What is breast reconstruction?
Breast cancer affects 1 in 6 women in the United States annually. Many patients are appropriately treated with breast conservation therapy that does not involve removal of the entire breast gland, only a portion of it. A group of patients, however, are recommended removal of the entire breast gland as optimal treatment for their breast cancer. This is called a mastectomy. Most current techniques in mastectomy allow for the skin envelop of the breast to be spared, or “skin sparing mastectomies.” Some specific candidates for mastectomy may be able to spare the nipple areolar complex, or “nipple sparing mastectomies.” Both of these groups of patients are candidates for volume restoration of the breast, or breast reconstruction. A plastic surgeon is specifically trained in techniques for breast reconstruction, and all patients treated with mastectomies are encouraged to meet with a plastic surgeon do discuss their options.
How is a new breast made?
To make a new breast, volume is restored to the skin envelope that remains after the mastectomy is complete. The process may begin at the time of the mastectomies, called immediate, or later, called delayed. To restore volume and shape to the breast, either a silicone implant or the patient’s own soft tissues may be used. Each patient must be evaluated and considered individually for their candidacy for each type of reconstruction. Factors that influence patient selection of the type that may be performed include patient preference, body size, breast size desired, breast size preoperatively, patient tobacco use, prior or planned radiation to the chest wall, and presence of medical conditions including diabetes, hypertension, and obesity. Your plastic surgeon will specifically evaluate your candidacy for each type to reconstruction and make recommendations.
Implant-based breast reconstruction
Implant-based reconstruction uses a silicone implant to restore volume to the breast. It may be immediate, or direct to implant at the time of mastectomy, or staged, where a tissue expander is placed at the time of mastectomy. The tissue is then expanded over a few months, and in a second stage, the expander is exchanged for the silicone implant.
Tissue expanders placed at the time of mastectomy are empty implants that are slowly filled with fluid once the skin wounds have healed. Sterile fluid is injected on a weekly basis to increase the volume of the breast skin flaps to a volume desired by the patient. Tissue expanders are useful for patients who are small and want to be larger. They are also useful for patients who are very large and have excess skin that needs to be removed to allow the new breast to be lifted back up onto the chest wall. Tissue expanders are not painful, but they are firmer than the implant that will ultimately replace them.
Silicone implants come in various sizes and are used to restored volume to the breast envelope.
Longevity: Silicone implants typically last around 20 years before a break in the shell around the silicone breaks and small leak may occur.
Tissue-based breast reconstruction
In tissue-based breast reconstruction, a patient’s own soft tissues may be used to restore breast volume. The most frequently used tissues are from around the lower abdomen and belly button (umbilicus). The transferred tissue is called a flap. The deep inferior epigastric perforator, or DIEP flap, is the one used most often in breast reconstruction. This procedure allows for the skin and fat to be transferred to the chest wall. The tissue is kept alive through a feeding set of blood vessels that are separated from the rectus muscle (six-pack muscle) and traced to their origin in the groin. The vessels (each about 2-3 mm in diameter) are then separated from their original large blood vessel in the groin. The patient’s internal mammary vessels are then freed from under 2 ribs along the side of the breast bone and brought forward to be reconnected under magnification with the vessels from the flap. The tissue is then shaped into a breast.