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Approximately 1 in 8 women in the United States (12%) will develop invasive breast cancer over the course of her lifetime (see www.breastcancer.org). There are many ways to treat breast cancer, and the conversation about your treatment may include discussion of chemotherapy before or after surgical treatment, and radiation. When considering surgical treatment of the disease, however, the two options for treatment of the breast are mastectomy and lumpectomy. Read More
Mastectomies are performed to remove all of the breast tissue, including your tumor. Lumpectomies remove only the tumor and a small amount of surrounding normal breast tissue. Lumpectomies are always followed by radiation to eradicate any residual cancer cells. The breast surgical oncologist often recommends one of these two options to the patient, but sometimes either option is available.After mastectomy, breast reconstruction may be performed in multiple steps, encompassing 3-4 procedures over approximately one year. The stages consist of:
Lumpectomy, the removal of a tumor with a small amount of surrounding normal breast tissue, is the other form of surgical breast cancer treatment. This is sometimes called “breast conserving therapy.” After lumpectomy, the breast is treated with radiation to eradicate any residual cancer cells. Although treatment with lumpectomy and radiation does not remove all breast tissue, this treatment may result in changes to the breast appearance. These changes are most noticeable in women with smaller breasts, or tumors that are large in comparison to the volume of the breast. Large tumors or lumpectomies in small breasts result in significant distortion of the breast or deformities. Unfortunately, radiation therapy changes the breast’s ability to heal from future surgical endeavors and can limit the reconstructive options available if a patient has a poor aesthetic outcome.
Plastic surgeons can reduce the risk of a poor aesthetic outcome by rearranging the breast tissue after lumpectomy to fill the resulting hole in the breast. This procedure is known as (breast) parenchymal rearrangement. The parenchymal rearrangement is typically performed 5-10 days after the lumpectomy, in order to allow pathologists to determine that the entire tumor has been removed before reconstruction is undertaken. It is common for a patient to undergo a breast lift or reduction to their healthy breast to preserve symmetry after parenchymal rearrangement is undertaken. This procedure on the healthy breast may be performed at the same time as the parenchymal rearrangement or after radiation is complete, depending on the specific medical and social issues in each person’s case.
Recurrence of breast cancer is rare. However, if it occurs, the options for reconstruction are impacted by the treatment choices that were made for the original cancer treatment. There is also a risk of breast cancer occurring in the opposite breast. This risk is typically low, often thought to be less than 0.5% per year for many patients. The options for reconstruction of the opposite breast are also influenced by the original treatment decision.
It is common to require radiation for treatment of a recurrence. Radiation increases the risk of capsular contracture (hardening of breast tissues) if a breast was reconstructed using an implant.
If a patient has previously undergone lumpectomy and radiation, mastectomy will be required for treatment of a recurrence and reconstruction typically involves bringing in tissue from non-radiated areas of the body due to the poor healing capacity and inability to stretch of the previously radiated skin.
If a DIEP or other abdominal tissue flap was previously used for breast reconstruction, the surgeon may not use the lower abdomen again for this purpose because the blood vessels from this area may only be used one time.
In each case, the plastic surgeon will discuss options for treatment with you before settling on the choice that best meets your needs and goals. Do not hesitate to ask questions during or after your visit.
For breast reconstruction using implants, an adjustable tissue expander is placed beneath the skin of the breast and the underlying pectoralis muscle. When this procedure is performed at the same time as your mastectomy, a one-day hospital stay is normal followed by an acute recovery period of approximately two weeks; returning to nomal activities by 6-8 weeks. Drains are present in the breast after surgery and these are usually removed within two weeks of the breast reconstruction procedure.
When tissue expanders are placed after a person has healed from their mastectomy (delayed reconstruction) it is less common to require a hospital stay or drains.
After a woman has healed from the placement of tissue expanders, a period that usual takes 2-3 weeks, she periodically returns to clinic so that a saline solution can be injected into the expanders to slowly stretch the overlying skin. This process may take several weeks to months. The injections of saline are performed in the office during a standard post-operative visit and typically cause minimal discomfort, similar to a sore muscle,that resolves over 1-2 days.
After the ideal breast size is achieved, a more permanent breast implant, filled with saline or silicone gel, is inserted in place of the tissue expander to give a softer and more natural-appearing result. The procedure to exchange your tissue expander for a permanent implant is typically performed as an outpatient and has a healing time of approximately one week.
After reconstruction with implants has been completed, a woman should continue to monitor the appearance and texture of her breasts. Over time, appearance and texture can change. Forty percent of women undergo another operation for their implants by seven years after their reconstruction.
Reasons for further operations:
Because of the long-term considerations with implant reconstruction, most women do undergo further operations to maintain their implants. Most of these are outpatient procedures with a relatively quick recovery.
Implant-based breast reconstruction is not a good option for patients who have previously been treated with radiation because of poor aesthetic outcomes and a high likelihood of healing problems.
For patients who require radiation after mastectomy and placement of the tissue expander, the timeframe to proceed with the additional steps in breast reconstruction may be prolonged. Radiation increases the risks of healing problems and infection in the implant-reconstructed breast. It also increases the risk of capsular contracture from 30% to 60%.
Tissue-based operations take more time than implant-based operations and have a recovery time of 1-3 months. However, a patient’s own tissue will yield the most natural appearance and a result that can endure for decades.
You may see this technique referred to as “flap reconstruction,” autologous reconstruction, or “free flap reconstruction.” Specific names that you may see are those referring to use of tissue from the abdomen: Transverse Rectus Abdominus Myocutaneous flaps (TRAM), free TRAM, muscle-sparing TRAM, Deep Inferior Epigastric Perforator flaps (DIEP), and others. Surgeons at Plastic Surgery Northwest use a newer procedure, known as the “free TRAM,” where the tissue is completely separated from the body before it is moved to the chest, regaining its blood flow when small blood vessels from the abdominal tissue are sewn to blood vessels in the chest. This technique is known as the free TRAM, the muscle-sparing TRAM, or the DIEP flap, depending on the amount of abdominal muscle that is moved with the skin and fat.
Before TRAM Reconstruction:
Mid TRAM Reconstruction:
The other technique for breast reconstruction is to use a woman’s own tissue to recreate the shape of a breast. You may see this technique referred to as “flap reconstruction,” autologous reconstruction, or “free-flap reconstruction.” Specific names that you may see are those referring to use of tissue from the abdomen: Transverse Rectus Abdominus Myocutaneous flaps (TRAM), free TRAM, muscle-sparing TRAM, Deep Inferior Epigastric Perforator flaps (DIEP), Transverse Upper Gracilis flaps (TUG) and others.
With autologous tissue reconstruction, skin, fat and sometimes muscle from the abdomen, thighs or other parts of the body are utilized to reconstruct the breast mound. This healthy tissue replaces tissue that is lost with a mastectomy and can help the body to heal, even after damage caused by radiation. The most commonly used tissue for autologous reconstruction is the skin and fat from the lower abdomen, as this best replicates the breast tissue that has been lost. This procedure tightens the abdomen where tissue is removed and results in a long scar, extending from hipbone to hipbone.
There are numerous variations on the technique that is used to move the abdominal tissue to the chest for breast reconstruction. Some surgeons rotate the belly tissue to the chest, leaving an attachment at the ribcage, a procedure called a “pedicled TRAM.” Surgeons at Plastic Surgery Northwest use a newer procedure, known as the DIEP for free muscle-sparing TRAM flap where the tissue is completely separated from the body before it is moved to the chest, regaining its blood flow when small blood vessels from the abdominal tissue are sewn to blood vessels in the chest. This technique provides improved blood flow to the reconstructed breast tissue and spares the muscles of the abdomen, preserving abdominal wall strength.
Sometimes a woman may not be able to use her abdominal tissue for breast reconstruction due to prior surgery, an absence of abdominal fat, or other factors. These patients may be able to use inner thigh, buttock, or other tissue to replace the lost breast tissue. Tissue-based breast reconstruction operations are much longer than operations to place implants for breast reconstruction, taking 8-12 hours for the initial reconstructive procedure. A patient usually remains in the hospital for 4 days after the operation and learns to take care of drains in her abdomen and breasts before returning home. The recovery following autologous tissue reconstruction is longer than that for implants, with level of energy being the slowest thing to return to normal. Women do not usually return to all of their normal activities or work for eight weeks after surgery.
Surgery to improve the appearance and symmetry of reconstructed breasts is often performed 3-4 months after this initial reconstruction. This procedure is typically performed as an outpatient and has a healing time of approximately one week.
Though the initial reconstruction is a significant commitment, once your autologous tissue reconstruction is complete, there is a very low likelihood of future procedures. Because they are your own tissue, breasts reconstructed in this fashion will gain or lose weight with you and will react to gravity the same way that the rest of your natural tissues do over time. Your reconstructed breasts feel soft and warm and provide you with the most natural appearance and a result that can endure for decades.
If radiation is required after your mastectomy, autologous tissue reconstruction should be delayed until one year after radiation has been completed to allow your blood vessels to recover. If radiation is performed after the flap is transferred, the risk of flap fibrosis and asymmetry is much higher, compromising some of the long-term benefits of this reconstructive option.