With 1 in 8 women in the United States developing Breast Cancer, the number of women seeking reconstruction is rising quickly. Whether undergoing a lumpectomy (partial breast removal) or a mastectomy (total breast removal), most women should be given the option to undergo reconstruction.
Breast Reconstruction is a catch-all for a variety of different surgical techniques that Plastic Surgeons can utilize to minimize or reverse the cosmetic abnormalities that occur after these potentially life saving procedures.
Why undergo Reconstruction?
The number one Goal is ALWAYS to remove the cancer and cure every patient of their disease. However, reconstruction is a close second in terms of importance. Research continues to show increased psychological benefits of women undergoing breast reconstruction after partial or total mastectomy. Women will often feel better after having such an important part of their self being restored. By undergoing reconstruction patients are able to fill out and feel comfortable in their bathing suits, and will not need to wear a breast prosthesis to fill out their bras.
Immediate vs Delayed?
So the first decision to make is timing of the reconstruction. For years, the only option was a delayed reconstruction. This meant undergoing mastectomy and then healing up from surgery, undergoing any necessary chemotherapy and/or radiation, and then finally undergoing the reconstruction. This is a very safe method of reconstruction but leaves a women without her breast(s) for several months or even more than a year. In addition, reconstruction can be more difficult as there is now much more scarring as well as potential radiation injury. The skin tends to be less elastic so tissue expansion can be very difficult.
Over the past decade, the number of immediate reconstructions has been steadily rising. In immediate reconstruction, the Plastic Surgeon is present at the TIME of mastectomy and BEGINS the reconstruction at the same time. Now depending on the type of reconstruction and circumstances, the reconstruction may not be fully completed at this time, but the process will be initiated. The benefits of this are that the reconstruction tends to be easier as there is no scarring to deal with. Psychologically, women are much happier and satisfied as they do not have to experience seeing themselves with no breast(s) and being completely flat chested. The disadvantage is that the final pathology and staging has not been completed and sometimes adjuvant therapy such as chemotherapy and radiation has not been decided on yet.
As there are numerous options for reconstruction, it is easiest to break it down into broad categories. The two main types of reconstruction are: implant based and tissue based.
This is by far the most common method of reconstruction. Most commonly the plastic surgeon will place a inflatable implant, called a tissue expander, in the pocket left behind after the breast is removed. After 2-3 week of healing, fluid or air is slowly added to the expander in the office every 1-2 weeks. The expander is filled to the desired size and then the patient will return to the operating room for an outpatient procedure to remove the expander and replace it with a soft, silicone breast implant. Additional outpatient procedures may be performed to improve symmetry, size and shape. Fat transfer procedures may be needed to help soften the edges of the implant. Nipple reconstruction is also offered if the patient chooses to complete the entire reconstruction.
This is also called, autologous reconstruction, which means using one’s OWN tissue to reconstruct the breast. There are MANY variations of this but the two most common sites to borrow tissue from are the abdomen and the back.
The transverse rectus abdominis myocutaneous flap (TRAM) is a workhorse of breast reconstruction. In this technique, the excess fat and skin of the lower abdomen can be left attached to the “six pack” muscle and rotated up onto the breast to recreate a very soft and natural appearing breast mound. The belly is then closed similar to a tummy tuck. The advantage of this technique is that it produces a very natural looking and feeling breast, and also gives the patient the benefit of some degree of a tummy tuck.
The latissimus is large muscle on either side of the back that helps strong exercises like pull-ups. The muscle as well as some overlying fat and a small area of skin can be borrowed and swung under the arm into the breast pocket to create a new breast. Oftentimes this may be combined with an implant or tissue expander as the amount of tissue from the back is often insufficient to create a very large breast. The advantage of this technique is using your own tissue especially in someone that does not have much excess skin and fat of the lower abdomen. It is also a quicker and easier surgery to recover from compared to the TRAM flap reconstruction.
Which option is right for me?
This is really something that needs to be determined on a case by case basis. Dr. Arslanian will need to review your history and physical exam findings. Things such as: type of mastectomy, possible radiation therapy and chemotherapy, your current size and desired size, and concomitant medical problems may all factor into what options are available and what might be the best solution for your individual circumstance. In general, there are a few broad things to consider with the two major categories of implant based vs. tissue based.
Surgery is quicker and typically easier recovery. There tends to be less post-operative pain and patients are back to their normal activities rather quickly. Usually patients will only need to remain in the hospital overnight after their initial surgery. Return to work is more rapid and complications are usually less severe, however, they could be more frequent
By committing to a implant based reconstruction one must accept the fact that they will be living with implants for potentially the remainder of their life. Even though they are safe, they do come with their own set of problems. They can become infected, they can rupture, they can become malpositioned and require revision surgery. Also, it typically means more surgeries than a tissue based reconstruction. At least one additional surgery will need to be done to exchange the expander for the implant.
The biggest advantage is using your own tissue rather than having an implant or foreign body. This tends to give patients a more natural feel and look to the breast, something an implant can never replicate. It also tends to mean less surgeries over the patients life time as the bulk of the reconstruction is done in the first operation.
Tissue-based surgery tends to be more difficult to recover from. Rather than being in the hospital overnight, patients may need to remain in the hospital anywhere from 3-7 days depending on their surgery and personal circumstances. The recovery process at home is much longer as well as the time to return to work. In addition, it now requires the healing of TWO separate locations; the breasts as well as the donor site from either the back or the abdomen. The surgeries themselves take much longer to perform than an implant reconstruction.
During your consultation, you will meet with Dr. Arslanian and his staff and have the opportunity to discuss your individual situation as well as your concerns and goals. Dr. Arslanian will will take detailed measurements of your breast and body and perform a complete examination. Photos will be taken to help Dr. Arslanian point out certain things and explain his approach to breast reconstruction. If you are deemed a good candidate, he will discuss the various options for breast reconstruction and make sure you are happy with your decision. He will also show you photos of other patients before and afters to help determine what size and look you are trying to achieve. His number one concern, however, will always be your safety.
There are times when a particular reconstruction may not be offered, or reconstruction altogether may not be offered. The only reason for doing this is to protect you and prevent unwanted complications. Some patients may not be good candidates based on their weight, other medical conditions, or extent of disease. We strive to “Do No Harm”, and at times have to turn patients away if reconstructive surgery is just too risky.