of a salt-water solution that typically begins immediately after surgery. The expander is inflated to approximately 50% to 75% of its final volume during the first procedure, and the remaining volume will be added during your follow-up visits over the course of 6 to 12 weeks after surgery.

Your surgery takes 1 to 1.5 hours for one side to be completed, longer if you are having surgery on both sides. You will be kept in the hospital overnight and should be able to go home in 1 to 2 days. This surgery will require placement of surgical drains to remove excess fluids from surgical sites immediately following the operation. In most circumstances, your surgeon will remove these drains when you come back for your 1 week or 2 week follow-up visit. If there is a lot of drainage, they will stay in for longer. You are likely to feel tired and sore for 1 to 2 weeks after reconstruction and take about 4 weeks to feel completely recovered. Most of your discomfort can be controlled by pain medication and muscle relaxants prescribed by our plastic surgeon.

The tissue expander process continues until the size is slightly larger than your desired reconstructed breast size. You may feel a sensation of stretching or pressure in the breast area during this procedure, but most women find it is not too uncomfortable. Filling of the expander stretches the skin and muscle to make room for a breast implant, much like a woman’s abdomen stretches during pregnancy. By filling the expander slowly over time, the tissue covering the implant is molded into a stable soft tissue pocket in preparation for the permanent implant insertion.

After the skin over the breast area has stretched enough, the expander will be removed in a second outpatient operation, and a permanent implant will be inserted in its place. Oftentimes, “touch up” work is done to make the implant more symmetrical. Pocket work is performed along with autologous tissue fat transfer (fat grafting). The need of potential chemotherapy or radiation will affect the timing of your second-stage surgery. The second procedure typically is much less invasive and requires much less downtime compared to the first procedure. The nipple and areola (the dark skin surrounding the nipple) are usually reconstructed in a subsequent third procedure along with any final fat transfer.

The exchange of the tissue expander for a permanent implant takes about 1 hour for one side. Dr. Zemmel and Dr. Reddy usually do not place surgical drains, and you can go home the same day as your surgery. You are likely to feel tired and sore for a week or so after the implant exchange. Much of your discomfort will be controlled by medication prescribed by our surgeon.

Dr. Zemmel and Dr. Reddy perform the latest tissue expander reconstructions using acellular dermal matrix (Alloderm or Flex HD) techniques.

What Is Acellular Dermal Matrix (ACDM)?

ACDM is the dermal component of the skin donated for the purpose of reconstructive surgery. ACDM has been used for over 10 years in breast reconstruction and in other applications such as abdominal wall reconstruction. During breast reconstruction, ACDM is placed inside the breast where it can augment and reinforce your own tissues. In the setting of breast reconstruction, ACDM serves as a way to artificially and immediately lengthen the pectoralis muscle to create a breast pocket without the use of a tissue expander. It is an essential component for allowing single-stage breast reconstruction.

acdm 1ACDM is donated tissue that has been processed to remove all of the cellular materials leaving only the collagen scaffolding of the dermis. This means that the graft material has an extremely low rate of rejection. The graft has been tested for infectious diseases similarly to other donated tissues. Once ACDM is placed, your body will incorporate the graft into your own tissues. Over a period of 3 to 6 weeks, your own cells should repopulate the scaffolding, and your blood vessels will grow into it. The ACDM essentially becomes part of your body.

The use of these artificial tissues has a number of advantages over traditional tissue expander techniques:

Single-Stage Breast Reconstruction

A single-stage direct-to-implant (DTI) breast reconstruction is completed in one surgical procedure at the same time as mastectomy. This eliminates the need for a tissue expander. Delayed reconstructions are typically not performed as the skin and overlying soft tissue become scarred and lose the elasticity needed to create a breast pocket. The breast cancer surgeon will normally perform a total nipple-areolar-skin sparing mastectomy. Your surgeon will then immediately begin the reconstructive procedure.

“The doctors at Richmond Aesthetic Surgery spent time answering my questions and explaining the process to me. They even answered questions I had not thought to ask.”

– Leigh

The skin flaps are examined to ensure good thickness and viability. The pectoralis major muscle is identified, and the muscle is raised from the chest wall. The serratus anterior muscle is also identified and raised in most patients to improve contour of the lateral mammary fold (side) of the breast. The acellular dermal matrix is then attached to the internal aspect of the inframammary fold, and the front edge of the serratus anterior muscle in a gentle arc to recreate the lower and side curves of the breast.

The upper border of the ACDM graft is then attached to the lower border of the pectoralis muscle to complete the breast pocket. The ACDM graft acts as a pectoralis major muscle extension. Multiple demo silicone implants are then placed in order to choose the optimal size and shape. A drain is then placed into the breast pocket to remove any fluid that may accumulate. Local anesthesia is injected into the pectoralis major muscle, serratus anterior muscle, and along the inframammary fold to give long-lasting pain relief after surgery. Finally, the upper and lower skin flaps are then redraped over the muscles and implants, and the incision is closed.

What Are the Benefits of Single-Stage Direct-to-Implant Breast Reconstruction?

There are a number of advantages to a direct to implant (DTI) reconstruction: