Breast Reconstruction
Breast cancer currently affects approximately one in eight women in the United States over the course of their lifetimes. The diagnosis of breast cancer can evoke significant psychological distress upon a woman. Concerns about the extent of the disease, as well as the consequences of treatment, can leave a patient overwhelmed.
At Lincoln Aesthetic Surgical Institute, we work with you and your other medical providers to help ease your concerns.
Treatment Options for Breast Cancer:
The treatment of breast cancer involves several variables and no two patients are the same. Factors that play a role in determining your treatment include your age, co-morbid medical conditions, tumor size, involvement of lymph nodes, as well as certain pathologic features.
Surgery is the mainstay in treatment of breast cancer. Options generally involve either breast conservative therapy (i.e., a lumpectomy) or total mastectomy. With breast conservative therapy, a tumor along with a healthy rim of normal breast tissue is removed. This offers the advantage of a potentially nonexistent or small breast deformity after the procedure, however in order to reduce the risk of developing recurrent or new cancer within the same breast, radiation therapy is usually needed to the remaining breast tissue.
With a mastectomy, the entire breast tissue is removed. This usually includes the nipple/areola, as this area also harbors breast tissue. With a mastectomy, there is often no need for post-operative radiation therapy. Deciding whether a mastectomy versus breast conservative therapy is best for you is made in conjunction with the surgical oncologist. If a mastectomy is desired, consideration should be made on whether to perform bilateral mastectomies.
Whether you choose a lumpectomy or mastectomy, sampling of the lymph nodes within the armpit (axilla) may be needed at the time of your surgery. This is important to help determine the extent or stage of disease, and helps guide further treatment, including radiation and hormonal therapy. Depending on the stage of your disease, as well as your age and menopausal status, chemotherapy also may be recommended. This is usually performed following surgery; however, in some patients with more locally advanced cancer, chemotherapy may be needed prior to surgery.
Hormonal therapy is also commonly needed following surgery. Breast cancer often contains receptors for the hormones estrogen and progesterone. In some tumors, these hormones act as signals that tell the tumor to grow. Medications including Tamoxifen, as well as newer class selective estrogen receptor modulators (SERMs) and aromatase inhibitors, may also be recommended to reduce your chance of recurrent disease. In addition, depending on tumor characteristics, your medical oncologist also may recommend certain targeted therapies such as the medication Herceptin to combat your cancer.
Radiation therapy is routinely used as an adjunct to breast conservative therapy to lessen the likelihood of recurrent cancer within the same breast following a lumpectomy. For a mastectomy patient, radiation is usually not necessary, as all of the breast tissue is removed. Nevertheless, as the treatment of breast cancer evolves, there are certain instances where radiation therapy may be necessary following mastectomy. Radiation may be recommended if the tumor size is large (greater than four to five cm in diameter) or if four or more lymph nodes within the axilla are found to have cancer within them at the time of surgery.
Breast Reconstruction
For women with breast cancer, the result or expected effects of surgery can lead to a severely altered self body image. A woman’s breasts are central to her femininity, and the loss of one or both breasts due to surgery can be profound.
At Lincoln Aesthetic Surgical Institute, we understand your concerns. For women who have undergone a prior mastectomy, or are scheduled to have the procedure, we can help you restore your self-confidence and body image. For women who have undergone a prior lumpectomy and are left with a distorted breast, we can help shape the breast back to a more aesthetically pleasing form.
Breast reconstruction may be performed either at the time of a mastectomy (i.e., immediate reconstruction) or later after the completion of your treatment of breast cancer (i.e., delayed reconstruction). The timing of the reconstruction varies. In general, candidates for immediate reconstruction are those with clinically early stage disease. This includes patients with smaller tumors and no evidence of palpably enlarged lymph nodes within the armpit or axilla.
There are advantages and disadvantages to both techniques. With immediate breast reconstruction, the reconstructive process begins at the time of the mastectomy, avoiding the potential need for an additional surgical procedure. Furthermore, with immediate reconstruction following a mastectomy, the majority of the natural skin of the breast is preserved, decreasing the need to obtain skin from other parts of the body, which is commonly needed with delayed reconstruction. In patients who do not undergo immediate reconstruction, the remaining skin over the breast will often contract down to lie flush with the chest wall.
Finally, immediate reconstruction allows the woman to feel more “whole” sooner after the mastectomy. Disadvantages of immediate reconstruction include the possibility of finding more extended disease at the time of mastectomy than was anticipated pre-operatively resulting in the need for potential adjuvant therapies including radiation.
Advantages of delayed reconstruction include allowing full treatment of the cancer without potential interruptions.
In general, there are two main types of breast reconstruction: implant-based reconstruction and reconstruction using your own body tissue (i.e., autologous reconstruction).
Implant-Based Breast Reconstruction
Implant-based reconstruction involves placement of an initial breast tissue expander at the time of the mastectomy. After the breast surgeon has removed the entire breast tissue underneath the skin overlying the breast, Dr. Mitchell places a temporary tissue expander device within a space created below the pectoralis major muscle within the chest. Placement underneath the muscle helps reduce the potential of rippling after the permanent implant is placed, by providing more soft tissue coverage over the implant.
The purpose of the tissue expander is to create a space for the eventual placement of a permanent implant. A tissue expander is basically a balloon with a small port located within it. The reason for the initial placement of the temporary expander is that the skin overlying the breast is usually supplied with blood vessels that run through the breast tissue itself. When the entire breast tissue is removed, so are the main blood vessels supplying the remaining skin.
Blood supplying the remaining skin over the breasts now comes from a network of vessels located within the dermis of the remaining skin. If a large permanent implant were inserted at the time of the mastectomy, this may produce internal pressure of the skin, disrupting blood flow and potentially leading to necrosis of the skin overlying the breast.
The tissue expander allows Dr. Mitchell to place some fluid within it to keep the skin from contracting down at the time of the mastectomy. Then, in the office setting, Dr. Mitchell can add more fluid slowly to the tissue expander to gradually stretch the remaining skin over the breast without compromising its blood supply.
At the time of the placement of the tissue expander, Dr. Mitchell often uses a product called Alloderm. Alloderm is a biological product made of human skin processed to remove all living cells and antigens within it. In essence, this leaves all the good products of the skin such as collagen and elastin. Alloderm acts as a scaffold, and the patient’s own living cells grow into the product and re-vascularize it. The purpose of the Alloderm is three-fold:
1) The pectoralis muscle helps provide coverage over the upper and medial portion of the tissue expander; however, it is not large enough to cover the entire expander. Alloderm is generally sewn in along the fold below the breast and attached to the muscle above to provide complete coverage over the implant. It acts as a sling to keep the initial tissue expander in the proper place within the breast.
2) The Alloderm provides an extra layer of tissue between the implant and the thin skin, to help reduce palpability and rippling that can occur.
3) Because Alloderm is re-vascularized, it provides an extra layer of protection if problems arise with healing of the incision over the breast. Before Alloderm, if the incision broke down and the implant was visible within the wound, then bacteria were present on the implant and the implant had to be removed in order to completely clear the infection. With Alloderm, many implants can now be potentially salvaged, should wound healing problems arise.
At the time of the mastectomy, one or two drains may be needed to remove fluid that may build up between the remaining breast skin and the underlying muscle and Alloderm. The drains remain in place until output is less than 30 ccs or milliliters per day. This typically takes between one to two weeks.
After the drains are removed and the incision has healed appropriately, in-office expansion of the tissue expander occurs. Using a magnet, Dr. Mitchell localizes the port to expand the tissue below the breast skin. A needle is inserted into the tissue expander and fluid is added to stretch the breast skin. The procedure causes minimal discomfort, as the skin overlying the breast is generally numb due to loss of sensory input following the removal of the breast tissue.
Patients often feel some pressure from the expanded implant, which generally eases as the skin relaxes and stretches. Patients typically receive the expansion every one to two weeks until the desired volume has been obtained. Once the desired breast volume is achieved, usually about one month, arrangements are made to place the final permanent breast implant. This is performed as an outpatient procedure.
Options regarding the type of permanent implant include either a silicone or saline breast implant. Both implants consist of a thin shell made of a silicone elastamer. These are available in a variety of shapes and sizes. Dr. Mitchell will help you choose the most appropriate implant. With all breast implants, there are certain long-term risks associated with the devices. The first is the risk of potential rupture of the shell. In general, the older the implant, the increased risk of rupture with time.
Diagnosing a ruptured saline implant is relatively straightforward. The saline used to fill the implant is the same saline used in intravenous fluid during your operation. If a saline implant leaks, the breast may suddenly decrease in size as the saline leaks out of the implant and is absorbed by your body. With silicone breast implants, detecting a leak is more difficult. First, the silicone used in the current generation of breast implants is a gel. It has certain cohesive properties to it which make the silicone molecules stick together. Also, silicone is non-absorbable. As such, the breast does not usually change in size.
Symptoms of a potential leak are subtle and may be as mild as a slight irregularity in the way the implants feel over time. Often, even on physical examination, it is difficult to discern if an implant is ruptured. If a silicone implant is suspected of being ruptured, an MRI of the breast may be needed. This currently is the most sensitive test for detecting a silicone implant leakage. It is approximately 80-90 percent effective for detecting a leakage. Current FDA recommendations for assessing silicone breast implant leakage include an MRI three years after placement, then every two years. If a leakage is diagnosed within either a silicone or saline breast implant, surgery is recommended to remove the leaking implant and replace it with a new implant.
Another risk inherent to all breast implants is the development of a capsular contracture. As with all foreign objects placed in the human body, the body reacts by forming scar tissue around the object. We refer to a capsule as the scar tissue that surrounds all breast implants, whether placed as part of breast reconstruction or for augmentation purposes only. In some patients, this capsule may cause problems over time — a condition called a capsular contracture. The first sign of a capsular contracture is that the implant begins to feel firmer than normal. In some women with breast implants, the capsular contracture can progress, causing the implant to shift locations from where it was initially placed. Finally, some women can develop pain in the breast due to the capsule. The development of a capsular contracture is best treated with surgery to release either part of or the entire offending capsule. The implant also may need to be exchanged for a newer one at that time.
There are advantages and disadvantages to both silicone and saline implants, and the choice for final implant is ultimately yours. Silicone implants offer a more natural feel. Current evidence regarding silicone implants has shown a decreased risk of rupture as compared to saline implants. Unfortunately, leakage is difficult to detect and may require a MRI to diagnose. With saline implants, a leak is easy to detect and the saline is harmless. With past silicone implants, there was a concern over a potential link between the silicone used to fill the implants and the development of potential connective tissue disorders (CTD). At present, no link has been shown between silicone breast implants and connective tissue disorders. Nevertheless, some patients still harbor reservations over the silicone implants and choose saline.
Autologous Based Breast Reconstruction
Autologous based breast reconstruction refers to using the patient’s own tissue to help reconstruct the breast. This generally involves transferring tissue from another part of the body to reconstruct the breast. The abdomen is most common site of excess tissue used to reconstruct the breast.
With all flaps of tissue taken from other parts of the body and used to reconstruct a breast, one key is universal. Each flap consists of tissue supplied by a certain blood source. Successful flaps involve transferring the tissue in a way that the blood supply to that living tissue is preserved so the flap will thrive.
The Transverse Rectus Abdominus Myocutaneous Flap (TRAM flap)
The Transverse Rectus Abdominus Myocutaneous Flap or TRAM flap is the most commonly used autologous method of reconstructing a breast following mastectomy. It has a proven track record and is generally extremely reliable. There are several variations of the flap, but in general, excess abdominal skin and fat are transferred from the lower abdomen to reconstruct the breast mound. The transferred skin and fat are identical to what is typically removed during an abdominoplasty or tummy tuck procedure. This offers the patient a smoother, flatter mid-section while at the same time reconstructing the breast.
The skin and fat overlying the lower abdomen is supplied by a blood vessel called the epigastric artery. This artery passes below the rib cage and under the rectus abdominus muscles within our abdominal wall. The vessel joins the iliac artery inferiorly. Beneath the muscle, little branches of the vessel called perforators pierce the overlying muscle and supply the blood to the skin and fat of the lower abdomen.
There are several techniques for transferring this tissue with its blood supply. The most common technique involves dividing the lower portion of the vessel before it joins the iliac artery. From here, the skin, fat, rectus abdominus muscle and underlying epigastric artery are lifted and passed through a tunnel under the skin up into the breast area created by the mastectomy. The blood supply to this skin and fat is now based upon the upper portion of the epigastric artery. This is referred to as a “pedicled” TRAM flap.
Other techniques to transfer excess lower abdominal tissue generally involve a process called “free tissue transfer” (i.e., free flap). These techniques were developed to help reduce potential side effects associated with the traditional pedicled TRAM flap. One concern with all potential flaps is blood supply. We know through anatomical dissections that the epigastric artery is simply not a straight pipe carrying blood uniformly beneath the muscle. The upper or superior portion of the blood vessel has a smaller diameter than the lower or inferior portion of the artery.
With all flaps, the better its blood supply, the less risk of problems. Because the diameter of the blood vessel is larger in the inferior portion of the vessel, more blood is supplied to the overlying skin and fat from the vessel. Unfortunately, if the upper portion of the blood vessel is divided, the skin and fat cannot be rotated into the breast area without first completely dividing the lower epigastric artery and using this end to supply the flap.
With a free TRAM, the blood vessel is divided in both the upper portion of the vessel as well as where it joins the iliac artery. Next, a recipient blood vessel is identified in the chest near the breast area and the larger diameter lower portion of the blood vessel is sewn into the recipient vessel in order to restore blood flow to the flap. This in theory improves blood supply to the flap. Further variations of the free TRAM, including the muscle-sparing approach as well as the Deep Inferior Epigastric Perforator (DIEP) flap, seek to limit the potential loss of natural muscle within the abdominal wall while preserving blood supply to the transferred skin and fat. These procedures add to the complexity of the case and increase time in surgery.
Generally, several factors are important in determining if use of the abdominal tissue is appropriate for breast reconstruction. First, previous abdominal surgeries may affect or influence the safety of these procedures. Upper abdominal incisions, such as those resulting from an open removal of the gallbladder, may affect potential healing of the abdominal skin after closure. In addition, prior lower abdominal surgeries influence its safety. For patients with a prior abdominoplasty, the normal perforators supplying the overlying skin and fat to the abdominal tissue have been divided and these patients are not candidates for a TRAM.
Secondly, ability to restore symmetry between the native, normal breast and reconstructed breast depends on the amount of available tissue in your lower abdomen. Some women simply do not have enough excess abdominal tissue to match the size needed to approximate the normal breast. Conversely, some women have too much excess abdominal tissue, which raises concerns over maintaining a good blood supply to the flap. In overweight patients who are not candidates for implant-based reconstruction, the more invasive free TRAM procedures are generally more indicated.
There are many factors in deciding whether implant-based or autologous reconstruction is best for you. With implant-based reconstruction, the additional procedure typically takes an additional two to three hours following the mastectomy, depending on whether it is unilateral or bilateral. With the use of the TRAM flap, additional operative time can be from up to six to twelve hours, depending on whether it is performed as a pedicled flap or free flap. With the use of implants, pain is limited post-operatively to the chest. The use of the abdominal tissue adds a second site at the abdomen. In general, patients may take up to two weeks to recover from placement of initial tissue expanders.
The TRAM flap procedures take approximately six weeks of recovery. With the TRAM flap procedures, the need for a second operative procedure and anesthetic is avoided to exchange temporary tissue expanders for permanent breast implants. Thus, restoration of the breast occurs sooner. Autologous reconstruction offers the most natural feel, as your own skin and fat is used to replace the breast tissue. Furthermore, long-term risks such as implant leakage as well as capsular contractures necessitating further surgeries are avoided with the use of autologous tissue. With implant-based reconstruction, scars are limited to your breast only.
With the use of a TRAM flap, you will have a scar running low on the abdominal wall from hip bone to hip bone, but you also will have an improved abdominal contour. Wound healing problems can occur with either procedure. In both procedures, potential necrosis of the breast skin flaps can occur with over-thinning of the mastectomy skin flaps during removal. Bleeding and infections are also possible. With a TRAM flap procedure, additional wound healing concerns are possible. Potential necrosis of the abdominal skin after closure is possible, as well as potential disruption in the blood supply to the umbilicus or belly button. Furthermore, patients who undergo a TRAM flap procedure can also develop potential abdominal wall hernias or weaknesses in the abdominal wall that may produce a bulge. Potential concerns include disruption in blood flow, causing part or potentially all of the tissue to die.
Other Autologous Based Flaps for Breast Reconstruction
Although the use of the excess abdominal tissue remains the mainstay in autologous reconstruction, other flaps of tissue are available. This includes the use of the gluteal tissue (i.e., the Superior or Inferior Gluteal Artery Free Flaps) as well as the latissimus dorsi muscle from the back. In general, these are used as secondary flaps in cases in which autologous reconstruction is indicated or preferred, but the abdominal tissue is not available.
The latissimus dorsi muscle deserves special consideration in cases of prior radiation to a breast due to previous breast cancer. This most often occurs when women present with a history of recurrent cancer within a breast treated with lumpectomy and radiation or in women who underwent a prior lumpectomy and radiation and developed a cancer within the previous non-affected side. Often, these women may elect to undergo bilateral mastectomies and desire implant-based reconstruction. For these patients, the effects of prior radiation to a breast inhibit wound healing. Using the latissumus dorsi muscle with its reliant blood supply assists in avoiding wound-healing problems, which can occur if a tissue expander or implant is used alone.
Symmetry in Breast Reconstruction
Whether a unilateral or bilateral procedure is desired, Dr. Mitchell’s ultimate goal is to produce a breast with an aesthetically pleasing form that matches between the two sides. In unilateral cases, this may often necessitate the need for a procedure on the contralateral side in order to restore symmetry. In bilateral cases, symmetry between the reconstructed breasts is often easier to achieve. Dr. Mitchell will discuss this with you in detail during your evaluation and subsequent visits.
Final Touches
Some women are happy to have a breast mound that in a bra gives them adequate shape and form. Some, however, also desire to undergo reconstruction of both the nipple and areola, which was removed during the mastectomy. Nipple reconstruction is typically performed within the office. The procedure takes approximately one hour.
In this procedure, Dr. Mitchell rearranges the skin on the breast in order to recreate a three-dimensional nipple that sticks up off the breast. This is typically performed one month following the placement of the permanent silicone implants or after reconstruction using autologous tissue. After the nipple reconstruction has healed properly, a tattoo is applied within the office to create the areola. This is typically one month after the nipple is recreated.
Contact us today or call at 402-483-8530 to schedule a breast reconstruction consultation. Dr. Mitchell will meet with you privately to decide if this procedure is right for you.
