Breast Cancer
Breast cancer can be a devastating diagnosis particularly when it involves the loss of your breasts which are a key component of a women's identity.
With a history of breast cancer, women have a right by law to have their breast reconstruction covered by their insurance provider, since it is medically necessary to restore a vital component of a women's body.
There are many ways to reconstruct a breast, all of which are performed by our Surgeons at SPS. A key component of knowing your options comes from a discussion with your surgeon about your particular needs as a patient and reconstructive goals.
Reconstructive Options
Implant based
Implants can be placed to reconstruct the breasts. This can be done Immediate (at teh time of mastectomy) or delayed (after mastectomy).
Depending on several factors including desired breast size, amount of skin remaining, and skin blood flow during surgery, your surgeon may need to use a tissue expander. This is basically a deflated implant that is used to expand the skin over time.
What to expect?
The tissue expander is placed in a first stage under the breast skin. We fill it as much as we safely can in your first surgery. Then, we will continue to fill the expander in clinic starting 2-4 wks after surgery depending on your healing. We expand usually every 2 weeks until we reach the desired size or as much as the skin will tolerate.
What does it mean to fill the expander?
Expanders are filled with saline in the office by placing a needle through the skin and into a port built inside the expander. This typically does not hurt at all since the mastectomy skin is many times numb after surgery. Sometimes the new expansion can fill tight; therefore, your surgeon will accommodate your expansion volume and rate based on your comfort.
When do I get a real implant?
The tissue expander is exchanged for a permanent silicone implant typically a few weeks after you have finished expansion, but is also dependent on skin quality and healing.
If you need radiation for your skin cancer, this will also change the plans and will be discussed with you based on your individual case.
Tissue Based
Breast reconstruction can also be performed using your own tissue. This may be performed based on the desire for a more natural and long lasting (no implant maintenance) type reconstruction or it may be suggested as the best option if you have undergone radiation.
What are the options for use of your own tissue?
The main options include DIEP flaps, peddled TRAM, and Latissimus dorsi muscle flap.
DIEP Flap
This flap (meaning segment of skin and fat to be used) comes from the lower abdomen (the tissue removed during a tummy tuck) and is transplanted to the chest by using microsurgery to reconnect the blood vessels from the abdominal skin to vessels at the top of the chest.
A microscope is used to give this tissue the best blood supply possible to help all of the skin and fat survive.
What should I expect with surgery?
This surgery is the longest and most tedious; however, it does come with great results. Expect to be in surgery for a good portion of the day and to spend at least one night in the ICU just to have appropriate nursing care for the flap. Nurses will check on the tissue every hour for 24 hours.
Except to spend 2-5 days in the hospital.
What is recovery like?
This surgery requires 4-6 to fully recover including no lifting more than 10lbs for the total 6 wks to let the abdominal wall heal.
TRAM Flap
This surgery uses the same tissue as DIEP but leaves the vessels connected and therefore does not require microsurgery or ICU stay. The recover period is the same as DIEP above and expect a few days in the hospital.
This may be chosen if the patient either does not want a long surgery, or isn't a candidate for longer surgery.
Latissimus Flap
This flap is muscle from the back that is used to cover an implant in settings where the implant needs more durable coverage such as when the patient has had radiation. This allows the patient to still use an implant but also have replacement of radiated tissue.
In certain situations, this can be used without an implant to make a small breast.
This surgery is also used for chest all reconstruction when needed.
Expect to spend 1-3 days in the hospital.
How many surgeries will I need?
Most breast reconstructions will require average of 2 surgeries. I like to explain to patients first surgery is to make the breast mound, and 2nd surgery is to make it look beautiful. This may include contouring, fat grafting, nipple reconstruction, or implant exchange.
Why does radiation matter?
Radiation is sometimes needed for breast cancer treatment after surgery. It does complicate the reconstructive process somewhat mainly due to the damage to the skin; however, we have ways to resolve this.
Dependent upon your individual case, your surgeon may suggest that you only have tissue based reconstruction with radiation due to the risk of complications with implants only.
For example, DIEP flaps can be used to replace the damaged, radiated skin of the chest.
All breast surgery is typically performed at least 6 months after radiation has been completed.
Breast conservation
Oncoplastic Breast Reduction
This is a great option for patients who are a candidate for lumpectomy based on their tumor size and location. This will be discussed with your breast surgeon.
After your breast surgeon performs a lumpectomy, we use a similar technique to a breast lift (mastopexy) to rearrange the breast tissue to make the breast lifted and normal contour.
This can be done to both sides to create symmetry. It is a great option for patients with large breasts who would also benefit from a breast reduction.
In smaller breasts, this can be used to prevent otherwise needing a mastectomy due to the rearrangement of tissue.
This also decreases the amount of radiation that is needed post op due to removing excess breast tissue in women with very large breasts.
What should I expect with surgery?
This is typically outpatient surgery- home the same day.
Patients recover similar to a breast reduction so therefore you will be feeling good at 2 weeks; however, I always say 6 weeks for total healing and recovery.
Once you are healed, you will begin radiation.
Radiation does "shrink" breast tissue, therefore, I do try to leave the cancer side about 10-15% larger so that when everything is finished, they will be more symmetrical.
