Breast reconstruction is performed on women who have lost one or both breasts to mastectomy, or who lack breasts due to congenital or developmental abnormalities. The goal of breast reconstruction is to create a breast mound and nipple that resemble the natural breast as closely as possible in shape, size and position. It is important to understand that in many circumstances this should be viewed as a series of surgeries or rather a “process”. Many women find the process of breast reconstruction to be both a physically and emotionally rewarding experience, but it does have its challenges. In general, if a woman is healthy, age is not a factor and she is committed to the process and what is required she may be a good candidate for breast reconstruction—either immediate or delayed depending on various circumstances. However, women with health problems such as obesity, diabetes and high blood pressure, and those who smoke, are advised to wait rather than have breast reconstruction immediately following mastectomy.
The reconstruction method best tailored to you depends on many factors, including:
-Amount of available tissue
-Past and future radiation therapy
-Anticipated cancer treatment plan and how this relates to your reconstructive plans
-Current breast size
During your consultation with Dr. Jarrell, he will meet with you and discuss how these factors should be considered in developing the reconstructive plan that is right for you. The plan that best fits you may not be the one best suited for someone else and Dr. Jarrell understands that each case is unique and he approaches each patient in this manner.
Immediate versus Delayed Reconstruction
Timing of breast reconstruction is one component in deciding the plan that is right for you. There are several factors that need to be considered. There are certain advantages to immediate breast reconstruction including the possibility of fewer operations required to complete the process, utilizing available tissue at the time of mastectomy, and immediately or shortly after surgery having the shape of a breast restored to your chest. There are, however many factors to be considered with this including characteristics of the cancer, additional cancer treatment that may be required, factors specific to your anatomy, condition of the available tissues at the time of surgery and your specific goals and motiviations. All of these things should be considered and your consultation with Dr. Jarrell takes this personalized approach to determine if this is the right option for you.
In other circumstances a delayed reconstruction may be the best option. Again taking into consideration your personal case is important in this process. If delayed reconstruction is the choice for you, there is the advantage of focusing on treatment of the cancer before entering into the process of breast reconstruction which has its own challenges and in certain patients this may be the safest option. Whatever option is decided, Dr. Jarrell provides caring experience to get you through the process.
Techniques for Breast Reconstruction
Breast reconstruction is performed in several steps, and there are essentially two types. Which one is used depends on many factors, some of which were mentioned above. Whichever type is used, a woman’s breast surgeon and plastic surgeon should work as a team during reconstruction.
Implant/Tissue-Expansion Breast Reconstruction
This technique is the most commonly used form of breast reconstruction and in Dr. Jarrell’s practice. In most cases, this is a two-stage process that can begin at the time of the mastectomy procedure or in other circumstances in delayed fashion. At the initial procedure a tissue expander is placed in the pocket and it may be either partially inflated or completely deflated depending on tissue requirements. This can be thought of as a space holder. Under most circumstances, Dr. Jarrell utilizes acellular dermal matrix (or ADM) to act as a support system for the implant reconstruction, provide additional coverage over the implant and to help re-establish some of the important anatomical features of the breast. One of the commonly used ADMs is Alloderm. (To learn more about this, see below.) Over the course of many post operative visits the tissue expander is filled which serves to mold or shape the breast and can serve to stretch the skin and establish the pocket for the implant that will be used to create the desired breast size.
During the weeks or months following your first surgery, saline solution is injected through a tiny valve beneath the skin on the implant’s surface to fill the tissue expander. Once this process is complete and after the tissues have had the appropriate amount of rest time, patients are usually scheduled for a second surgery whereby the tissue expander is accessed, removed and replaced with the final silicone implant that creates the reconstructed breast mound. This second surgery is usually much easier in terms of recovery and is typically performed on an outpatient basis.
Based on many factors including patient anatomy, symmetry, and individual goals for breast reconstruction, additional procedures may be considered as part of the breast reconstruction process. These include symmetry procedures (mastopexy or breast reduction), scar revisions or implant revisions, fat grafting and nipple reconstruction. During your reconstructive process, Dr. Jarrell will discuss with you the need for any or each of the procedures based on your individual goals and results and help guide you through the journey.
Autologous-Tissue Breast Reconstruction
Autologous-tissue breast reconstruction is used in some circumstances to create a new breast. This set of procedures involves using your own tissue sometimes in combination with implants or tissue expanders to create a breast mound. This type of reconstruction can be physiologically challenging for patients. This type of reconstruction can offer the option of a natural feel and in some cases can avoid the use of breast implants. Under certain circumstances such as previous radiation, this type of surgery may be required to recruit healthy, un-radiated tissue from other areas of the body in order to achieve the reconstruction process.
One example of this is using the tissue from the back (called the latissimus dorsi muscle flap) to bring healthy tissue into the chest for reconstruction. In most cases, a combination of this with a tissue expander/implant is used to reconstruct the final breast mound. And the process continues in a similar fashion to what is described above.
There are a number of different flap techniques; which one is used depends on the individual patient.
Recovery From Breast Reconstruction
Recovery varies widely based upon the type of procedure used for breast reconstruction, as well as whether reconstruction immediately follows mastectomy. Hospital stays range from 1 to several days depending on the technique. In most cases, tissue expander reconstruction is outpatient or overnight surgery and is usually the easiest to recover from. Patients are tired and sore for 1 to 2 weeks, and recovery takes 3 to 6 weeks. Compression garments or post surgical bras are typically worn, and stitches are taken out in a week to 10 days. Surgical drains are usually left in place to prevent a buildup of fluid in the reconstructed breast. These must be managed at home and can remain in place for variable amounts of time (on average 2-3 weeks). Keep in mind with each technique, the process of getting back to normal can depend on how you heal and your individual process of recovery.
Risks Of Breast Reconstruction
In addition to the risks associated with surgery and anesthesia, those related to implant/tissue-expansion breast reconstruction include infection or fluid (seroma) around the implant, implant leaks and ruptures, and implant deflation or shifting, asymmetry, and capsular contracture (hardening of scar tissue) . Risks related to autologous breast reconstruction, depending upon the technique used, include fat necrosis, and a mismatch between chest tissue, native breasts and/or donor tissue.
Correcting reconstructive problems typically requires additional surgery.
Results Of Breast Reconstruction
A reconstructed breast will not look the same as the original breast. And although the goal is to match the size, shape, position as closely as possible and other attributes of the remaining breast, an exact match is not possible. To achieve symmetry, the remaining breast may be operated on to make it bigger or smaller, or to lift it.
In addition to not looking the same as the original, a reconstructed breast has little sensation, although different techniques may affect the final result.
AlloDerm® Regenerative Tissue Matrix For Breast Reconstruction (Acellular Dermal Matrix – ADM)
Many women who undergo mastectomies opt for breast reconstruction. AlloDerm® Regenerative Tissue Matrix, which is manufactured by Allergan, is frequently used during the reconstruction process. AlloDerm tissue can replace some of the breast tissue removed during surgery and provide support for implants. It is created by taking tissue from a carefully screened donor (cadaver), and then putting the tissue through a cell-removal process that reduces the likelihood of rejection, yet leaves the basic tissue structure intact. Because it is produced from natural human tissue, it is not only well tolerated, but actually grows into the patient’s tissue for a strong, natural repair. The product is also used for some types of head and neck plastic-surgery reconstruction, and for hernia repair. According to its manufacturer, AlloDerm Regenerative Tissue Matrix has been used successfully in more than one million grafts and implants.
Advantages Of Using AlloDerm Regenerative Tissue Matrix
In addition to allowing for single-step breast reconstruction because of tissue expansion, using AlloDerm tissue may result in more natural-looking breasts than when implants alone are used. Breast reconstruction incorporating AlloDerm tissue may provide the following advantages:
Increased support for the implants
Reduced visibility of implants
Better definition of the breast fold
Skin reinforcement and prevention of thinning
Prevention of pectoral muscle retraction
AlloDerm Regenerative Tissue Matrix is also occasionally used for purely cosmetic breast surgery.