If You're Considering Breast Reconstruction…

Reconstruction of a breast that has been removed due to cancer or other disease is one of the most rewarding surgical procedures available today. New medical techniques and devices have made it possible for plastic surgeons to create a breast that can come close in form and appearance to matching a natural breast. Frequently, reconstruction is possible immediately following breast removal (mastectomy), so the patient wakes up with a breast mound already in place, having been spared the experience of seeing herself with no breast at all.

But bear in mind, post-mastectomy breast reconstruction is not a simple procedure. There are often many options to consider as you and your doctor explore what's best for you.

This information will give you a basic understanding of the procedure -- when it's appropriate, how it's done, and what results you can expect. It can't answer all of your questions, since a lot depends on your individual circumstances. Please be sure to ask your plastic surgery team if there is anything you don't understand about the procedures.

The Best Candidates For Breast Reconstruction…

Most mastectomy patients are medically appropriate for reconstruction, many at the same time that the breast is removed. The best candidates, however, are women whose cancer, as far as can be determined, seems to have been eliminated by mastectomy.

Still, there are legitimate reasons to wait. Many women aren't comfortable weighing all the options while they're struggling to cope with a diagnosis of cancer. Others simply don't want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeons to wait, particularly if the breast is being rebuilt in a more complicated procedure using flaps of skin and underlying tissue. Women with other health conditions, such as obesity, high blood pressure, or smoking, may also be advised to wait.

In any case, being informed of your reconstruction options before surgery can help you prepare for a mastectomy with a more positive outlook for the future.

All Surgery Carries Some Uncertainty And Risk…

Virtually any woman who must lose her breast to cancer can have it rebuilt through reconstructive surgery. But there are risks associated with any surgery and specific complications associated with these procedures.

In general, the usual problems of surgery, such as bleeding, fluid collection, excessive scar tissue, or difficulties with anesthesia, can occur although they're relatively uncommon. And, as with any surgery, smokers should be advised that nicotine can delay healing, resulting in conspicuous scars and prolonged recovery. Occasionally, these complications are severe enough to require a second operation. Other risks include infection, wound dehiscence, delayed or poor wound healing, pain, chronic pain, disability, and asymmetry.

Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment, should cancer recur. Your surgeon may recommend continuation of periodic mammograms on both the reconstructed and the remaining normal breast. If your reconstruction involves an implant, be sure to go to a radiology center where technicians are experienced in the special techniques required to get a reliable x-ray of a breast reconstructed with an implant.

It is unknown what affects radiation therapy will have on a reconstructed breast. Radiation affects every patient differently, but can cause hyper-pigmentation due to burns, and changes in the texture and quality of the skin. Some patients who desire to use their own tissue for reconstruction will have a tissue expander placed at the time of their mastectomy, undergo radiation treatment, and then at a later date have the expander removed and recreate the breast using their own tissues. This prevents the nice, soft reconstructed breast from undergoing changes from radiation.

Some studies have shown that patients who have radiation therapy are at an increased risk for problems with permanent implants. These problems include capsular contracture, infection, and wound healing difficulties causing loss of the implant. Discuss these options with your surgical oncology and plastic surgery team.

Women who postpone reconstruction may go through a period of emotional readjustment. Just as it took time to get used to the loss of a breast, a woman may feel anxious and confused as she begins to think of the reconstructed breast as her own.

Planning Your Surgery…

You can begin talking about reconstruction as soon as you're diagnosed with cancer, or when you find out that you are genetically predisposed to malignancy. Ideally, you'll want your breast surgeon and your plastic surgeon to work together to develop a strategy that will put you in the best possible condition for reconstruction.

After evaluating your health, your surgeon will explain which reconstructive options are most appropriate for your age, health, anatomy, tissues, and goals. Be sure to discuss your expectations frankly with your surgeon. He or she should be equally frank with you, describing your options and the risks and limitations of each. Post-mastectomy reconstruction can improve your appearance and renew your self-confidence -- but keep in mind that the desired result is improvement, not perfection.

Insurance Coverage…

Federal and state laws require insurance companies to pay for all or part of the cost of breast reconstruction at any time after removal a patient's breast tissue. This includes any surgery required on the opposite breast for symmetry. Our staff is experienced in working with all major insurers for these procedures. We will work with you to keep your out-of-pocket expenses to an absolute minimum.

Preparing For Your Surgery…

Once you have scheduled a surgery date your oncologist and your plastic surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain vitamins and medications. You will also receive information regarding blood work and tests you will need to provide to us prior to your procedure. You will also have a pre-operative teaching appointment to see one of the nurse practitioners in oncology or plastic surgery who will give you information about how to plan for your surgery, and what to expect afterwards.

The Surgery…

While there are many options available in post-mastectomy reconstruction, you and your surgeon should discuss the one that's best for you.

IMPLANT BASED RECONSTRUCTION

The most common technique combines expansion of the breast skin utilizing a temporary tissue expander, followed by insertion of a permanent silicone or saline breast implant. This type of reconstruction requires two separate operations.

At the same time as your mastectomy, your surgeon will insert a tissue expander beneath your skin and chest muscle. Through a tiny valve mechanism located inside the expander, the nurse practitioner will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. You may feel a sensation of stretching and pressure in the breast area during this procedure, but most women find it is not too uncomfortable. This process will begin usually two weeks after your mastectomy, once your drains are removed. This procedure stretches the skin and muscle to make room for a temporary implant, just like a mother's belly stretches during pregnancy. The process continues until the size is slightly larger than your other breast. After the skin over the breast area has stretched enough, the expander will be removed in a second operation and a more permanent implant will be inserted. Some expanders are designed to be left in place as the final implant. The nipple and the dark skin surrounding it, called the areola, are reconstructed in a subsequent procedure.

Chemotherapy or radiation may be recommended to you by your surgical oncologist following your mastectomy. If you choose to have these treatments it will delay the tissue expansion process by approximately 4-8 weeks.

Types Of Implants…

If your surgeon recommends the use of an implant, you'll want to discuss what type of implant should be used. A breast implant is a silicone shell filled with either silicone gel or a salt-water solution known as saline.

Because of concerns that there is insufficient information demonstrating the safety of silicone gel-filled breast implants, the Food & Drug Administration (FDA) has determined that new gel-filled implants should be available only to women participating in approved studies. This currently includes women who already have tissue expanders who choose immediate reconstruction after mastectomy, or who already have a gel-filled implant and need it replaced for medical reasons. Eventually, all patients with appropriate medical indications may have similar access to silicone gel-filled implants.

The alternative saline-filled implant, a silicone shell filled with salt water, continues to be available on an unrestricted basis, pending further FDA review.

As more information becomes available, these FDA guidelines may change. Be sure to discuss current options with your surgeon.

If an implant is used, there is a remote possibility that an infection will develop, usually within the first two weeks following surgery. In some of these cases, the implant may need to be removed for several months until the infection clears. A new implant can later be inserted.

The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways, and sometimes requires either removal or "scoring" of the scar tissue, or perhaps removal or replacement of the implant.

FLAP RECONSTRUCTION (DIEP, SIEA, TRAM, SGAP, LATISSIMUS DORSI FLAP)

An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the abdomen, back, or buttocks.

DIEP/SIEA Flap, Latissimus Dorsi Flap, SGAP Flap…

Another flap technique uses tissue that is surgically removed from the abdomen, back or buttock and then transplanted to the chest by reconnecting the blood vessels to new ones in that region. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well.

Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about a silicone implant. In some cases, you may have the added benefit of an improved abdominal contour.

 3D CT Angiography of Abdominal Wall Vascular Perforators to Plan DIEAP Flaps

TRAM Flap…

In this type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat, and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself, without need for an implant.

Chemotherapy or radiation may be recommended to you by your surgical oncologist following your mastectomy. If you choose to have these treatments it will delay your secondary procedures by a few months.

After Your Surgery…

IMPLANT BASED RECONSTRUCTION

You will be in the hospital overnight and will be able to go home the next day. Many reconstruction options require a surgical drain to remove excess fluids from surgical sites immediately following the operation. In most circumstances, these drains will remain in for 1-2 weeks. If they are highly productive they will stay in longer.

You are likely to feel tired and sore for a week or two after reconstruction. Most of your discomfort can be controlled by medication prescribed by your doctor.

FLAP RECONSTRUCTION

This type of operation will require you to stay in the hospital for 3-4 days. You will also have 3-4 surgical drains depending on if one or two breasts are reconstructed. In most circumstances, these drains will remain in for 1-2 weeks. If they are highly productive they will stay in longer.

The recovery time for flap reconstruction is 4-6 weeks. You will be sore for about a week or two and then begin to improve everyday.

Follow-up Procedures…

Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery may be required to replace a tissue expander with an implant, to reconstruct the nipple and the areola, or to enlarge, reduce, or lift the other natural breast to match the reconstructed breast. These secondary procedures are outpatient procedures and usually do not require the use of drains. The recovery time is based on the extent and complexity of the procedure, but usually ranges from a few days to a few weeks.

Getting Back To Normal…

Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. Most scars will fade substantially over time, though it may take as long as one to two years, but they'll never disappear entirely.

Follow your practitioner's advice on when to begin stretching exercises and normal activities. As a general rule, you'll want to refrain from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following reconstruction. You may also be referred to a physical therapist both before and/or after your surgery for exercises to help with your recovery.

Many women want to know when they can get back to doing everyday things like driving, carrying the shopping or doing the housework and gardening. This will vary, depending upon the type of surgery you have had and upon you as an individual. It is a good idea to discuss this further with your practitioner.

It is usually fine to start driving again when you feel that you could safely do an emergency stop or move the steering wheel around suddenly, if necessary. Some women find that this is possible within a few weeks of the surgery, and others find that it takes longer. Some insurance companies have specific guidelines about when you can drive again after an operation, so it is helpful to check this with your car insurance company.

Your New Look…

Chances are your reconstructed breast may feel firmer and look rounder or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. But these differences will be apparent only to you. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.

We would like to thank you for choosing us at the Johns Hopkins Hospital to participate in your care. We look forward to working together as a team to help restore you femininity and support you in looking and feeling your best.

Please do not hesitate to contact our Nurse Practitioner, Melanie Erb, with any further questions. She can be reached via email at mmemmen1@jhmi.edu or via telephone at (410) 502-3316. If you have questions regarding scheduling your surgery or pre and post-op appointments please contact our clinical coordinators Sheila Hobbs at shobbs4@jhmi.edu and Lynn Stoots at (410) 955-9477 for Dr. Gedge Rosson.

Advantages and Disadvantages Of DIEP/SIEA Flap Reconstruction…

Advantages:

• Since the reconstruction involves using the patient's own tissues, the risks of implant reconstruction are avoided.
• Most patients have less postoperative pain than after a TRAM flap and are therefore able to leave the hospital sooner, and return to normal activities quicker than after a TRAM flap.
• Because the abdominal muscle is not removed, patients have less risk of developing hernias at the site where the flap is removed than patients who have had a TRAM flap.
• It is typically easier to match the contralateral natural breast with the patient's own tissue when compared with implant reconstruction.
• Patients essentially end up with a "tummy tuck" at the same time as the breast reconstruction.

Disadvantages:

• DIEP/SIEA flap reconstruction generally requires a longer and more difficult surgery at the first stage when compared with implants or TRAM flaps.
• Patients will have a scar across the lower abdomen where the flap is obtained

Advantages and Disadvantages of Implant Reconstruction…

Advantages:

• The recovery from the initial expander placement surgery is usually quicker than flap surgery.
• It may be easier to control the final size of the reconstructed breast with implant reconstruction.
• There are no additional scars on the patient's body other than those on the breasts.

Disadvantages:

• Because most patients require placement of an expander first followed by secondary replacement of the expander with an implant, this requires at least 2 surgical stages and multiple visits to the plastic surgeon's office between these stages for tissue expansion.
• It is important to realize that for patients who are having a unilateral (one-sided) mastectomy, matching the other natural breast with an implant can be difficult. The shape and "feel" of an implant is not exactly like that of a natural breast.
• In the short term, implants can become infected or malpositioned and require surgery to correct these problems.
• In the longer term, implants can develop capsular contracture (tightening of the soft tissues around the implant), implant malposition, and implant rupture. All of these can require secondary procedures.

Related Links:

• Spring 2006 Newsletter - See pages 13-15