Breast Reconstruction Surgery
Breast reconstruction surgery is a procedure designed to rebuild or replace breast tissue lost to injury or surgical revision. Often performed in conjunction with or following breast cancer removal, breast reconstruction can be accomplished using the patient’s own tissues or a prosthetic inserted beneath the skin. The purpose of breast reconstruction surgery is to correct both the physical deformity caused by procedures such as mastectomy and the emotional loss associated with breast cancer surgery.
About the Procedure
While each procedure is a highly individualized experience, dependent upon the complexity of the case, the following information can act as a guide for what to expect from your procedure:
- Stage 1: Tissue Expander Placement: 2 to 4 hours including mastectomy. General anesthesia. 1 to 2 day hospital stay.
- Stage 2: Tissue expander exchange to final implant with fat grafting. 1.5 to 2 hours. General anesthesia. Outpatient.
- Stage 3: Nipple reconstruction with additional fat grafting. 1.5 hours. General or local anesthesia. Outpatient.
- Side Effects: Temporary soreness, swelling, bruising, numbness, burning sensation.
- Risks: A few risks include infection, asymmetry, permanent decrease in sensitivity in nipples and breast skin. Tightening and hardening of breast tissue surrounding prosthetic implant or rupture of implant may also occur, requiring additional surgical intervention to release scar tissue or replace the implant.
- Recovery: Daily living may be resumed immediately. Return to non-strenuous work, with lifting limited to 10-lbs. or less, may be resumed in 2-4 weeks. No forceful pushing, pulling, or repetitive upper body movements for 3 weeks.
- Exercise: Light exercise may be resumed at 1/3 intensity, with 1/3 the number of repetitions, amount of weight, and heart rate, at 3 weeks postoperative. Activity can be increased to 2/3 intensity at 6 weeks, with full intensity possible at 8 weeks.
- Fading & Scar Improvement: Visible reduction in scarring should be obvious in 6 to 24 months.
- Bruising: Bruising to the affected area should last no more than 2 to 4 weeks.
- Swelling: Moderate to significant swelling may be apparent for up to 4 weeks, with subtle to mild swelling possible for 2 to 3 months, depending upon the extent of the procedure.
- Duration of Results: Tissue expander will be replaced by permanent prosthesis in 3 to 6 months. Implants may require replacement or removal at some point in the future. Results of the procedure are intended to last years/decades.
- Office Visits: 1) 5-7 Days postoperative. 2) 7-10 days postoperative. 7 to 10 visits will be required within the first 3 months to gauge the success of the procedure. Annual visits will be required once reconstruction is complete.
- Garment Worn: Support as needed for 6 weeks.
- Pain Medications: Narcotics or ibuprofen as needed for pain and swelling.
- Estimated Cost of Procedure: Covered by most medical insurance plans.
Breast Reconstruction Candidates
Most women who have undergone mastectomy are candidates for breast reconstruction surgery. Many patients are candidates for immediate mastectomy reconstruction, even if they are undergoing radiation and chemotherapy. Other patients are advised to delay surgery and pursue breast reconstruction after radiation therapy is complete.
In either case, reconstruction will be carefully coordinated with your primary physician to ensure an optimum outcome from the procedure.
How Breast Reconstruction is Performed
In general, there are two types of procedures used to reconstruct the breast following a mastectomy:
- Autologous Tissue Only: This procedure uses the body’s own tissue to reconstruct the breast. The downside to this procedure is the obvious sacrifice of healthy tissue for the reconstruction, as well as the creation of a secondary wound site to borrow the tissue.
- Prosthesis: This type of reconstruction involves the use of a tissue expander and an implant to rebuild the breast. In conjunction with autologous fat transfer (liposuction with grafting of the fat into the reconstructed breast) a very natural result can be achieved with minimal impact on the remainder of the body.
Our preferred method of breast reconstruction involves the use of tissue expanders, implants and fat grafting.
When a prosthesis is to be used, a tissue expander is often placed beneath the residual muscle and skin remaining after the mastectomy. This device can be slowly filled in the weeks following surgery in order to stretch the skin and prepare it for the permanent placement of a silicone or saline implant. After the required size is achieved with the tissue expander, it is left in place for several months to allow the skin and muscle to adjust to their new conformations.
In an autologous tissue reconstruction, tissue transfer often involves the use of a muscle flap from either the back or the lower abdomen, with varying amounts of skin and fat being transferred with the muscle tissue.
In many patients, using the lower abdominal tissue (a TRAM Flap reconstruction) ensures a larger selection of skin, fat, and muscle to rebuild the breast mound than would be found on the back, eliminating the need for a prosthetic. Using the TRAM flap allows surgeons to make use of the blood supply from the rectus abdominis muscle for the reconstructed area. This technique is appropriate for patients who have lost a significant portion of breast tissue through mastectomy, or those with a greater degree of droop to the remaining breast.
For smaller reconstructions, skin from the back and a portion of the latimus dorsi muscle can be rotated through a tunnel in the armpit to the chest wall, with a skin expander or implant placed beneath the flap of skin to recreate the form of the breast.
Many factors are taken into consideration when choosing an appropriate treatment plan. These include the availability of donor tissues, the need for post-adjuvant therapies, such as radiation or chemotherapy, medical history, and lifestyle considerations.
As we mentioned earlier, fat grafting is essential to giving a reconstructed breast its natural look. This procedure involves removal of fat from the patient’s body: most often the thighs, stomach, or buttocks. Once procured, this fat is injected into the skin and tissue surrounding the prosthetic in order to both give the reconstructed breast a natural softness, and too, to fill its shape, minimizing the need for use of other healthy tissues in the body during the process of breast reconstruction.
Each patient’s needs are carefully evaluated at the time of consultation to determine the best course of action when approaching breast reconstruction. All aspects of the patient’s past medical history, operative reports from the initial surgical procedure, pathology reports from tissue removal, and any other information supplied by the general surgeon, oncologist, and radiation therapist are taken into consideration.
The physician will use this information to best determine which breast reconstruction option is best suited to the patient. During the initial consultation, a frank discussion should take place between the physician and patient to determine the patient’s specific needs and expectations for the procedure.
When a course of action is decided upon, all fees and the potential length of the patient’s hospital stay will be discussed. Information will be provided to help guide the patient in talks with their insurance carrier regarding coverage for the procedure.
Before the Procedure
In order to assist with the recovery process, patients are encouraged to adopt a holistic approach to health and fitness. Proper diet, regular exercise, and regular medical screenings are essential to ensuring a good outcome from any procedure.
Routine laboratory tests, including blood counts, blood chemistries, pregnancy testing (when applicable) and ECG for patients older than 50, will be performed prior to the procedure.
It is recommended that patients avoid the following substances prior to any surgical procedure:
- Aspirin: Aspirin and aspirin containing substances may inhibit blood clotting.
- Nicotine: Nicotine may act as a vasoconstrictor, impairing circulation following any surgical procedure. Smoking should be discontinued 2 weeks prior to, and 4 weeks following any procedure.
The Day of the Procedure
Breast reconstruction following mastectomy is major surgery and will be performed under general anesthesia. The procedure will take from 3 to 5 hours, with follow-up in the recovery room for a period of approximately one hour.
It may be necessary to insert silicone drain tubes with attached collection bulbs into the surgical area to aid in postoperative drainage. The patient will be instructed in the care necessary to keep these clean and open during their use. Patients are advised to empty the bulbs once or twice daily and record the amount of drainage collected to determine optimal removal time. Drains usually remain in for 2-3 weeks. Total hospitalization following the initial surgical event is typically 1-3 days.
After the Procedure
- Light activity is encouraged immediately after the procedure, while vigorous exercise and strenuous activity are to be avoided for at least 4-6 weeks following the initial hospital stay.
- Patients will receive prescriptions for antibiotics to be taken for approximately five days postoperatively to prevent infection. It is strongly recommended that the prescription be taken as directed. A mild pain medication will also be prescribed to be taken as needed.
- Patients may shower after the first post-operative visit at day 5. Full submersion in hot water (bathing) is discouraged for three weeks following surgery.
- Small amounts of fluid may collect in the area of reconstruction. There is no cause for concern should this happen, as the fluid is asymptomatic and will be reabsorbed back into the body over a period of a few weeks. Occasionally, drains may have to be replaced if the fluid continues to build up.
- The weaker bruise and tissue fluid will gradually be replaced with stronger scar tissue over a period of 6-8 weeks. Until the scar tissue has been formed, the wound is held together by sutures put in place at the time of the procedure. Too much stress placed upon the sutures can cause them to rupture, leading to complications, such as infection.
- Maturation of the scar tissue occurs over a period of 6-12 months. During this period, the scar tissue will become thinner, finer, and will lose much of the reddish hue it has immediately following surgery.
Breast Reconstruction Risks, Limitations, and Potential Complications
As with any surgical procedure, there are risks from, and limitations to, breast reconstruction. While complications with this procedure are rare, patients should be aware of the following:
- Scarring: As with any surgical procedure, there is the potential for scarring, although every effort is made to ensure the appearance of scars is minor.
- Pain: Pain is not uncommon after any surgical procedure. Patients will be provided with a prescription for pain medications to use after the procedure.
- Anesthesia intolerance: The most common side effects of general anaesthesia include nausea, vomiting, and sore throat.
- Bleeding: A small percentage of patients report unusual bleeding following surgery. Excessive bleeding may require emergency drainage in the operating room.
- Infection: As with any operation, there is a risk for infection. Patents are closely monitored and any evidence of infection is treated with antibiotics. Serious infections may require temporary removal of a tissue expansion or implant. Infection risk is higher in patients who have undergone radiation treatment.
- Asymmetrical appearance: All breasts have some degree of asymmetry. Revisionary procedures may be required for unacceptable post-operative asymmetry.
While any of these complications are possible, they are rare. The vast majority of breast cancer reconstruction surgeries are completed with no complications.
Breast Reconstruction Costs
Breast reconstruction is a covered benefit under most medical insurance plans. There may still be a significant cost of pocket expenses associated with high deductibles. We encourage you to speak directly to your insurance carrier regarding your individual plan.
For more information regarding breast reconstruction surgery at Boulder Plastic Surgery, contact our office at (303) 578-4193.