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“Being diagnosed with breast cancer can be a bewildering and frightening experience for patients. There are many decisions to make. My goal as a plastic and reconstructive surgeon is to work in collaboration with patients, listening to their desires and needs, making sure that they know all of their options. I believe reconstruction can be a door to a new chapter in a patient’s life after breast cancer treatment, helping patients to look and feel great again.”
Breast reconstruction is categorized by two components: the timing of the reconstructive surgery and the type of surgery performed. Breast reconstruction can be performed at the same time as the breast surgeon performs the mastectomy (sometimes referred to as “immediate reconstruction”), or the reconstructive surgery can be performed anytime after the time of mastectomy (sometimes referred to as “delayed reconstruction”). The delay can range from weeks to even years after the original mastectomy was performed, but is mainly influenced by the need for radiation therapy after mastectomy. In these cases, breast reconstruction is usually delayed or postponed until after radiation treatments are completed and patients are given time to heal. Each patient is different, and the timing of surgery is determined by collaboration between each patient, the breast oncology surgeon and Dr. Beale, the reconstructive surgeon.
Breast reconstruction surgeries come in two general types: autologous breast reconstruction (meaning the patient’s own tissue is used) and implant-based breast reconstruction. In general, implant-based reconstruction is performed by placing a tissue expander under the breast skin and chest muscle during the same surgery as the mastectomy procedure. A tissue expander is a balloon like device that is blown up with liquid in order to stretch skin and tissue, creating room for an implant. The expander is slowly inflated every week in the office over a three to eight week process. After the overall goal is reached for final breast size, a second surgery is performed to remove the expander and replace it with an implant. Implant-based reconstruction can also be combined with a latissimus flap (a thin muscle from the back) in cases where radiation therapy is necessary.
DIEP Flap Breast Reconstruction
Although autologous breast reconstruction can utilize tissue from many areas of the body to recreate the breast, including the inner thigh, flank, and back of the thigh and buttock, the most common tissue or “flap” used is the TRAM flap or DIEP flap. TRAM flap breast reconstruction is a procedure where an ellipse of skin, including portions of the rectus abdominus muscles (the “six pack” muscles), are harvested from the lower abdomen from one or both sides as well as the small blood vessels that supply these muscles and the overlying skin. The tissue is then placed on the chest to recreate the breasts. The blood supply is maintained by connecting the blood vessels harvested with the flap to small blood vessels in the chest under a microscope. This type of surgery is called “microsurgery” or a “free-flap”. DIEP flap or deep inferior epigastric perforator flap is similar, except that when harvesting the same ellipse of abdominal skin, the small blood vessels that travel through the rectus abdominus muscle are used without taking any of the muscle with the flap. This way, women are left with all of their stomach muscles in place, leading to a speedier recovery with less chance of loss of abdominal strength. One of the best things about DIEP flap breast reconstruction is that the extra skin used from the lower abdomen for the reconstruction is the same tissue removed during a tummy tuck. So even though the surgery and recovery may be a little bigger, the breast reconstruction is more realistic and it’s like having a tummy tuck at the same time.
Further steps common to all types of breast reconstruction are nipple reconstruction and “matching procedures.” Nipple reconstruction is necessary unless a “nipple sparing” mastectomy was performed, for which a small sub-set of patients are candidates. For patients who undergo a traditional mastectomy, a final surgery will be performed to create a raised nipple using small flaps on the reconstructed breast. After healing, tattooing can be used to give the reconstructed nipple a fleshy color to resemble an areola, thus completing the reconstructive process. For patients who have undergone autologous or implant breast reconstruction on just one breast, “matching procedures” consisting of breast lifts and/or breast augmentation will be offered to make the native breast symmetric with the reconstructed breast.
A one to three day stay in the hospital occurs after implant-based reconstruction, depending on if one or both breasts were reconstructed. After DIEP flap breast reconstruction, patients will stay one to two nights in the ICU in order to monitor the flap, and then approximately two nights in a regular hospital room, most patients able to return home three to six days after surgery. The recovery related to the use of the abdominal tissue adds a little extra time to recovery over the hospitalization for just a mastectomy alone, but most patients resume normal activity within a couple of weeks and may exercise fully in four weeks. Subsequent stage surgeries done after the initial reconstructive procedure are usually day surgeries not requiring a stay overnight in the hospital. Drains are routinely used in both the placement of tissue expanders after mastectomy and in all autologous reconstructive procedures and are removed in four to ten days.
Call us for an appointment to discuss how breast reconstruction can help you look and feel great again.