Breast Reconstruction
If You're Considering Breast Reconstruction...
Reconstruction of a breast that has been removed due to cancer or other disease is one of the most rewarding surgical procedures available today. New medical techniques and devices have made it possible for surgeons to create a breast that can come close in form and appearance to matching a natural breast. Frequently, reconstruction is possible immediately following breast removal (mastectomy), so the patient wakes up with a breast mound already in place, having been spared the experience of seeing herself with no breast at all.
But bear in mind, post-mastectomy breast reconstruction is not a simple procedure. There are often many options to consider as you and your doctor explore what's best for you.
This information will give you a basic understanding of the procedure – when it's appropriate, how it's done, and what results you can expect. It can't answer all of your questions, since a lot depends on your individual circumstances. Please be sure to ask your surgeon if there is anything you don't understand about the procedure.
An expander is gradually filled with saline through an integrated or separate tube to stretch the skin enough to accept an implant beneath the chest muscle.
A TRAM flap uses muscle, fat and skin from your abdomen to reconstruct the breast. The flap may either remain attached to the original blood supply and be tunneled up through the chest wall, or be completely detached and formed into a breast mound.
A Latissimus Dorsi flap uses muscle, fat and skin from the back tunneled to the mastectomy site and remains attached to its donor site, leaving blood supply intact.
Tissue can be taken from the back and tunneled to the front of the chest wall to support the reconstructed breast.
The transported tissue forms a flap for a breast implant, or it may provide enough bulk to form the breast mound without an implant.
The Best Candidates for Breast Reconstruction
Most mastectomy patients are medically appropriate for reconstruction, many at the same time that the breast is removed. The best candidates, however, are women whose cancer, as far as can be determined, seems to have been eliminated by mastectomy.
Still, there are legitimate reasons to wait. Many women aren't comfortable weighing all the options while they're struggling to cope with a diagnosis of cancer. Others simply don't want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeons to wait, particularly if the breast is being rebuilt in a more complicated procedure using flaps of skin and underlying tissue. Women with other health conditions, such as obesity, high blood pressure, or smoking, may also be advised to wait.
In any case, being informed of your reconstruction options before surgery can help you prepare for a mastectomy with a more positive outlook for the future.
All Surgery Carries Some Uncertainty and Risk
Virtually any woman who must lose her breast to cancer can have it rebuilt through reconstructive surgery. But there are risks associated with any surgery and specific complications associated with this procedure.
In general, the usual problems of surgery, such as bleeding, fluid collection, excessive scar tissue, or difficulties with anesthesia, can occur although they're relatively uncommon. And, as with any surgery, smokers should be advised that nicotine can delay healing, resulting in conspicuous scars and prolonged recovery. Occasionally, these complications are severe enough to require a second operation.
If an implant is used, there is a remote possibility that an infection will develop, usually within the first two weeks following surgery. In some of these cases, the implant may need to be removed for several months until the infection clears. A new implant can later be inserted.
The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways, and sometimes requires either removal or scoring of the scar tissue, or perhaps removal or replacement of the implant.
Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment, should cancer recur. Your surgeon may recommend continuation of periodic mammograms on both the reconstructed and the remaining normal breast. If your reconstruction involves an implant, be sure to go to a radiology center where technicians are experienced in the special techniques required to get a reliable x-ray of a breast reconstructed with an implant.
Women who postpone reconstruction may go through a period of emotional readjustment. Just as it took time to get used to the loss of a breast, a woman may feel anxious and confused as she begins to think of the reconstructed breast as her own.
Planning Your Surgery
You can begin talking about reconstruction as soon as you're diagnosed with cancer. Ideally, you'll want your breast surgeon and your plastic surgeon to work together to develop a strategy that will put you in the best possible condition for reconstruction.
After evaluating your health, your surgeon will explain which reconstructive options are most appropriate for your age, health, anatomy, tissues, and goals. Be sure to discuss your expectations frankly with your surgeon. He or she should be equally frank with you, describing your options and the risks and limitations of each. Post-mastectomy reconstruction can improve your appearance and renew your self-confidence -- but keep in mind that the desired result is improvement, not perfection.
Your surgeon should also explain the anesthesia he or she will use, the facility where the surgery will be performed, and the costs. In most cases, health insurance policies will cover most or all of the cost of post-mastectomy reconstruction. Check your policy to make sure you're covered and to see if there are any limitations on what types of reconstruction are covered.
Preparing For Your Surgery
Your oncologist and your plastic surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain vitamins and medications.
While making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days, if needed. Breast reconstruction usually involves more than one operation. The first stage, whether done at the same time as the mastectomy or later on, is usually performed in a hospital.
Follow-up procedures may also be done in the hospital. Or, depending on the extent of surgery required, your surgeon may prefer an outpatient facility.
Types of Anesthesia
The first stage of reconstruction, creation of the breast mound, is almost always performed using general anesthesia, so you'll sleep through the entire operation.
Follow-up procedures may require only a local anesthesia, combined with a sedative to make you drowsy. You'll be awake but relaxed, and may feel some discomfort.
Types of Implants
If your surgeon recommends the use of an implant, you'll want to discuss what type of implant should be used. A breast implant is a silicone shell filled with either saline or elastic silicone gel.
While there are many options available in post-mastectomy reconstruction, you and your surgeon should discuss the one that's best for you.
Skin expansion
The most common technique combines skin expansion and subsequent insertion of an implant.
Following mastectomy, your surgeon will insert a balloon expander beneath your skin and chest muscle. Through a tiny valve mechanism buried beneath the skin, he or she will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has stretched enough, the expander may be removed in a second operation and a more permanent implant will be inserted. Some expanders are designed to be left in place as the final implant. The nipple and the dark skin surrounding it, called the areola, are reconstructed in a subsequent procedure.
Some patients do not require preliminary tissue expansion before receiving an implant. For these women, the surgeon will proceed with inserting an implant as the first step.
Flap reconstruction
An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the back, abdomen, or buttocks.
In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat, and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself, without need for an implant.
Another flap technique uses tissue that is surgically removed from the abdomen, thighs, or buttocks and then transplanted to the chest by reconnecting the blood vessels to new ones in that region. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well.
Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about a silicone implant. In some cases, you may have the added benefit of an improved abdominal contour.
Follow-up Procedures
Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery may be required to replace a tissue expander with an implant or to reconstruct the nipple and the areola. Many surgeons recommend an additional operation to enlarge, reduce, or lift the natural breast to match the reconstructed breast. But keep in mind, this procedure may leave scars on an otherwise normal breast and may not be covered by insurance.
After Your Surgery
You are likely to feel tired and sore for a week or two after reconstruction. Most of your discomfort can be controlled by medication prescribed by your doctor.
Depending on the extent of your surgery, you'll probably be released from the hospital in two to five days. Many reconstruction options require a surgical drain to remove excess fluids from surgical sites immediately following the operation, but these are removed within the first week or two after surgery. Most stitches are removed in a week to 10 days.
Getting Back to Normal
It may take you up to six weeks to recover from a combined mastectomy and reconstruction or from a flap reconstruction alone. If implants are used without flaps and reconstruction is done apart from the mastectomy, your recovery time may be less.
Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. Most scars will fade substantially over time, though it may take as long as one to two years, but they'll never disappear entirely. The better the quality of your overall reconstruction, the less distracting you'll find those scars.
Follow your surgeon's advice on when to begin stretching exercises and normal activities. As a general rule, you'll want to refrain from any overhead lifting, strenuous sports, and sexual activity for three to six weeks following reconstruction.
Your New Look
Chances are your reconstructed breast may feel firmer and look rounder or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. But these differences will be apparent only to you. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.
FAQ
How long is my recovery?
Immediate breast reconstruction should not prolong your recovery from mastectomy. Most often, dissolvable sutures are used along the incisions. You will have drains, to collect fluid, in the reconstructed breast. You should be able to resume normal activity within a few days after surgery. Strenuous exercise and heavy lifting should be avoided for 3-4 weeks following surgery.
How long will I be in pain?
You will be sore for a few days and may even experience some muscle spasms/twinges in your chest. Tightness in the chest may persist for several days. You will be given a prescription for pain medication to use immediately post-op, and can switch to Ibuprofen or other over the counter medication after a few days. You may also have an On Q-pump, which will infuse medication into your breast to help with pain. This will be removed around 5 days post operatively.
How often will I need to come to the office for follow-up visits?
Your first post-op visit will typically be within three days after surgery. We will check your incision(s), observe for signs of infection, and monitor your recovery. We will then see you on a weekly basis until your drains are ready to be removed.
When can I go back to work?
Most patients take 2-4 weeks off of work. If your job requires physical labor, you should allow yourself 3-4 weeks before heavy lifting.
When can I drive?
You can drive as soon as you are off of the narcotic pain medication and feel alert enough and physically able to do so.
What medications will I be on after surgery?
You will be given prescriptions for pain medication: usually Percocet and Vicodin. You may take one or the other to control your pain. You will also be given a prescription for Valium, to help with muscle spasms. A prescription for Zofran is also given; you can have this filled if you need to. This can be used to control post-operative nausea and vomiting that some patients experience after anesthesia. We may also give you a prescription for an antibiotic to prevent infection.
Can I go home the same day?
Most patients spend one night in the hospital following a mastectomy. If you have already had your mastectomy, and this is a delayed reconstruction, you may be able to go home the same day following surgery. You will need someone to drive you home and stay with you the first night.
Will I have dressings/bandages to change?
You may have Dermabond, an adhesive glue covering your incisions. Your incisions can get wet. Do not apply any ointment or scar products to your incision until discussed with our office. If you have had a nipple sparing procedure, we sometimes have you put ointment (A&D Ointment, Vaseline or Bacitracin) on your nipple and areola three times daily.
Will I have drains?
Yes, usually two drains per side are necessary in the reconstructed breast to help collect fluid that accumulates following surgery. These are left in place when you leave the hospital. You will need to empty and measure the output of the drains at least twice daily. The nurse will show you how before you leave the hospital. The amount of time the drains stay in place varies with each person. Usually they stay in place for 1-2 weeks. They are concealed pretty well when secured under loose garments.
Will I require a blood transfusion?
Bleeding is always a potential risk of surgery. The procedure does not require a blood transfusion because blood loss is kept to a minimum during surgery. However, if you are adamant about blood donation or refusal, please let Dr. Spear and the nurses know prior to surgery.
When can I have sex?
You may have sex when you feel comfortable enough. However, anything other than gentle manipulation of the breasts immediately post-op could harm the incision.
When can I shower?
Sponge bathe until you are seen for your first post-operative visit.
Do my sutures need to be removed?
Dr. Spear usually uses dissolvable sutures. They are not noticeable, and are absorbed by the body.
When can I travel?
You may travel within a couple of days, as long as you feel comfortable. We like to see you within a couple of days following surgery, and once the following week to monitor your recovery.
How do I prevent constipation?
Narcotic pain medication can cause constipation. We recommend taking Colace or Pericolace. This medication is available over the counter at the pharmacy. You should begin taking this medication when you get home, and continue as long as you are on the narcotic pain medication. Increasing your fiber intake, eating fruits and vegetables, and drinking plenty of fluids also help. If constipation becomes a serious problem, we suggest either a Dulcolax suppository or drinking Milk- of- Magnesia.
What if I cannot urinate?
Following anesthesia, some patients have difficulty urinating. If you go home and are unable to urinate within six hours, you might need to be catheterized. Go to the Emergency Room; either Georgetown or one that is closer to your home. Patients are usually able to urinate after the medication leaves your system.
How can I reach someone, after office hours if I have a problem?
If you have a problem and the office is closed, you may contact the Plastic Surgery fellow or chief resident. You will be given their pager number after surgery.