Breast reconstruction, choice and you

One of the most important things to know about breast reconstruction is that you have choices — you have the choice to have reconstruction. Or not to. Also, you may have different types of reconstruction to choose from. These choices will vary for each person based on the starting point. You may have already undergone treatment like a lumpectomy, mastectomy or radiation therapy. This could also be your initial diagnosis.

You may have decided to have one or both breasts removed. Your general surgeon will allow you to make these choices, but they may have recommendations. The Women’s Health and Cancer Rights Act of 1998 allows you to have surgery on the opposite side as needed for symmetry.

In this article, I will focus on reconstructive options after mastectomy. I’ll provide a brief overview of the types of breast reconstruction and suggest some scenarios that may be ideal for different patients, depending on the circumstances.

Some of the information may seem technical, but I hope you will feel more informed and capable of helping to make decisions that are best for you.

When thinking about breast reconstruction, it is important to keep a number of factors in mind. First and foremost, you have options. If it’s your initial diagnosis, your options may be guided by your starting point as well as by your answers to a number of questions, including:

• Do you have small or large breasts?
• Are they symmetric?
• Do your breasts drop?
• Has your surgeon given you the option of sparing the nipple?
• What size do you want to be?

Other factors include the location of the tumor or tumors in the breast and whether you know in advance if you will need radiation.

 Tissue expander and implant based reconstruction

With its many advantages, tissue expander and implant based breast reconstruction has been the most common type of reconstruction for decades. However, these have some limitations.

During the first surgery, after the general surgeon performs the mastectomy, the plastic surgeon creates a pocket under the pectoralis muscle and above the rib cage, inserting a partially deflated saline balloon called a tissue expander. An acellular dermal matrix is sometimes used to expand this space.

After discharge, the patient returns, usually weekly, to have the expander accessed with a small needle. Saline is added until achieving the desired size. Botox can be used to minimize spasm of the muscle as it stretches. At a planned, second-stage surgery months later, the expander is removed and adjustments are made to the skin and the internal scar capsule as needed to improve shaping and symmetry. A saline or silicone implant is then placed in the pocket that was created by the expander.

Advantages include limiting surgery to only the chest, having input into the final size and adjusting for any asymmetries through fill volumes. Many types of other breast reconstruction are also reserved in case a more major revision becomes necessary.

One limitation is breast size. The largest FDA-approved silicone implant available is currently 800cc, and the largest saline implant only adds another 20 percent.

Many patients have wonderful cosmetic results with this type of breast reconstruction; however, radiation can impact the results. Radiation or infection can cause hardening and tightening of the implant capsule — known as capsular contracture — causing pain and distortion in some patients. Patients with a history of radiation prior to expander placement can have limited expansion and an increased complication rate.

My role as a plastic surgeon is to provide breast reconstruction education to my patients so that they may make an informed decision from the options they have, taking into account each individual starting point and desired end point.

Pre-pectoral breast reconstruction

The pre-pectoral technique is relatively new to the world of breast reconstruction. In the procedure, the expander, or implant, is wrapped in the acellular dermal matrix (ADM), rather than being placed under the pectoralis muscle. The ADM is then anchored to the surface of the muscle in the mastectomy space.

ADMs have been used in surgery for many years. After an expander is initially placed, a second surgery is required to exchange it for an implant. Whether an expander or an implant is placed, rippling and wrinkling will be more visible in most patients because the ADM is much thinner than the pectoralis muscle. Patients should anticipate additional planned outpatient surgery to harvest fat through liposuction. This fat is then grafted into thin areas on the chest, usually the visible upper chest and cleavage.

An advantage of pre-pectoral breast reconstruction is that it is less painful. Also, since full or nearly full size is achieved after the initial surgery, fewer or no visits are needed for expansions. Patients with non-droopy A, B or C cup breasts find this a great option. It produces wonderful results in patients undergoing nipple-sparing mastectomy while still looking very good in patients undergoing a standard skin-sparing mastectomy.

Size limitations are among the drawbacks of this option as are the risk of fluid accumulation and possible difficulty in patients with too much relative skin excess.

Autologous tissue reconstruction

There are many autologous breast reconstruction options — those using the body’s own tissues. The main advantage of all types of autologous reconstruction is the more natural look and feel of the tissues. Size and shape are mainly determined at the first surgery, but minor revisions are often needed for ideal contouring and symmetry as swelling subsides. This surgery is often done at the time of the mastectomy. It does not take place, however, when radiation is a known need. In these cases, reconstruction is delayed until months after radiation has been completed.

The autologous options involve many flaps and are named after the muscle or blood vessels used to supply the tissue. There are many options including:

• The latissimus dorsi (LD) flap takes an area of skin from the back along with the majority of the LD muscles through the high under arm (axilla) into the front chest wall. The blood supply is still attached by its source blood vessel. Usually accompanied by an expander or implant, it rarely has adequate bulk on its own to create a breast mound. The LD technique has the advantage of adding flap volume if the largest implant is inadequate and brings healthy skin and tissue to a radiated field. Drawbacks include a large back scar and potential fluid accumulation.
• A traverse rectus abdominis (TRAM) flap takes the area of skin and soft tissue from the lower abdomen along with the rectus abdominis muscle and rotates it on its blood supply into the mastectomy space. If performed on both sides, the abdominal donor site may need mesh reinforcement to prevent hernia formation. A significant advantage is creation of a soft, fatty tissue breast, which usually avoids the added use of implants and, in effect, a high abdominoplasty making the abdomen thinner and more firm at the donor site. Many patients like the natural feel of the fatty tissue in the breast mound. The procedure cannot be performed on patients with scars in certain areas on the abdomen. Other drawbacks include a small risk of hernia formation, length of surgery and a recovery time that is often longer.
• The word “free” in free flap reconstruction indicates tissues taken “free from the body” and reconnected in another site, in this case the breast. Free flap is another popular type of autologous tissue reconstruction, the most common of which is the Deep Inferior Epigastric Perforator (DIEP) flap. To reconnect blood vessels in a new site, part of the rib near the breast bone is usually removed to gain access to the recipient vessels. The donor site blood vessels are hooked up to the recipient site vessels using magnification, requiring the expertise of a plastic surgeon who has been trained in microsurgery. This procedure has become an increasingly popular choice among patients. It features the same advantages as a TRAM flap while usually sparing the rectus muscles, which preserves the strength and integrity of the abdominal wall. It also shares the disadvantages of the TRAM procedure, with the additional risk of clots in the blood vessel hook-up.

Goldilocks mastectomy without or with expander or implant placement

A traditional transverse pattern of skin removal is insufficient and the available implant sizes are inadequate in some patients with very large and droopy breasts. The Goldilocks technique is very beneficial to patients in this subgroup and can be performed in patients who will receive radiation therapy.

Skin removal is drawn in a breast reduction pattern, removing excess skin vertically and horizontally. The excess skin of the bottom of the central breast is treated on the front and the back, so it can be tucked in under the skin closure to both add volume and a natural appearance to the breast mound.

This can be done:

• On its own
• In conjunction with fat grafting the pectoralis muscle
• In conjunction with sub-muscular expander reconstruction
• With pre-pectoral acellular dermal matrix wrapped expander
• Direct to implant reconstruction

Benefits include a much better breast shape and proportional volume in patients who have large native breasts. Another potential benefit is creation of a small breast mound without an implant in patients who do not desire to return to their pre-operative size.

Drawbacks include areas of layered skin for self-breast exam and the potential for areas of fat necrosis.

Fat grafting

To obtain useable fat, patients undergo liposuction, usually from the abdomen, hips or thighs. This fat is filtered and injected using a blunt-tipped needle into areas of the breast with contour abnormalities or visible implant wrinkling or rippling. It can also add volume to create a more natural appearance.

Fat grafting is rarely done as a sole reconstruction procedure. Some people are too thin for fat grafting and its drawbacks include palpable fat globules, or oil cysts.

Your decision

To review goals for reconstruction and options for your specific situation, meet with a qualified, board-certified plastic surgeon. Though your surgeon or other people in your life may give you recommendations, ultimately, it is your decision.