Breast Reconstruction Surgery
Breast reconstruction surgeries aim to restore the volume and shape of one or both breasts following breast cancer treatments (lumpectomy, mastectomy), and acquired or congenital deformity. Breast reconstruction is recognized as an important process that can significantly improves quality of life for breast cancer survivors, trauma survivor, or patients with congenital anomaly. Thus, it is strongly recommended for patients of all ages.
The two main methods of breast reconstructions are implant-based and autologous tissue-based (patient’s own tissue) reconstructions.
Who are Candidates for breast reconstruction?
The best candidates are healthy people with realistic expectations of surgery. Patients with medical problems can safely proceed with surgery with guidance from their primary care physicians. If radiation is needed before or after surgery, implant based can still be considered but autologous tissue is the preferred method. In addition, fat transfer into the radiated tissue may reduce the risk of capsular contracture and associated complications. In the US, breast reconstructions are required by law to be covered by medical insurances.
Implant-based breast reconstruction is the most commonly performed after mastectomy to restore the shape of the breasts. This can be performed immediately after the mastectomy or as a delayed procedure. It can also be single stage direct-to-implant or two stage tissue expander-implant techniques.
Direct-to-implant technique involves using implants and dermal matrix to reconstruct the breast in one surgery. This reconstruction is suitable for individuals who have normal size and shape breasts and healthy skin envelope after cancer removal.
Tissue expander-implant based reconstruction involves the initial placement of tissue expanders, which are silicone shell implant that can be expanded with salt water after placement. Immediately after the mastectomy or any time after, tissue expander can be placed in a reconstructed pocket with acellular dermal matrix partially under the muscle (sub-pec) or completely over the muscle (pre-pec). After initial placement surgery, the tissue expander can be filled with saline to the final volume. At a separate procedure, the tissue expander is removed, and a permanent saline or silicone implant will be placed.
Fat transfer is almost always recommended for implant-based reconstruction to augment the overlying skin and soften the transition between the implant and the chest wall. It can be done after direct to implant procedure, after tissue expander procedure, or after permanent implant placement.
How is Implant based Breast reconstruction performed?
Implant based breast reconstruction can be performed as one stage, direct to implant, or two stage, tissue expander placement followed by exchange to permanent implants. The implant or tissue expanders can be placed on top the muscle or under the muscle with dermal matrix as internal support. The approaches are tailored to each patient goals and breast shapes.
What is Recovery Like for implant based reconstruction?
Most patients can go home the same day after surgery however some patients may require one night in the hospital for close monitoring. Downtime from surgery is between 1-2 weeks. Moderate swelling and minor bruising is expected in the first week. Small tubes are generally placed underneath the skin during surgery and often removed 2 weeks after surgery. Majority of the swelling will resolve by one month after surgery. Discomfort from swelling and pain along the scar are the major complaints after surgery.
Autologous tissue-based reconstruction uses patient’s own tissue, from the abdomen, the thighs, the buttock, or the back to reconstruct the breasts. The tissue can be attached to its own blood supply (pedicle flap) or in case of free flap reconstruction, the tissue and its blood supply can be detached from the source and microsurgical reattach to blood vessels around the chest area. Autologous breast reconstruction is a longer operative procedure with a longer recovery time compared to implant breast reconstruction.
Deep Inferior Epigastric perforator (DIEP) FLAP is one of the most commonly used autologous breast reconstruction. This technique uses patient’s lower abdomen tissue, skin, and blood vessels (deep inferior epigastric) to reconstruct the breasts.
Latissimus dorsi pedicle flap has been the workhorse flap in chest and back reconstruction. The flap can be muscle only or taken with overlying skin and fat. In breast reconstruction, it is often used as a rescue flap as additional coverage in case of mastectomy skin flap necrosis (dead tissue overlying the implant) in implant reconstruction or in case of failure of the free flap reconstruction.
Who are Candidates for tissue-based breast reconstruction?
The best candidates are healthy people with realistic expectations of surgery. Patients with medical problems can safely proceed with surgery with guidance from their primary care physicians. Because tissue-based reconstruction uses patients’ own skin and fat to reconstruct the breasts, extremely thin patients may not have sufficient tissue for breast reconstruction.
How is Tissue based Breast reconstruction performed?
Most often the tissue from lower abdomen is used to reconstruct the breast. The tissue and its blood supply are separated from its surrounding and reconnect to the blood supply within the breast pocket (internal mammary vessels) or near by (thoracodorsal vessels). The wound from the donor sites is reapproximated. If lower abdominal tissue is used, umbilicalplasty (reconstruction of the belly button) is required as in abdominoplasty.
What is Recovery Like?
Most patients require to stay a few nights in the hospital for close monitoring. Downtime from surgery is between 2-3 weeks. Moderate swelling and minor bruising is expected in the first week. Small tubes are generally placed underneath the skin of the breast(s) and the donor site(s) during surgery and often removed 2 weeks after surgery. Majority of the swelling will resolve by one month after surgery. Discomfort from swelling and pain along the scar are the major complaints after surgery.
Oncoplastic breast reconstruction is a general term referring to different methods of reconstruction to correct any residual deformities from lumpectomy (partial removal of the breast). Depending on the patient’s breast shape, fat transfer, local tissue rearrangement, or breast reduction can be performed to optimize the aesthetic outcome after cancer surgery.