Dr. Brown is well versed in the multiple different techniques in breast reconstruction, and he will spend a significant amount of time with you discussing the specifics of your diagnosis, cancer treatment plan, and which reconstructive options may be best for you. The information below will cover the general concepts in different breast reconstruction techniques. If you have a new diagnosis of breast cancer or have had treatment for breast cancer in the past and are interested in discussing your reconstruction options, come see Dr. Brown.
Breast reconstruction, although very important to many women, is a choice. The first step in the process is to decide whether you want reconstruction. There are some women who make a personal choice to not undergo any additional surgery and or their other health problems make it unsafe to have reconstruction. If you decide not to have breast reconstruction, you may elect to use an external prosthesis in your bra instead.
If you do decide to have breast reconstruction, there are many factors that go into deciding the best options for you. Regardless of techniques, this is a process that usually takes 2-3 procedures over the time span of 3-6 months. There are some cases where reconstruction can be achieved in one stage, but these are less common. Explore the tabs below to learn more about the different options for breast reconstruction.
At the time of your consultation, Dr. Brown will discuss each option with you and help you decide which may be best for you.
Tissue Expander/Implant Breast Reconstruction
One option for breast reconstruction is the use of breast implants. There are a few patients who, depending on several factors, may be candidate for a one stage breast reconstruction where the implant is placed at the time of the mastectomy. For most patients, implant based breast reconstruction is a two stage process which starts with placement of a tissue expander at the time of the mastectomy. The tissue expander acts as an adjustable implant. At the time of the mastectomy, some of the skin and nipple may be removed, and the remaining skin has been traumatized by the surgery, so the tissue expander is only partially inflated to give this skin a chance to recover. When you return to the office for your post-operative visits, Dr. Brown will inject more fluid into the expander to begin to stretch the remaining breast skin. This continues on a weekly basis until the appropriate size and volume has been achieved. A few weeks after this, the second stage operation takes place. This is usually an outpatient procedure during which the tissue expander is removed and a softer, more natural implant is placed. This second surgery is also used as a chance to perform any revisions to the shape and symmetry of the breast and possibly perform fat grafting to smooth the contours. Occasionally, the patient may need another minor operation for revisions or symmetry procedures.
The benefit of implant based breast reconstruction is that the surgery is shorter than other techniques and there are no additional incisions/scar on the body or donor sites that have to heal. In addition, the overall recovery from the surgery is slightly faster than some other options. There are a few possible problems that can arise when using implants for breast reconstruction. The first is infection. Although the infection rate is low, a few percent, if the implant becomes infected, many times it needs to be removed which results in loss of the reconstruction. The second is implant rupture. Although breast implants are lasting longer, they are still a man-made device that will eventually fail. If you go on to live a long, healthy, happy life, at some point you will likely need to have your implants replaced. The third possible issue, is capsular contracture. The body naturally forms a capsule around any implant, but in some patients, this process can become too active and develop into a thick and hard capsule that can distort the shape of the breast and cause pain when severe. One other factor that is important to consider is whether you will require radiation for treatment of your breast cancer. Reconstruction using implants in the face of radiation leads to a significantly higher risk of complications and is generally not recommended.
Abdominal Tissue/DIEP Flap Breast Reconstruction
The second major way to reconstruct the breast is by using your own tissues instead of an implant. This is done by taking excess, expendable tissue from one part of the body and using it to create a breast. The most common technique is to use a flap of tissue from the lower abdomen. This is usually done as a free tissue transfer using advanced microsurgery techniques and may be called a free muscle sparing TRAM (transverse rectus abdominus myocutaneous) flap or DIEP (deep inferior epigastric perforator) flap. The skin and fat of the lower abdomen are removed similar to a tummy tuck, but the small blood vessels that give this tissue life are dissected free from the underlying abdominal muscles and moved with the skin and fat. Dr. Brown strives to preserve as much of the abdominal muscle as is possible. The flap of tissue is then moved to the chest where the blood vessels are reconnected to new blood vessels using a microscope to restore the blood flow to the tissue. This can be thought of as a transplant using your own tissues. Dr. Brown then shapes the tissue into the form of a breast. The abdomen is closed similar to a tummy tuck with a long, low hip to hip incision.
This surgery is longer than placement of tissue expanders and requires a several day stay in the hospital, but the majority of the breast reconstruction is complete at that stage. Most patients undergo a second stage a few months later to have a revision to fine tune the symmetry and shape of the breasts. This is generally done as an outpatient surgery.
The use of your own tissues for breast reconstruction using a DIEP flap is especially helpful when radiation therapy is required for your breast cancer treatment. Studies have shown that using implants for breast reconstruction in the setting of radiation leads to a very high risk of complications. In this setting, the DIEP flap can be used to replace radiated tissues with more healthy tissue and recreate a breast without the need for an implant in many patients.
Using the DIEP flap method, the reconstructed breast is made from your own tissues and avoids many of the problems that can be seen with implant based reconstructions. This tends to yield a more stable, long lasting reconstruction, and most people feel that the reconstructions done using your own tissues feel and look more natural. As a secondary benefit, some of the extra skin and fat from the lower abdomen is removed similar to a tummy tuck. The trade-off for this is a longer surgery and longer hospital stay. In addition, you will have a secondary surgery site on the abdomen that has to heal and will have scars. Not all patients are good candidates for a DIEP flap breast reconstruction due to factors such as: particular prior abdominal surgeries, history of blood clotting disorders, other medical problems, and being very thin or very obese. Dr. Brown will evaluate all of these factors as well as your wishes and help decide with you which techniques may work best.
Latissimus Dorsi Breast Reconstruction
Breast reconstruction using the latissimus flap is usually a combination approach that uses some of your own tissues and an implant. The skin and latissimus muscle from the back is moved around to the breast while keeping it attached to its blood supply in the arm pit area. This tissue is then used to replace any missing breast skin that has been removed at the time of mastectomy or to replace damaged skin in the setting of radiation. Rarely, the breast can be reconstructed out of the tissues from the back alone, but most patients require the addition of an implant to give additional volume to the breast. Depending on your particular situation, this may be done in one stage with placement of the implant at the time of the flap, or in two stages with placement of a tissue expander at the time of the flap and an exchange for an implant at a second stage.
This technique can be helpful in patients who are not candidates for abdominal based reconstruction due to prior abdominal surgery or blood clotting disorders, but need the addition of healthy skin and tissue to the breast reconstruction instead of implants alone. This can be particularly true in patients who have had radiation. The surgery is shorter and the recovery is slightly faster than the abdominal/DIEP flap surgery, but is more involved than tissue expanders/implants alone.
Breast Conservation/Partial Breast Reconstruction
While the trend in the treatment of breast cancer has been toward less aggressive surgery, the use of lumpectomy or breast conservation therapy has become more widely used. This is ideal for patients with small tumors who do not want to lose their whole breast. After your surgery you will be required to have radiation therapy if you choose to undergo breast conservation. Dr. Brown and your breast cancer surgeon can work together to determine whether you are a candidate for breast conservation/lumpectomy. If you choose to have a lumpectomy, Dr. Brown can rearrange some of the remaining breast tissue at the same time to help reduce the risk of having any significant deformity. If you have large breasts or breasts that hang significantly, a breast lift or breast reduction can be done on both sides at the same time as the removal of the cancer to give the best results in one stage.
Symmetry Procedures for the Other Breast
When breast cancer affects only one side, the reconstruction of that breast may not be able to match the remaining normal breast on the other side. When this is the case, the other breast may require the placement of an implant, a breast lift, or a breast reduction depending on your body and your wishes. This is generally done at a secondary operation as we finalize the reconstruction and work on achieving the best symmetry possible.
Nipple and Areola Reconstruction
Once you and Dr. Brown are satisfied with the overall shape and symmetry of the breasts after reconstruction, the final stage is the nipple and areola reconstruction. This is not mandatory, and some patients do not have this done, but many feel like it is the thing that makes the reconstructed breast look like a breast to them. Nipple reconstruction is generally done either at the same time as a revision or in the office under local anesthesia by rearranging small local flaps of tissue on the reconstructed breast. Approximately 2 months later, the areolar pigmentation can be recreated with tattooing which can also be done in the office setting.