Breast Cancer Reconstruction in General:
As a Cosmetic and Reconstructive Plastic Surgeon, Dr. Elisa Burgess is highly committed to providing exemplary breast cancer reconstruction in a caring and compassionate manner. Dr. Burgess and her office staff strive to offer exceptional care to all patients in a comfortable and friendly office setting.
Breast Cancer reconstruction is a specialized group of surgical procedures which recreate the breast, following a mastectomy or lumpectomy. There are several different options to recreate the breast and Dr. Burgess guides her patients towards the best option for their individual situation with an optimal outcome. The reconstructed breasts will look different from your natural breast, but they can look very nice and natural in clothing. Below is a general overview of breast cancer reconstruction and the possible options available in our clinic.
At the time of mastectomy, or at a later date, a tissue expander can be placed underneath the pectoralis muscle. The tissue expander is a temporary implant that contains a port within its shell. This port allows for adding more saline or air, once the mastectomy incision has healed, to expand or fill the tissue expander. This process is known as expansion. Your expansions normally start several weeks after surgery and usually occur every two weeks until you have reached your goal.
During a quick, in-office procedure, Dr. Burgess or her nurses will use a very fine needle to place about 50mL of saline or air into the port of your tissue expander through a numb area on your chest. The pectoralis muscle may feel tight and uncomfortable that evening. Each patient has their own expansion schedule that can easily work around chemotherapy appointments, as well as their personal life. The number of required expansions is very patient-specific. Your final expanded volume depends on your individual goals for breast size, breast anatomy and how well you tolerate the overall process.
Once you have reached a volume that you and Dr. Burgess feel is acceptable, you will undergo a day surgery to remove the tissue expander and replace it with a silicone or saline implant.
Burgess Plastic Surgery patient who underwent nipple sparing mastectomies and implant placement after tissue expanders (incision in the inframammary fold).
Acellular Dermal Matrix (ADMs):
After mastectomy the remaining tissue over the chest wall may be very thin, and the natural anatomy of the pectoralis muscle may not be adequate coverage for the implant in this case, An Acellular Dermal Matrix (ADM) may be employed to provide lower pole for better support and coverage. An ADM is often a human cadaveric or porcine product that is utilized at the time of tissue expander placement.
The ADM is sewn into the pectoralis muscle, allowing for greater support in the lower breast pole, while supporting the tissue expander and eventually, the implant. It can provide a natural shape or “hang” to the breast. The ADMs also support cellular growth and healing, while providing stabilization of the implant. It is also possible that the tissue expander or implant could be placed on top of the muscle (or pre pectoral) but it would typically be wrapped in a large piece of ADM.
Direct to implant:
Direct-to-implant breast reconstruction surgeries are performed at the time of mastectomy, and require the general surgeon and the plastic surgeon working in sync for part of the same procedure. Patients who have sufficient breast skin remaining after mastectomy may be well suited for direct-to-implant breast reconstruction. While direct-to-implant method avoids the use of a tissue expander, secondary procedures may still be preferred to improve symmetry, or breast size. Also, unless the initial mastectomy was done using a nipple-sparing approach, most women will proceed with reconstruction of the nipple and areola.
Latissimus Dorsi Flap:
Another surgical option for some women is to reconstruct the breast using their own skin, tissue and latissimus muscle taken from the back and tunneling it to the breast area. This surgery is a favorable procedure for those that have undergone radiation and need fresh tissue to the chest.
This is a major surgical procedure that can take 4-5 hours. Most women require several weeks off of work and should not work out vigorously for 8 weeks. Some patients require a tissue expander as well for additional volume, which is then replaced with a permanent implant once their expansion process is complete. Patients can expect a scar on the mid-back/shoulder area.
The TRAM (transverse rectus abdominis muscle) is a major surgical procedure that involves using your own abdominal skin, fat and muscle to create and contour one or both breasts. This surgery can be upwards of 12 hours of surgical time and a 2-4 day hospital stay. The recovery from this surgery, as compared to the tissue expander procedure, is a greater length of time. As with all reconstruction options, your surgeon will help guide you in choosing. This surgery is best for women who have some excess abdominal fat.
Here, the transverse rectus abdominis muscle with fat and skin, is partially released and lifted up to form a new breast. Since your surgeon is harvesting this tissue from your abdomen, you also will end up with a tummy tuck but the abdominal wall will be reconstructed as well, usually with a piece of mesh or ADM (acellular dermal matrix). It is important to remember that this surgery will involve a scar across your lower abdomen and the breast area. It is possible you will have some abdominal muscle weakness after this surgery.
Since your new breasts are created from your own tissue, they may feel natural. However, the skin sensation and coloring will be different since the skin and tissue came from a different area of the body. It is important to keep in mind that only certain patients are good candidates for the TRAM flap surgery.
DIEP Flap and Muscle SparingTRAM:
The DIEP Flap and muscle sparing tram types of breast reconstruction uses your own skin and fat to recreate the breast from the abdominal area.
In this microsurgical procedure, blood vessels known as the deep inferior epigastric perforators, (DIEP) along with skin and fat are removed from the abdomen and relocated to the chest to create breasts. This type of flap surgery leaves the abdominal muscles intact. However, due to the complexity of this surgery there are few facilities that offer the DIEP technique. Dr. Burgess does not routinely perform them but would be happy to refer you to a surgeon who does.
Lumpectomy and Breast Reduction:
Sometimes a breast reduction may be an option for larger breasted women who have been diagnosed with breast cancer. The mass is removed at the same time as the breast reduction and often the unaffected breast is reduced as well. Many factors are considered, such as the specific cancer diagnosis, stage, tumor location, breast size, treatment modalities and personal goals.
Following lumpectomy, a breast reduction will remove excess breast and fatty tissue in one or both breasts, making them smaller, lifted and more proportional to your body. Your size, anatomy and tumor location will dictate what type of surgical approach your plastic surgeon may use.
We perform fat grafting in conjunction with other methods of reconstruction. For some women, Dr. Burgess will remove fat from another part of her body (i.e. stomach or thighs) and place back into flatter areas of the reconstructed breasts to create better fullness.
Once your breast reconstruction is complete, you may consider undergoing nipple reconstruction. This usually occurs at least three months after your final implant placement or muscle flap surgery, to allow your new breasts to heal and settle. However, nipple reconstruction may be done much later, depending on patient preference.
Nipple reconstruction, also known as Nipple-Areolar Complex (NAC), is a quick day surgery which uses your own tissue on the breast to create a nipple. The reconstructed nipple has projection, but no feeling or function. The areola is created by bringing in skin from another area of the body, such as the lower abdomen or axilla as a skin graft and then covering the nipple areolar complex with a protective dressing for about 5-6 days. Once this dressing is removed care must be taken to not injure them. Patients should avoid vigorous exercise for about one month. Most patients do not require much time off of work, usually only a few days, and find this surgery to be the easiest step in the whole reconstruction process. Some patients go on to have tattooing after their nipple reconstruction surgery, but others simply decide to only do the 3D tattoo without surgery.
Surgery to the Unaffected Breast:
Some women chose to only have a mastectomy to the affected or cancerous breast. This is known as a one-sided or unilateral mastectomy. However, to create symmetry between the reconstructed breast and the natural breast, patients often require surgery to the unaffected side. The type of surgery is patient specific. Some smaller breasted women may require an augmentation, or implant to the natural breast, while some women may only need a breast lift. Others still may need a breast reduction to the non-cancerous breast if they are naturally very large breasted. Surgery to create symmetry is normally done at the time your final implant is placed to your reconstructed side, or after you have healed from your muscle flap surgery. With unilateral reconstruction there is no firm time frame for surgery to create symmetry.
The entire reconstruction process can take around one year to complete. Each patient has their own reconstruction timetable, with independent factors, such as chemotherapy, radiation or personal and family agendas that may affect surgery scheduling. Breast reconstruction is usually a staged process, to allow for healing, settling of the new breasts or implants and mental adjustment to your new look. Because breast cancer reconstruction is an elective procedure, patients should be in good overall health.
Support groups:There are many support groups available to those with breast cancer, breast cancer survivors and their families. For more information please click below.