About the Breast Reconstruction Procedure
There are many options available today in breast reconstruction. A woman’s anatomy, the surgeon’s recommendations and your desired results will together determine which method is best for you. Breast reconstruction can create a very natural-looking breast for women. Often, only a lumpectomy is needed which most often does not require any time of breast reconstruction. If a mastectomy (is needed, then breast reconstruction can be done either at the time of the mastectomy (primary reconstruction) or after at a second stage (secondary reconstruction). Breast reconstruction tries to recreate national-looking breasts for those who have experienced mastectomy.
Types of Breast Reconstruction
Prosthetic reconstruction is the most frequently done breast reconstruction after mastectomy. This involves using a breast implant to create the form of the breast. That implant can be placed in different positions on the chest wall.
Sub-muscular Placement (Full Muscle Cover):
The breast tissue sits on top of the Pectoralis Major muscle. When a mastectomy is performed, the pectoralis major muscle remains at the base of the surgical site. An implant can be placed behind the muscle but, because muscles are naturally tight, the muscle must be stretched slowly, over a period of time, to fill the cavity and create the breast form. This is done by placing and “expander” behind the muscle at the time of the mastectomy. This expander has a metal valve incorporated within the implant. The skin is closed, usually with a drain in place. Once the wound has healed, usually around 3 weeks post operatively, the expander can be slowly filled to allow stretching of the muscle. “Expansion” is done in the office over a period of time and is usually painless. Once expansion is complete usually 1-2 months, the patient is returned to the operating room for an outpatient procedure too exchange the expander for a permanent implant. Adjustments to the breast shape can be done at that time.
Partial Muscle Cover
In some instances, the pectoralis muscle can be cut at its base to make more room behind the muscle and allow direct placement of an implant at the time of the mastectomy. However, to keep the implant behind the muscle some tissue must be placed at the bottom of the pocket and attached to the cut end of the muscle and the lower part of the bottom of the breast, to prevent the implant from migrating to the pre-pectoral position. This tissue is usually some type of denatured collagen. Denatured collagen is a fancy name for human donated cadaver skin. This donated skin to treated in some fashion too remove all cellular elements and sterilized so that it can be placed in the patient’s body without generating a rejection reaction by the body.
In recent years, pre-pectoral placement of an implant for breast reconstruction has become more popular. This means placing the implant above the pectoralis major muscle, basically where the breast tissue was prior to the mastectomy. However, because the skin and tissue left after a mastectomy is performed is thin, the implant can be more visible and less hidden. To better hide the implant, denatured collagen is typically placed between the implant and the skin.
Advantages and Disadvantages Type of Implant Placement
Each location of implant placement has advantages and disadvantages. Certainly, placing the implant behind the pectoralis muscle allows for less visibility of the implant. Both saline and silicone implants are minimally visible, hiding potential rippling or waviness of either implant. When the skin of the mastectomy is placed back on the muscle, the circulation of the skin can be improved by new blood vessels that grow into the skin from the muscle. The implant maybe better protected from infection if there are small openings or skin breakdown after the mastectomy. There are disadvantages of this method. It is more painful in the first few weeks after surgery and patients typically spend 1-2 days in the hospital after the mastectomy. There is something called “animation deformity” where the implant can move out of position if the pectoralis muscle contracts strongly. In most of the patients this is not a significant issue but it can certainly be a problem for some people. At times, individual nerves can be transected to reduce this issue. There have been some patients who have complained of a tight feeling across the chest when implants are placed behind the muscle. Keep in mind that many cosmetic breast enlargements are done by placing the implants behind the muscle.
Partial Muscle Cover
This type of reconstruction where the implant is partially covered by the pectoralis muscle has some of the same issues that full muscle cover has but there is the addition of a foreign object; the denatured collagen. Animation deformity may be greater with this method. This method does potentially allow for an implant to be placed at the time of the mastectomy also known as “direct to implant” placement.
Pre-pectoral placement of an implant for breast reconstruction has the main advantage of a less painful post-operative recovery. Most patients leave the hospital the day following the mastectomy. The implant however, can be more visible in this position. Waviness or rippling can occasionally be seen, especially in the upper pole of the breast. Some patients are brought back to surgery at some point to add fat into the superficial layers of the breast to potentially hide the implant. This, at times, needs to be done several times to achieve the best results. There is no animation deformity with the implant in this position since the pectoralis muscle is below the implant. There is a very small risk that any unfortunate recurrence of the breast cancer that occurs on the muscle can be hidden by the implant. This is a very small risk and is typically only an issue if the original lesion was very close to the muscle. This is something that can be discussed with the patient’s surgeon prior to surgery.
Skin Expansion with a Breast Implant
Reconstruction with an implant is the most frequent type of breast reconstruction. If a final implant is used at the time of the mastectomy it is called a “direct to implant procedure”. Occasionally an expander is required to stretch the breast skin to allow placement of the final implant. The implant was previously typically placed behind the pectoralis muscle or “submuscular placement”. Now, frequently the implant is placed above the pectoralis muscle or “pre-pectoral placement”. Occasionally the implant is covered with the muscle only in the upper portion and this is called “partial muscle cover”. Which type of reconstruction is best for you should be discussed thoroughly with your surgeon.
Denatured collagen is really skin that has been treated to remove all cellular tissue and any contaminants. This can be from animal origin but most frequently is from human cadaver skin donations. It is used in many types of breast reconstruction to help cover the implant. In “pre-pectoral placement” reconstruction, the implant is typically entirely covered with denatured collagen.
Although flap reconstruction is more involved at the initial procedure than reconstruction with an implant, many women still prefer it because it may allow the breast to be rebuilt with natural tissue. Also, unlike the implant method, the breast mound is completed at the initial operation without the need for expansion over an extended time period. In one method, the breast is reconstructed using a tissue flap – consisting of a portion of skin, fat, and or muscle –most commonly from the abdomen. This is typically called a DIEP (deep inferior epigastric perforator) flap reconstruction. In this procedure only, the blood vessels are used and most of the rectus muscle is left in place. With this technique, the tissue that is removed from the abdomen is surgically transplanted to the chest by reconnecting the flap’s blood vessels to vessels in the chest region. Although technically more complicated, this microsurgical reconstruction may provide a more natural and less traumatic reconstruction in many women. The procedure can take a 6-8 hours for one-sided reconstruction and 8-12 hours if both breasts are done. Hospitalization can vary but is typically 5-7 days. Occasionally (10%) the patients need to return to surgery to correct possible clot in the small blood vessels but the procedure is 95% successful.
What to Expect
Once the breast mound is restored in the initial procedure, one or more follow-up procedures will be performed to replace a tissue expander with a permanent implant, improve on the shape of the TRAM flap reconstruction or to reconstruct the nipple and areola. An additional operation to lift or reduce the opposite breast to match the appearance of the reconstructed breast may also be recommended.
Anesthesia and Surgery Facility
General anesthesia in all circumstances. For the TRAM flap technique, the inpatient hospital stay ranges from 4-7 days. For the tissue expander technique, the inpatient hospital stay ranges from 1-3 days. Operative time is variable, depending upon the technique and whether reconstruction is performed at the same time as the mastectomy. The number of hours will be determined for each patient by the physician.
Side Effects | Recovery
Recovering from breast reconstruction will vary significantly depending upon the method chosen, whether immediate reconstruction is performed, and individual factors. In general, it may take up to 6 weeks to recover from a combined mastectomy and reconstruction, or from a flap reconstruction alone. If implants are used without flaps and reconstruction is done apart from the mastectomy, your recovery time may be less.
Duration of Result
It is very normal to go through a period of adjustment to your new look. Concerns about the reconstructed breast are likely to pass within a few months as a woman begins to incorporate her reconstructed breast as her own.
Most women who undergo breast reconstruction find that the procedure provides both physical and emotional rewards. For many women, breast reconstruction represents a new beginning, the chance to put breast cancer behind them and get on with their lives.