breast reconstruction

 

Breast Reconstruction is NOT cosmetic surgery and as such the costs relating to it should be covered by your medical aid at least in part.

What is breast reconstruction?

 

Breast reconstruction is achieved through several plastic surgery techniques that attempt to restore a breast to near normal shape, appearance and size following mastectomy.  It is not possible to re-create a breast as good as the one you were born with, but at least reconstructive surgery can enable you to feel feminine again and to look ‘normal’ in a costume on the beach or in your underwear.

 

Although breast reconstruction can rebuild your breast, the results are highly variable:

 

  • A reconstructed breast will not have the same sensation and feel, as the breast it replaces.

  • Visible incision lines will always be present on the breast, whether from reconstruction or mastectomy.

  • Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the back, abdomen or buttocks.

 

A note about symmetry:

 

If only one breast is affected, it alone may be reconstructed.  In addition, a breast lift, breast reduction or breast augmentation may be recommended for the opposite breast to improve symmetry of the size and position of both breasts.

 

Breast reconstruction candidates

 

Breast reconstruction is a highly individualized procedure.

You should do it for yourself, not to fulfill someone else’s desires or to try to fit any sort of ideal image.

 

Breast reconstruction is a good option for you if:

 

  • You are able to cope well with your diagnosis and treatment.

  • You do not have additional medical conditions or other illnesses that may impair healing.

  • You have a positive outlook and realistic goals for restoring your breast and body image.

 

Breast reconstruction typically involves several procedures performed in multiple stages.  It can:

 

  • Begin at the same time as mastectomy, or;

  • Be delayed until you heal from mastectomy and recover from any additional cancer treatments.

 

It’s important that you feel ready for the emotional adjustment involved in breast reconstruction.  It may take some time to accept the results of breast reconstruction.  Breast reconstruction is a physically and emotionally rewarding procedure for a woman who has lost a breast due to cancer or other condition.

 

The creation of a new breast can dramatically improve your self-image, self-confidence and quality of life.

 

What to expect during your consultation

 

The success and safety of your breast reconstruction procedure depends very much on your complete candidness during your consultation.  You’ll be asked a number of questions about your health, desires and lifestyle.

 

Be prepared to discuss:

 

  • Why you want the surgery, your expectations and desired outcome.

  • Medical conditions, drug allergies and medical treatments.

  • Use of current medications, vitamins, herbal supplements, alcohol, tobacco and drugs.

  • Previous surgeries.

  • The options available in breast reconstruction surgery.

  • The likely outcomes of breast reconstruction and any risks or potential complications.

  • The course of treatment recommended by your plastic surgeon, including procedures to achieve breast symmetry.

 

Dr. Schoenfeld may also:

 

  • Evaluate your general health status and any pre-existing health conditions or risk factors.

  • Examine your breasts, and take detailed measurements of their size and shape, skin quality, and placement of nipples and areolae.

  • Take photographs for your medical record.

  • Discuss your options and recommend a course of treatment.

  • Discuss likely outcomes of breast reconstruction and any risks or potential complications.

 

Breast reconstruction risks and safety information

 

The decision to have breast reconstruction surgery is extremely personal.  You’ll have to decide if the benefits will achieve your goals and if the risks and potential complications are acceptable.  Dr. Schoenfeld will explain in detail the risks associated with surgery.

 

You will be asked to sign consent forms to ensure that you fully understand the procedures you will undergo and any risks or potential complications.

 

The possible risks of breast reconstruction include, but are not limited to, bleeding, infection, poor healing of incisions, and anesthesia risks.

 

You should also know that:

 

  • Flap surgery includes the risk of partial or complete loss of the flap and a loss of sensation at both the donor and reconstruction site.

  • The use of implants carries the risk of breast firmness (capsular contracture) and implant rupture, both of which may need repeat surgery.

 

It is important to note that breast implants do not impair breast health.  Careful review of scientific research conducted by independent groups such as the Institute of Medicine has found no proven link between breast implants and autoimmune or other systemic diseases.

 

Visit www.breastimplantsafety.org for current information.

 

Where will my surgery be performed?

 

Surgery for your breast reconstruction is most often performed in a hospital setting, possibly including a short hospital stay, and Dr. Schoenfeld will use general anesthesia.  Some follow-up procedures may be performed on an outpatient basis, and local anesthesia with sedation may be used.  These decisions will be based on the requirements of your specific procedure and in consideration of your preferences and Dr. Schoenfeld’s best judgment.

 

Preparing for breast reconstruction surgery

 

Prior to breast reconstruction surgery, you may be asked to:

 

  • Get lab testing or a medical evaluation.

  • Take certain medications or adjust your current medications.

  • Stop smoking well in advance of surgery.

  • Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they can increase bleeding.

 

Special instructions you receive will cover:

 

  • What to do on the day of surgery.

  • The use of anesthesia during your breast reconstruction.

  • Post-operative care and follow-up.

  • Breast implant registry documents (when necessary).

 

Dr. Schoenfeld will also discuss where your procedure will be performed. Breast reconstruction surgery may be performed in an accredited surgical center, or a hospital.

 

What are my choices when it comes to breast reconstructive surgery?

 

We can divide reconstructive options into two big groups, each group having various options:

 

  • Autologous reconstruction = using your own body tissue (flaps).

  • Alloplastic reconstruction = using implants.

 

Sometimes one would use a combination of both the above options.

 

There are advantages and disadvantages to each of these groups of procedures and it can be difficult to compare one option with another as the pro’s of one operation are different to the con’s of another.

 

In general, flap techniques, using your own body tissue,

  • Can take longer to do,

  • Can have a slightly longer recovery period.

  • Can have donor site problems.

  • Can be more risky in the immediate post operative period.

  • Can take longer to heal.

  • Can withstand radiotherapy to the area better than implant reconstructions.

 

The flap techniques can however

  • Better match a natural slightly droopy remaining opposite breast.

  • Feel and look more natural.

  • Change appropriately with natural ageing and weight gain or loss.

  • Potentially have a lower long-term complication rate and hence lower re-operation rates over time.

 

The most commonly performed FLAP techniques are

  • TRAM flap (using tummy skin & fat).

  • DIEP flap (a variation of the TRAM flap).

  • Latissimus Dorsi flap (using skin & fat from the shoulder blade area).

  • SGAP / IGAP flap (using skin & fat from the upper or lower buttock area).

 

A TRAM flap uses donor muscle, fat and skin from a woman’s lower abdomen to reconstruct the breast.

 

These flaps are either “pedicled” or “free” flaps.

  • In a pedicled flap, the tummy muscle is transferred together with the overlying skin and fat from the lower abdomen. A tunnel is created on the anterior chest wall and the flap passed through the tunnel, after which the flap is used to create the breast mound.  The donor area on the tummy is then closed in a similar fashion to a tummy tuck procedure.

  • In a free flap procedure (such as the DIEP flap), the flap is completely detached from its original blood supply while carefully preserving the small blood vessel pedicle. Blood vessels on the chest recipient area are then prepared and the flap is transferred to the chest. The flap blood vessels are connected to the chest recipient vessels with the use of a microscope. The abdomen donor area is then closed in a similar fashion to a tummy tuck procedure.

 

A latissimus dorsi flap uses muscle, fat and skin from the back tunneled to the mastectomy site under the arm. The donor area is closed leaving a scar on the back, if possible hidden in the bra line.

Occasionally, the flap can reconstruct a complete breast mound, but often there is insufficient volume to do so on its own. It thus provides the muscle and tissue necessary to cover and support a breast implant if the chest tissue is deficient to cover the implant on its own.

 

In general, implant techniques

  • Are quicker to do.

  • Have a shorter recovery period.

  • Have no associated donor site and its possible problems.

 

The implant techniques however

  • Feel more firm than natural breast tissue.

  • Do not droop with age like a natural breast and are thus more difficult to match a remaining breast if it has not been operated on.

  • Are more likely to have complications in the long term (capsular contracture / implant rupture) which may require additional surgery.

  • May not be ideal if radiotherapy is required.

  • Typically required multi-stage surgery, first placing a tissue expander to stretch the tissue on the chest wall, in order to create space sufficient to accommodate an implant. This expander is inflated in the consulting rooms every 2-3 weeks and is then removed and replaced with a permanent implant at a second operation. This process typically takes around 9-12 months to complete.

 

In certain circumstances, both implant and flaps are required together.

 

Why is it so often necessary to expand the tissue prior to placing a permanent implant, when a cosmetic “boob job” is done in one simple stage?

 

With cosmetic breast enlargement, there is sufficient tissue to cover the implant by virtue of the fact that breast tissue is still present.  After a mastectomy however, there is by definition very little or no breast tissue remaining. One shouldn’t ideally simply place an implant just beneath the skin, as this could lead to problems.  After a mastectomy, it is thus necessary to stretch the pectoral (chest) muscle and skin over a period of a few months, in order to create sufficient space for the ultimate implant of adequate size to be completely covered by muscle as well as the overlying skin.

 

Tissue expansion stretches healthy skin to provide coverage for a breast implant.

 

Reconstruction with tissue expansion allows an easier recovery than flap procedures, but it is a more lengthy reconstruction process.

 

It requires many office visits over 3-6 months after placement of the expander to slowly fill the device through an internal valve to expand the muscle and skin.

 

A second surgical procedure will be needed to replace the expander if it is not designed to serve as a permanent implant.

 

A breast implant can be an addition or alternative to flap techniques. Saline and silicone implants are available for reconstruction.  Your surgeon will help you decide what is best for you.  Reconstruction with an implant alone usually requires tissue expansion.

 

Nipple and areola reconstruction

 

Breast reconstruction is completed through a variety of techniques that reconstruct the nipple and areola.  Dr Schoenfeld will discuss various options that best suit your needs.  This part of the surgery is relatively minor and can sometimes even be done under local anaesthesia as an outpatient should you prefer.  Although some women choose not to have the nipple and areola reconstructed, I highly suggest it, as it turns the reconstruction from a “mound” int a breast!  This is typically done 6 months after a flap technique has been used, or at the time of expander-implant exchange in the case of implant technique.

 

What about the opposite breast?

 

Matching procedures are typically done at the final stage in order to best achieve symmetry between the two sides.  This may involve either a breast reduction or a breast lift or a breast augmentation with or without a lift – it depends entirely on what your remaining opposite breast looks like, your desires, and on what one can realistically achieve with your reconstruction.  It is virtually impossible to obtain exact symmetry with the remaining breast, but the aim is to get you as close to it as possible.

 

Breast reconstruction recovery

 

Following your breast reconstructive surgery for flap techniques and/or the insertion of a breast implant, dressings will be applied to your incisions.

 

An elastic bandage or support bra may be used as it to minimize swelling and support the reconstructed breast.

A small, thin tube may be temporarily placed under the skin to drain any excess blood or fluid.

A pain pump may also be used to reduce the need for narcotics.

 

You will be given specific instructions that may include:

 

  • How to care for your surgical site(s) following surgery.

  • Medications to apply or take orally to aid healing and reduce the risk of infection.

  • Specific concerns to look for at the surgical site or in your general health.

  • When to follow up with Dr. Schoenfeld.

 

Be sure to ask Dr. Schoenfeld specific questions about what you can expect during your individual recovery period.

 

  • Where will I be taken after my surgery is complete?

  • What medication will I be given or prescribed after surgery?

  • Will I have dressings/bandages after surgery? When will they be removed?

  • Will there be drains? For how long?

  • When can I bathe or shower?

  • When can I resume normal activity and exercise?

  • When do I return for follow-up care?

 

Healing will continue for several weeks as swelling decreases and breast shape and position improve.  Continue to follow Dr. Schoenfeld’s instructions and attend follow-up visits as scheduled.

 

Breast reconstruction results

 

The final results of breast reconstruction following mastectomy can help lessen the physical and emotional impact of mastectomy.  Over time, some breast sensation may return, and scar lines will improve, although they’ll never disappear completely.  There are trade-offs, but most women feel these are small compared to the large improvement in their quality of life and the ability to look and feel whole.  Careful monitoring of breast health through self-exam, mammography and other diagnostic techniques is essential to your long-term health.

 

When you go home

 

If you experience shortness of breath, chest pains, or unusual heart beats, seek medical attention immediately.  Should any of these complications occur, you may require hospitalization and additional treatment.

 

The practice of medicine and surgery is not an exact science.

Although good results are expected, there is sadly no guarantee.

In some situations, it may not be possible to achieve optimal results with a single surgical procedure and another surgery may be necessary.

 

Breast reconstruction words to know

 

  • Areola:  Pigmented skin surrounding the nipple.

  • Breast augmentation:  Also known as augmentation mammaplasty; breast enlargement by surgery.

  • Breast lift:  Also known as mastopexy; surgery to lift the breasts.

  • Breast reduction:  Reduction of breast size and breast lift by surgery.

  • Capsular contracture:  A complication of breast implant surgery which occurs when scar tissue that normally forms around the implant tightens and squeezes the implant and becomes firm.

  • DIEP flap:  Deep Inferior Epigastric perforator flap which takes tissue from the abdomen.

  • Donor site:  An area of your body where the surgeon harvests skin, muscle and fat to reconstruct your breast – commonly located in less exposed areas of the body such as the back, abdomen or buttocks.

  • Flap techniques:  Surgical techniques used to reposition your own skin, muscle and fat to reconstruct or cover your breast.

  • General anesthesia:  Drugs and/or gases used during an operation to relieve pain and alter consciousness.

  • Grafting:  A surgical technique to recreate your nipple and areola.

  • Hematoma:  Blood pooling beneath the skin.

  • Intravenous sedation:  Sedatives administered by injection into a vein to help you relax.

  • Latissimus dorsi flap technique:  A surgical technique that uses muscle, fat and skin tunneled under the skin and tissue of a woman’s back to the reconstructed breast and remains attached to its donor site, leaving blood supply intact.

  • Local anesthesia:  A drug injected directly to the site of an incision during an operation to relieve pain.

  • Mastectomy:  The removal of the whole breast, typically to rid the body of cancer.

  • SGAP flap:  Superior Gluteal Artery perforator flap which takes tissue from the buttock.

  • Tissue expansion:  A surgical technique to stretch your own healthy tissue and create new skin to provide coverage for a breast implant.

  • TRAM flap:  Also known as transverse rectus abdominus musculocutaneous flap, a surgical technique that uses muscle, fat and skin from your own abdomen to reconstruct the breast.

  • Transaxillary incision:  An incision made in the underarm area.

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