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Breast Reconstruction: What Can Be Done?

Sep 1, 2007
Restoration or reconstruction of a breast has greatly advanced since the days of the radical mastectomy.

If a woman is a good candidate for reconstruction, she can usually expect a breast mound that will fill a bra cup to her desired volume, along with a nipple and areola, if desired. The opposite breast can be made to match by augmentation, reduction or lifting.

These procedures are covered by insurance, as mandated by law. In addition, significant breast symmetry as a result of lumpectomy/radiation or multiple biopsies can be corrected with reconstructive surgery. The word "can" is used because breast reconstruction is a matter of choice.

Some women choose to wear a breast prosthesis with their bra. Others may choose reconstruction, which is not limited to one's age. The overall health condition and status of the cancer are the issues that determine feasibility.

Consultation with a plastic surgeon prior to mastectomy is part of a comprehensive breast care center program. The patient should be fully informed of her options for immediate versus delayed breast reconstruction. The technique(s) recommended are based upon her anatomy, medical background and anticipated future cancer treatments.

Decision-making in breast reconstruction begins with the simple question of whether breast reconstruction will be part of the woman's recovery process.

Some women know the answer immediately; others need days or weeks to decide. Once the decision is made to go ahead with the procedure, the next question is which technique to select. In each case, the decision is based upon surgical preference and which technique will be better in the face of any anticipated treatments of chemotherapy and/or radiation therapy.

The two most common types of breast reconstruction are the tissue expander/implant technique and the transverse abdominus musculoctaneous (TRAM) flap. A third technique is the latissimus dorsi musculocutaneous flap with a breast implant. The table shown here summarizes and compares these techniques.

With the plastic surgeon's guidance, the most appropriate technique can be selected for breast reconstruction, taking into account the desires, health status and unique anatomy of the individual woman.

The expander/implant technique requires two stages. The first stage of this breast reconstruction is placement of the tissue expander below the pectoralis chest muscle. This procedure adds less than one hour to the mastectomy time with the same overnight hospital stay.

The second stage is the exchange of the tissue expander for the permanent saline or silicone gel filled breast implant. This stage requires general anesthesia, but is usually less than one hour in duration unless a procedure on the opposite breast is added.

Breast implants are confirmed safe by multiple medical studies. Both saline and gel filled breast implants were released years ago by the Food and Drug Administration (FDA) to be used for breast reconstruction and for replacement of older or present gel implants.

The TRAM flap technique uses autogenous, or one's own tissue to create a breast mound. This surgery takes an average of five hours in addition to mastectomy completion with the average hospital stay of five days and an average recovery time of five weeks.

The abdominal skin above the belly button is lifted off the abdominal fascia and sutured down to the pubic area skin with replantation of the belly button. The four to five week recovery period is necessary to straighten and strengthen the abdominal walls and muscles. Activity levels usually return to the normal, pre-operative status.

The latissimus dorsi flap with implant is usually used as a salvage technique in the face of previous radiation or surgery. The flap consists of the latissimus muscle with an overlying skin paddle from the back. It usually requires a breast implant to obtain the desired breast shape and volume.

The implant is placed below the latissimus muscle after the muscle is passed onto the chest wall through a tunnel at the base of the axilla (underarm). It is a useful reconstructive technique in the face of irradiated breast skin with deformity after lumpectomy and a lack of an adequate volume of abdominal fat.

Nipple areolar reconstruction can be performed at the time of the second stage reconstruction. Or, it can be done as a separate procedure as an outpatient under local anesthesia. The skin on the breast mound is the source of the nipple reconstruction with a full thickness skin graft, usually from the inner, upper thigh skin used for the areolar reconstruction. This skin is usually textured and pigmented resulting in a realistic appearing areola.

An extensive and detailed consultation with the plastic surgeon is mandatory for a patient to be truly informed and guided to make the best decision about breast reconstruction in conjunction with the treatment recommendations from the breast surgeon and oncologist.
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