- 1 Description
- 2 Options
- 3 Indications
- 4 Evaluation
- 5 Options
- 6 Procedure Details
- 7 Recovery
- 8 Frequently Asked Questions (FAQs)
- 8.1 What are the options of breast reconstruction?
- 8.2 What factors determine the best approach?
- 8.3 When is the best time to have breast reconstruction surgery?
- 8.4 How can a woman’s breast be reconstructed?
- 8.5 What are the common breast reconstruction procedures performed using a patient’s own tissue?
- 8.6 Why is a tissue expander sometimes used in a breast reconstruction?
- 8.7 What are the different types of breast implant reconstruction?
- 8.8 What is AlloDerm® Tissue Matrix and how does it work?
- 8.9 How does AlloDerm® Regenerative Tissue Matrix incorporate into the body?
- 8.10 How long has AlloDerm® Tissue Matrix been available?
- 8.11 With so many choices, how do I know which implant technique is right for me?
- 8.12 What is the recovery period after breast reconstruction?
- 8.13 How long will I have to take off work from my breast reconstruction surgery?
- 8.14 If I want to have breast reconstruction with my mastectomy, what should I do?
- 8.15 Why does breast reconstruction surgery sometimes have to be revised?
- 8.16 Who is a candidate for breast reconstruction surgery?
- 8.17 How do I know if breast reconstruction is right for me?
- 8.18 How can smoking after the healing process of breast reconstruction surgery?
- 8.19 How long does it take for the swelling to go away after breast reconstruction surgery?
- 8.20 Will I have to wear support garments after breast reconstruction surgery?
- 8.21 Is it true that reconstructed nipples sometimes appear hard?
- 8.22 How prominent will my scars be from my breast reconstruction?
- 8.23 I had a mastectomy years ago so can I still have breast reconstruction surgery?
- 8.24 How painful is breast reconstruction surgery?
- 8.25 Will my reconstructed breast match my healthy breast?
Breast reconstruction is a surgical procedure to rebuild and reconstruct a woman’s breasts after mastectomy, trauma, illness, or congenital defects. Although many variables influence a woman’s decision to consider breast reconstruction, the most common motivating factor is the removal of one or both breasts during a mastectomy after breast cancer. At Gabbay Plastic Surgery, located in Beverly Hills, California, Dr. Joubin Gabbay M.D. has helped many women who have faced the anguish of losing one or both breasts by reconstructing natural-looking and feeling breasts.
Breast reconstruction techniques have improved dramatically over the past decade, and breast cancer advocacy and awareness has led to the coverage of breast reconstruction procedures by the majority of health insurance companies. The Federal Women’s Health and Cancer Rights Act of 1998 mandates that health insurance also cover all stages of breast reconstruction after mastectomy. Research has shown that reconstructive breast surgery can have a positive emotional and psychological impact on breast cancer survivors, and can provide a sense of closure to the traumatic experience of battling breast cancer.
As a result of advances in reconstructive surgical technology and techniques, there are many options available for breast reconstruction procedures; however, the three primary reconstructive methods involve using artificial breast implants, the patient’s own body tissue (autologous tissue), or a combination of the two techniques. During your complimentary initial consultation, Dr. Gabbay will conduct a thorough medical evaluation and listen carefully to your reconstructive surgery goals before creating a customized treatment plan for your breast reconstruction surgery.
Breast cancer is the most common cancer among women in the United States (other than skin cancer), and the chance of a woman having invasive breast cancer at some point in her life is about 1 in 8. Breast reconstruction can begin at the same time as a mastectomy (immediate reconstruction), or at a later date (delayed reconstruction). If you are facing a mastectomy due to breast cancer, it is very important that you talk to your physician about post-mastectomy breast reconstruction options. By doing so, your surgeon can utilize specific mastectomy techniques in order to provide a better foundation for your future reconstructive surgery. Breast reconstruction can be performed for partial mastectomies as well as complete mastectomies. If you would like additional information about breast reconstruction surgery, please contact Gabbay Plastic Surgery today.
Some of the most common reasons patients elect to undergo breast reconstruction include:
- Full or partial mastectomy resulting from breast cancer treatment
- Significant deformity of breast after lumpectomy (partial removal of breast)
- Genetic deformity
- Accident or injury to breasts
If you are interested in learning more about breast reconstruction surgery, please call Gabbay Plastic Surgery and let us schedule your personal consultation with Dr. Gabbay. During your meeting, Dr. Gabbay will discuss your overall expectations and aesthetic goals, in order to determine whether breast reconstruction surgery is a suitable option for you.
You should come to your consultation prepared to discuss your medical history (including any past surgeries), present medical conditions, allergies, and medications. It is imperative that you are honest and provide complete information, as numerous medical conditions can potentially increase the risks and complications associated with surgery. If Dr. Gabbay feels that you are a good candidate for breast reconstruction surgery, he will explain the different techniques, costs and potential side effects before scheduling your procedure. When choosing Dr. Gabbay, you can be assured that you are in the hands of a surgeon who has undergone extensive training and is highly esteemed by his colleagues and patients alike.
Implant Based Breast Reconstruction: the implants used in breast reconstructive surgery are made out of silicone gel or saline (or a combination of both) and are placed underneath the chest muscle. Compared to natural tissue flap procedures, implant surgery is shorter and results in fewer scars; however, the entire reconstructive process can take longer to complete unless the patient undergoes a nipple-sparing mastectomy combined with direct-to-implant reconstruction.
Depending upon how tight the patient’s skin is after mastectomy, it may be necessary to place a tissue expander under the skin and muscle to create a pocket (envelope) for the new breast implant. After the tissue expander is in place, saline (salt water) solution is injected through a tiny valve and filled over a period of a few weeks to gradually expand the skin to make room for the permanent implant insertion. The final stage of implant-based breast reconstruction is to construct a nipple, and then tattoo the areola and nipple area to create a more authentic breast appearance. If additional support is needed to keep the implant in place, an acellular dermal matrix (comprised of human skin cells) may be utilized. Depending on the patient’s needs, Dr. Gabbay may recommend a fat transfer (fat will be harvested from the abdomen, thighs, buttocks, or hips) to graft onto the edges of the reconstructed breast, thereby creating a more natural silhouette.
Direct-To-Implant Reconstruction: also called “one step” reconstruction, the direct-to-implant procedure involves using an acellular dermal matrix (donated human tissue from which the cells have been removed or Strattice™ derived from porcine dermis) to complete the reconstructive process. By alternatively stitching patches of acellular dermal matrix to the sides of the muscle or along the inframammary fold, an instant pocket for the implant is created. Direct-to-implant reconstruction does not require any tissue expansion, and when this procedure is combined with a skin-sparing and nipple-sparing mastectomy, patients can complete their entire reconstruction in a single operation.
Tissue Flap Breast Reconstruction: tissue flap breast reconstruction involves the transfer of skin, fat, or muscle to form a tissue flap that helps to recreate the breast. During tissue flap reconstruction, a breast mound is created using tissue taken from other parts of the body (i.e. the abdomen, back, thighs, or buttocks), which is then transplanted to the chest by reconnecting the blood vessels. Flap procedures are more complex than implant reconstruction procedures, and recovery can take more time (although the overall reconstruction timeline is shorter) because flap reconstruction involves surgery at the chest and the donor site. Unlike traditional implant reconstruction with expanders, flap procedures form full-size breasts that look and move naturally because they are made from human tissue. Breasts created from flaps need a healthy blood supply to survive, and there are a number of options in terms of harvesting the blood vessels for the procedure.
Tissue flap reconstructive options include:
- Transverse Rectus Abdominus Myocutaneous (TRAM) Flap: for the TRAM flap procedure, the skin and fat from the lower abdominal region and the rectus muscle are utilized to reconstruct the breast.
- Latissimus Dorsi (LD) Myocutaneous Flap: the latissimus dorsi tissue flap uses harvested tissue from the upper back to reconstruct the breast. For a thin patient with low breast volume, this procedure may be used without an implant as the primary reconstructive method. The latissimus dorsi flap is often used as a backup option for patients with wound healing problems, and can also be used for patients who have had previous radiation and are not candidates for other autogenous procedures.
- Deep Inferior Epigastric Perforator (DIEP) Flap: the DIEP technique uses tissue from the stomach region to reconstruct the breast. During the DIEP flap procedure, skin and fat from the lower abdominal region is removed without having to harvest any of the rectus abdominis muscle, because the blood supply is provided through the perforator vessels from the rectus muscle. The DIEP procedure is comparable to the TRAM flap surgery; however, the DIEP flap minimizes injury to the abdominal wall muscle, which translates to less post-op pain and a lower risk of hernia formation.
- Superior Gluteal Artery Perforator (SGAP) Flap: the SGAP procedure involves harvesting skin and fat from either the superior or inferior gluteal vessels, and utilizes the blood supply provided through the perforator vessels of the gluteus muscle.
- Transverse Upper Gracilis (TUG) Free Flap: the TUG flap utilizes the fatty tissue of the inner thigh to reconstruct the breast. The gracilis muscle (small adductor muscle of the thigh) and its blood vessels carry the blood supply and allow the free transfer to the chest. The skin and fat carried by the inner thigh flap can be extracted just below the groin and buttock crease enabling the donor site to be closed similarly to a thigh lift, resulting in a well concealed scar.
- Superficial Inferior Epigastric Artery (SIEA) Flap: the SIEA flap utilizes the skin and fat of the lower abdomen, and incisions are made in the skin and fat only, allowing the flap to be transferred based on the superficial inferior epigastric vessels, which translates to less post-operative pain and no risk for hernia. Unfortunately, only a minority of patients are candidates for the SIEA flap because the superficial vessels are very small, and may not be present in some patients because of previous surgeries (i.e. Caesarean section or hysterectomy).
Breast reconstruction surgery is performed under general anesthesia, and usually takes 3-8 hours, depending on the type of surgery you are having, the complexity of the procedure, and if one or both of your breasts are being reconstructed.
The timing of the surgery can be customized to meet your specific needs, as explained below:
- Simultaneous Breast Reconstruction: immediate breast reconstruction performed at the same time as the mastectomy. This option is best suited for patients who do not require breast radiation as a part of their treatment.
- Staged Breast Reconstruction: during staged reconstruction, a tissue expander will be inserted after the mastectomy to keep the breast skin stretched and supple in preparation for the insertion of the implant, which can be placed several months after radiation concludes. This procedure is a good option for patients who do need radiation therapy, because if radiation is performed on a newly reconstructed breast, the cosmetic appearance of the breast may be altered.
Other surgical options for breast reconstruction include:
- Nipple Reconstruction: the final stage of breast reconstruction is the creation of a nipple using the patient’s own tissue
- Micropigmentation (Tattoo): the areola and nipple can be tattooed after the nipple reconstruction has completely healed, in order to create a more authentic looking breast
Lastly, it is important to consider the opposite breast when planning your breast reconstruction. Although some women choose to leave the healthy breast untouched, many want to achieve symmetry with the newly reconstructed breast, and may elect to undergo a unilateral breast reduction, breast lift, or breast augmentation to create a symmetrical and balanced appearance.
You can expect some discomfort and/or pain following your breast reconstruction surgery, which can be controlled with pain medication. Your incisions will be wrapped with gauze and bandages and you will be given a surgical bra to facilitate the healing process. You will be advised to limit your physical activity for at least six weeks and will return to the office for follow-up appointments so that Dr. Gabbay can monitor your progress. Depending upon the type of breast reconstruction you had performed, the recovery process can take a few weeks to a few months.
Frequently Asked Questions (FAQs)
What are the options of breast reconstruction?
Breast reconstruction options generally fall into two categories that include reconstruction with breast implants, or by using the patient’s own fat tissue.
What factors determine the best approach?
The primary factor when determining the best approach for breast reconstruction is the patient’s anatomy, and whether they have sufficient tissue in the abdomen, back, or other areas to transplant fat to the chest area. If so, using the patient’s own tissue is an option, however, when that is not the case, implant-based options must be considered. Other determining factors include the severity of the disease, which can affect the timing of breast reconstruction, because in most cases, a patient should wait until radiation or chemotherapy is completed to use tissues harvested from other areas of the body.
When is the best time to have breast reconstruction surgery?
Your physician and Dr. Gabbay will help you decide the best time to have breast reconstruction surgery and the options include:
- Simultaneous Breast Reconstruction—Women have the option to have immediate reconstruction of their breast(s) at the same time as their mastectomy, and this is a reasonable option for women who do not need breast irradiation.
- Staged Breast Reconstruction—Many women who require radiation therapy are advised to have staged breast reconstruction, instead of simultaneous breast reconstruction, because if radiation is performed on a newly reconstructed breast, over time it can alter its cosmetic appearance. For staged breast reconstruction, a tissue expander will be inserted after your mastectomy to keep the breast skin that was saved during the mastectomy stretched and supple, in preparation for the final implant reconstruction, performed several months after radiation is completed.
- Delayed Breast Reconstruction—A woman may choose to have delayed breast reconstruction, and for many this occurs because they were not aware that immediate breast reconstruction was an option at the time of their mastectomy.
How can a woman’s breast be reconstructed?
A woman’s breast can be reconstructed in one of two ways that include:
- Implants—Implants are made out of silicone or saline (or a combination of both), that can be inserted during or after a mastectomy. Breast implants used in breast reconstruction are placed underneath the chest muscle, versus on top of the muscles, as it is sometimes done with breast augmentation.
- Flaps—During flap reconstruction, a breast is created using tissue taken from other parts of the body (such as the abdomen, back, buttocks, or thighs), before it is transplanted to the chest, by reconnecting the blood vessels to new ones in the chest region.
What are the common breast reconstruction procedures performed using a patient’s own tissue?
The most common reconstruction procedure that uses tissues from a patient’s own body is called the Transverse Rectus Abdominus Myocutaneous (TRAM) flap. During this surgery, Dr. Gabbay will harvest skin and fat tissue from the donor area and transfer it to the chest wall. In addition, he will remove and transfer the abdominal muscle that carries blood vessels needed for the skin and fat to survive. The TRAM flap procedure flattens the abdominal donor site (similar to the way that a tummy tuck works), however; removing the muscle can sometimes cause problems, and this procedure can take longer to recover, because the additional donor sites have to heal as well.
Perforator flap procedures also involve transferring the patient’s skin and fat tissue from the abdomen to create a new breast shape, but the difference between the perforator flap and the TRAM technique, is that no muscle tissue is removed. Instead, blood vessels are connected from the flap to those on the chest wall in order for the tissue to survive.The most common perforator flap, the Deep Inferior Epigastric Perforator (DIEP) flap, allows a flat donor site.
Why is a tissue expander sometimes used in a breast reconstruction?
Breast reconstruction surgery with implants may use a balloon-like device called a tissue expander. Putting in a tissue expander requires two stages. Iit is a temporary device made of a material similar to plastic, supported with an internal sling called AlloDerm, that is attached to the chest wall. After breast cancer surgery, the expander is filled with saline through a built-in port to slowly stretch the patient’s skin, until there is enough room to perform the second stage of breast reconstruction surgery with permanent implants. The second part of this procedure involves opening the incision, taking out the expander, and placing a final breast implant.
What are the different types of breast implant reconstruction?
There are three techniques used in breast implant reconstruction that include:
- The use of biologic tissue matrix
- Full muscle coverage
- Partial muscle coverage
Full muscle and partial muscle coverage techniques have traditionally been used in breast implant reconstruction, but they have limitations. The use of a tissue matrix has increased the options for breast implant reconstruction, and in some cases it has many advantages over full muscle coverage and partial muscle coverage techniques. Supporting the lower part of the breast using a tissue matrix provides the benefits of both full muscle coverage and partial muscle coverage.
What is AlloDerm® Tissue Matrix and how does it work?
AlloDerm® Tissue Matrix provides support for breast implant reconstruction procedures, it is derived from donated human tissue, and it acts as a replacement for missing tissue in the body. This tissue goes through a process where cells are removed, without damaging the integrity of the tisuue, and AlloDerm® Tissue Matrix is anchored into the breast, between the pectoralis muscle and the chest wall, at the lower pole of the breast. AlloDerm® Tissue Matrix is accepted by the body, and allows the patient’s own cells to grow through it, allowing it to become a part of the patient’s own body. It serves as a “hammock” to provide an internal foundation, helping form a more natural looking breast.
How does AlloDerm® Regenerative Tissue Matrix incorporate into the body?
AlloDerm® Tissue Matrix is manufactured using a process that removes both the top layer of skin (epidermis) and cells to help minimize the risk of rejection. What remains are the structural components that create a natural framework for the body to accept the tissue matrix, and AlloDerm® Tissue Matrix is remodeled into the patient’s own tissue.
How long has AlloDerm® Tissue Matrix been available?
AlloDerm® Tissue Matrix was introduced in 1994 as a skin graft and has been used for thousands of burn patients without any complications. It was pioneered for post-mastectomy breast reconstruction in 2001, and has since become the most common approach for breast implant reconstructions.
With so many choices, how do I know which implant technique is right for me?
During your consultation, Dr. Gabbay will help you choose which type of implant best suits your body shape and individual needs, and the two general categories for implants are saline-filled, and the new generation of silicone cohesive gel-filled implants. Saline implants have been more commonly used in breast reconstruction although gel implants are gaining in popularity, and the advantages of gel implants are that they tend to be softer, with a more natural breast tissue feel. They have less rippling and visibility, as compared to saline implants.
What is the recovery period after breast reconstruction?
The recovery period after breast reconstruction is different for every patient, depending on the type of reconstruction they have.
How long will I have to take off work from my breast reconstruction surgery?
Depending on the type of surgery you have, and how physical your job is, the time you need to take off work will vary.
The following are general guidelines that may apply to a patient with a desk job that requires no lifting:
- Mastectomy with placement of a tissue expander (1-2 weeks)
- Mastectomy with latissimus dorsi flap (2-3 weeks)
- Mastectomy with pedicle TRAM flap (6-8 weeks)
- Mastectomy with abdominal free TRAM, DIEP, or SIEA flap (4-6 weeks)
- Mastectomy with GAP flap (6-8 weeks)
- Exchange tissue expander to implant (1 week or less)
- Exchange unilateral tissue expander and augment/reduce/lift opposite breast (1-2 weeks)
- Nipple areola reconstruction (1 week of less)
If I want to have breast reconstruction with my mastectomy, what should I do?
First of all, it is crucial that when you evaluate your treatment plan for breast cancer, you talk to your physician about breast reconstruction as well. By doing this, part of your treatment plan can accommodate your breast reconstruction surgery,and proper measures can be taken to begin the breast reconstruction procedure.
Why does breast reconstruction surgery sometimes have to be revised?
There are many reasons why an original breast reconstruction operation may require a revisionary plastic surgery operation, and that includes radiation and in some case the results of the original operation did not meet the patient’s desired expectation. Additionally, some patient characteristics such as stretched out skin, massive weight loss, chest wall deformities, or thin tissue can create special challenges that may need to be corrected in the future.
Who is a candidate for breast reconstruction surgery?
Most commonly, breast reconstruction is intended for women who have lost one or both breasts due to a mastectomy. Breast reconstruction is also used for women who have lost a breast due to a congenital deformity or injury.
How do I know if breast reconstruction is right for me?
The decision for breast reconstruction is a personal one and is often not easy to make because the choice that is right for one woman, may not be right for another. The long-term effects of living without a breast affects every woman differently, and after a mastectomy, some patients choose to wear an artificial external breast, while others decide to do nothing to alter their appearance at all. Fortunately, improvements in plastic surgery techniques offer better results today than ever before, making breast reconstruction an option for women facing a mastectomy and many who have undergone the procedure say it not only improves their physical appearance: it has psychological benefits that promote a sense of wellness for the woman, as well as her family.
How can smoking after the healing process of breast reconstruction surgery?
Smoking causes blood vessels to constrict, reducing the blood supply and oxygen carried to the surgical area, and recovery tissues need good circulation and plenty of oxygen. For this reason, smoking slows the healing process, and that is why it is required that you quit smoking before and after reconstruction.
How long does it take for the swelling to go away after breast reconstruction surgery?
The swelling and/or bruising of your tissue may last 4-8 weeks, and longer for patients that have had prior radiation. Unrelated to swelling, it may take several months for the final appearance of your reconstruction to become evident. It is essential that you give yourself healing time, because everyone heals at a different rate. Scheduling revision or nipple reconstruction surgery before the breasts have totally settled and healed can result in an unsatisfactory aesthetic outcome.
Will I have to wear support garments after breast reconstruction surgery?
There are many varying opinions about what patients should wear after surgery, and it is important that the proper choice is made depending on your surgery, as well as your personal preferences and Dr. Gabbay’s recommendations.
Is it true that reconstructed nipples sometimes appear hard?
The skin on the reconstructed breast is used to create a nipple, and in the first weeks and months after a nipple reconstruction, the size of the nipple will shrink due to the natural forces of wound healing. After the healing is completed, the nipple will continue to maintain its final height, but it will not respond to cold or stimulation the way a normal nipple does.
How prominent will my scars be from my breast reconstruction?
Every woman’s reconstruction breast surgery is different and your scars will depend mainly on how your mastectomy was performed, as well as your breast reconstruction technique. Immediate reconstruction, performed at the same time as your mastectomy, can be accomplished with little or no scarring; while a delayed reconstruction will leave a scar across the reconstructed breast.
I had a mastectomy years ago so can I still have breast reconstruction surgery?
Reconstruction breast surgery can be performed at any time, whether it is during your mastectomy while you are still asleep on the operating table, or weeks, months, or even years later.
How painful is breast reconstruction surgery?
The tolerance of pain from any surgery is dependent on the individual as well as the procedure performed. Typically, recovery from tissue flap surgery is more uncomfortable than implant reconstruction, but any discomfort can be controlled with pain medication.
Will my reconstructed breast match my healthy breast?
Dr. Gabbay is committed to matching your reconstructed breast to your natural breast and in some cases, when necessary, the healthy breast can be augmented, reduced, or lifted as necessary to achieve a better match.