BREAST RECONSTRUCTION

What is breast reconstruction surgery?

The goal of breast reconstruction surgery, also known as reconstructive mammaplasty or postmastectomy surgery, is to restore one or both breasts to near normal shape, appearance, symmetry, and size following mastectomy, and lumpectomy, or congenital deformities. Breast reconstruction often involves multiple procedures performed in stages and can either begin at the time of mastectomy or be delayed until a later date.

Breast reconstruction generally falls into two categories: implant-based reconstruction or tissue-based or flap reconstruction. Implant reconstruction relies on breast implants to help form a new breast mound. Flap (or autologous) reconstruction uses the patient's tissue from another part of the body to form a new breast.

Several factors should be taken into consideration when choosing which option is best, such as the type of mastectomy, any post-surgical chemotherapy or radiation, the patient's body type, and aesthetic goals. Discussing your cancer surgery with a plastic surgeon before undergoing a mastectomy is crucial, because the proposed cancer removal surgery may significantly affect the choices and the results of any type of breast reconstruction.

If only one breast is affected, it alone may be reconstructed. In addition, a breast lift, breast reduction, or breast augmentation may be recommended for the opposite breast to improve the symmetry of the size, shape, and position of both breasts.

"Surgeons who have the necessary training, expertise, and experience in reconstructive surgery are fit to perform cosmetic surgeries with excellent outcomes. Those surgeons only trained in aesthetic procedures will have much more difficulty doing the same. The more tools and training in plastic surgery the surgeons have, the more qualified they are! "

Who is a good candidate for breast reconstruction surgery?

You may be a good candidate for breast reconstruction surgery if you can cope well with your diagnosis and treatment, you do not have additional medical conditions or other illnesses that may impair healing, and have a positive outlook and realistic goals for restoring your breast and body image. Also, you may consider surgery if you think breast reconstruction will give you a sense of psychological well being or a feeling of “wholeness”, will help restore your feelings of femininity and confidence in your appearance, will improve symmetry if only one of your breasts is affected and will allow you to wear low-cut necklines and normal swimwear.

Although breast reconstruction can rebuild your breast, the results are highly variable. A reconstructed breast will not have the same sensation or feel as the breast it replaces and visible incision lines will always be present on the breast. Also, reconstruction or mastectomy and certain surgical techniques will leave incision lines at the donor site that are commonly located in less exposed areas of the body such as the back, abdomen, or buttocks.

What should I expect during a consultation for breast reconstruction surgery?

During your initial consultation, you will have the opportunity to discuss your cosmetic goals. Dr Ricardo will evaluate you as a candidate for breast reconstruction surgery and clarify what approach is best for you. Alternative and additional treatments may be considered, once Dr Ricardo understands your goals and medical condition. It is important to be completely honest during the consultation and be prepared to discuss your surgical goals, medical conditions, drug allergies and medical treatments, current medications, vitamins, herbal supplements, alcohol, tobacco and drug use, and previous surgeries.

Dr Ricardo will also evaluate your general health status and any pre-existing health conditions or risk factors, examine your breasts and take measurements of their size and shape, skin quality and placement of nipples and areola, take photographs, discuss your options available in breast reconstruction surgery and recommend a course of treatment, discuss any risks or potential complications and share before-and-after photos of cases similar to yours.

The success and safety of your breast reconstruction surgery depend very much on your complete candidness during your consultation. It's very important to understand all aspects of your procedure. It's natural to feel some anxiety, whether it's excitement about your anticipated new look or a bit of preoperative stress. Don't be shy about discussing these feelings with Dr Ricardo.

How should I prepare for breast reconstruction surgery?

In preparing for breast reconstruction surgery, you may be asked to get lab testing or a medical evaluation, take certain medications or adjust your current medications, stop smoking in advance of surgery and avoid taking aspirin, anti-inflammatory drugs, and herbal supplements as they can increase bleeding.

Your surgery will be performed in an accredited hospital and requires likely spending at least two days in the hospital for observation unless you and Dr Ricardo have made other plans for your immediate postoperative recovery. You must arrange for a friend or family member to drive you to and from surgery and to stay with you the first night following the hospital’s discharge.

Dr Ricardo and the entire staff will provide thorough preoperative instructions and answer any questions you may have. The goal is to help you achieve the most beautiful and natural-looking results, as well as to make your surgical experience as easy, comfortable, and safe as possible.

What are the steps of a breast reconstruction procedure?

Step 1 – Anaesthesia

Medications are administered for your comfort during the surgical procedure. The choices include intravenous sedation and general anaesthesia. Dr Ricardo will recommend the best choice for you.

Step 2 – Flap techniques reposition a woman's tissue to create or cover the breast mound

Sometimes a mastectomy or radiation therapy will leave insufficient tissue on the chest wall to cover and support a breast implant. In these cases, breast reconstruction usually requires either a flap technique or tissue expansion.

A TRAM flap uses donor muscle, fat, and skin from a woman's lower abdomen to reconstruct the breast. The flap may either remain attached to the original blood supply and be tunnelled up through the chest wall, or be completely detached, and formed into a breast mound.

Alternatively, Dr Ricardo may choose the DIEP flap or SIEA flap techniques, which do not use abdominal muscle but transfer only skin and fat to the chest from the abdomen. If there is insufficient tissue on the lower abdomen, other donor sites such as the buttocks or thighs may be selected (SGAP flap, TUG flap, PAP flap).

A latissimus dorsi flap uses muscle, fat, and skin from the back tunnelled to the mastectomy site and remains attached to its donor site, leaving the blood supply intact. Occasionally, the flap can reconstruct a complete breast mound, but often the latissimus flap provides the muscle and tissue necessary to cover and support a breast implant.

Step 3 – Tissue expansion stretches healthy skin to provide coverage for a breast implant

For women who do not require breast radiation and would like to avoid a separate donor site, implant-based reconstruction is an option. Reconstruction with tissue expansion allows an easier recovery than flap procedures, but it can be a more lengthy reconstruction process. It usually requires several office visits over 1-2 months after placement of the expander to gradually fill the device with saline through an internal valve to expand the skin. Newer air-filled devices may allow patient-controlled expansion at home using a remote dosage controller. A second surgical procedure will be needed to replace the expander if it is not designed to serve as a permanent implant.

Step 4 – Surgical placement of a breast implant creates a breast mound

A breast implant can be an addition or alternative to flap techniques. Dr Ricardo may also use an implant as a temporary placeholder during other breast cancer treatments until you are ready for more involved flap reconstruction techniques. Reconstruction with an implant alone usually requires tissue expansion. Direct-to-implant breast reconstruction may be an option for some women undergoing mastectomy with certain tumor characteristics and breast shapes. Dr Ricardo will help you decide what is best for you.

Step 5 – Breast reconstruction with implants using an acellular dermal matrix

Acellular dermal matrix (ADM) is a sheet of tissue that has had its cells removed leaving a framework of collagen and elastin for support and cover. This tissue is specifically prepared to allow your body tissues to gradually grow into this material, ultimately replacing it with your collagen and blood vessels.

In the case of breast reconstruction, the acellular dermal matrix acts like a hammock under the mastectomy skin-muscle envelope that supports the tissue expander and can also improve implant placement. This framework of molecules allows your body's cells to grow into the matrix, promoting the regenerative process that takes place during tissue expansion. ADM is usually combined with your chest muscle to cover the expander and maintain its position, and subsequently the position of the implant.

The ADM procedure can be less invasive than other techniques, permitting a larger breast mound to be created at the time of the mastectomy and decreasing the number of office visits needed to reach the desired implant volume. When ADM is used, the expander can often be replaced with the final implant sooner than with other tissue-expansion techniques. In rare circumstances, an expander is not needed and the final implant can be placed into the created hammock at the time of the mastectomy with no further surgery required.

The use of ADM products has enabled Dr Ricardo to offer immediate breast reconstruction to more patients and to improve the overall results of breast reconstruction. Whether or not you're a candidate for this technique depends on the quality of your mastectomy skin envelope.

Step 6 – Reconstructing a nipple and areola, breast revision techniques

For women who are not candidates for nipple-sparing mastectomy, breast reconstruction is completed through a variety of techniques that reconstruct the nipple and areola. Techniques usually involve folding skin to create the shape of a nipple followed by tattooing. Three-dimensional nipple-areola tattooing may be used alone to create the appearance of a realistic nipple with the illusion of projection. Breast reconstruction outcomes can often be enhanced with staged revision procedures that improve symmetry, use liposuction with fat grafting, and improve the appearance of the donor site.

Step 7 – Closing the incisions

Incisions are closed with layered sutures in the breast tissue and the donor site if flaps are used. Sutures, skin adhesives (glues), or tapes close the skin incisions.

What should I expect during my breast reconstruction recovery?

Following your breast reconstruction surgery for flap techniques and/or the insertion of a breast implant, gauze or bandages may be applied to your incisions. An elastic bandage or support bra will minimize swelling and support the reconstructed breast. A small, thin tube may be temporarily placed under the skin to drain any excess blood or fluid.

You will be given specific instructions that may include: How to care for your surgical site(s) following surgery, medications to apply or take orally to aid healing and reduce the risk of infection, specific concerns to look for at the surgical site or in your general health and when to follow up with Dr Ricardo. Remember to always follow his instructions to ensure the success of your surgery.

The surgical incisions mustn't be subjected to excessive force, swelling, abrasion, or motion during the time of healing. Sutures will be removed when it is appropriate. Implant-based reconstruction is the simplest and least painful and has the shortest recuperation time. Typically, most women can do most routine activities within two to three weeks. Flap-based procedures, which require surgery in two areas, are more demanding and recuperation varies, depending on which flap procedure was performed. However, you must realize that the amount of time it takes for recovery varies based on what your surgery entails.

What results should I expect after my breast reconstruction surgery?

Over time, some breast skin sensation may return, and scar lines will improve, although they will never disappear completely. Take care of your scars by keeping them moist, massaging the scar line, and use a scar management product to smooth and flatten scars, making them less noticeable. There are trade-offs, but most women feel these are small compared to the large improvement in their quality of life and the ability to look and feel whole.

Careful monitoring of breast health through self-exam and other diagnostic techniques is essential to your long-term health. The final results of breast reconstruction following mastectomy can help lessen the physical and emotional impact of mastectomy.

This is a way of removing any reminders of your mastectomy and breast cancer experience. It can help you feel better about how you look and restore confidence in your sexuality.