Breast Reconstruction

Handling breast cancer often requires surgical removing of breast tissue.
This is one of the hardest circumstances a woman has to deal with. To face this condition, the surgeon must create a new breast, as similar possible as the old one, according to each patient’s condition. Most patients, who have undergone a mastectomy and reconstruction, feel better when they have recovered their lost body shape and femininity.

The reconstructive surgeon is a physician that wants to help you to resume your normal life.

What is breast reconstruction?

The answer for many tumoral breast diseases frequently is the breast tissue removal. As a consequence, the patient’s anatomy suffers a modification that may be partial or complete, and affects the shape and function of the treated organs. In these cases, the oncologist and the plastic surgeon must work together to ensure the closest possible anatomical reconstruction.

Mammary reconstruction pursues to restore the external appearance of the breasts through different reconstructive surgical techniques improving patient's quality of life.

In United States, immediate mammary reconstruction after a mastectomy has become the rule. Many are the benefits deriving from the simultaneous breast reconstruction. The immediate treatment helps woman to face the emotional shock from cancer and makes easier the surgeon´s work, as in the mastectomy surgery it is possible and better to preserve tissue to reconstruct the organ than wait for a more complex surgery later. However, the possibility of immediate reconstruction after the removal depends on the stage of the disease.

The devastating emotional effects of mastectomy may be lessened through an early reconstruction. Nearly every person who has had a mastectomy is a candidate for some method of breast reconstruction. Breast reconstruction during mastectomy can reduce the emotional impact of losing the organ.

The mammary reconstruction patient - How do I know if I am a candidate for breast reconstruction surgery?

The oncologist frequently refers the patient to the plastic surgeon, when she has not been treated immediately after mastectomy. For breast reconstruction the cancerous lesion must have been completely removed. During consultation, after a thorough physical examination, the doctor may evaluate the possibility of mammary reconstruction.

Most common women reasons for mammary reconstruction after a mastectomy include:

1 Feeling complete again.
2 Recovering femininity.
3 Avoiding the use of external prosthesis.
4 Being able to use different clothes.

Psychological and emotional effects of breast reconstruction

For women the emotional and psychological impact from mastectomy is the consequence of a self-image anatomical alteration. Breasts are organs symbol of femininity, sexuality, and fertility. The psychological trauma is therefore centered on the patient’s body self-perception that may reach significant levels.

Most women who have had mastectomy suffer a very traumatic experience. Diagnosis of breast cancer changes woman´s life, and it is a major matter of concern and uncertainty. But dealing with mastectomy may be even a most painful event. This is a very difficult process which depends more of a positive self-concept than the body image. The patient´s partner support seems to be a decisive factor in this process.

Despite the emotional and psychological complications of this process, the patient should know that reconstruction after mastectomy is possible in nearly all cases. Surgeon`s commitment is to perform the appropriate technique for the most realistic results. Today´s post-mastectomy breast reconstruction employs a variety of plastic surgery techniques in an effort to restore a breast as closely as possible to former appearance. The procedure may be performed using free flaps, cutaneous flaps, muscular or musculocutaneous flaps. However, it is important for patients to understand that nothing compares to mother nature´s work. While it is possible to achieve reasonable aesthetical results, these results will never reach the perfection of the original organ. A woman who wants to have a breast reconstruction must be realistic about what to expect from reconstruction. For breast reconstruction patients, the medical oncologists and psychologists work in conjunction with the plastic surgeon to plan patient management.

What is a flap? What is a pedicled flap?

What are expanders?

When your doctor talks about expanders, he means a technique that allows the gradual stretching of the chest tissue to create space for placement of a permanent implant later. This surgery method is known as breast reconstruction with tissue expanders and may involve two phases. In a first procedure, an implant tissue expander is placed beneath the major pectoralis muscle and over the Inframammary fold. This method is performed through a transaxillary approach. Once the tissue expander is placed, through a tiny valve the surgeon injects a saline solution.

It requires many visits to the surgeon after tissue expander placement to slowly fill the device through the internal valve. The expansion is performed under sterile conditions and the tissue expander is slowly inflated until it reaches the right size. The expander is left in place for approximately two months and a half, or for the time that may be required.

In the second surgical procedure, the expander is removed through the same incision it was inserted through, and the adequate size silicone gel implant is inserted. The aim is to reach as closely as possible the remaining natural breast size.

The nipple-areola complex reconstruction surgery is scheduled a few months later.

What is the expander like?

Surgical Procedure / Breast Reconstruction

Breast Reconstruction Surgery Preparation

It is considered you are in surgery from the moment you arrive to the surgical area until you have sufficiently recovered from anesthesia. Before surgery, your surgeon, anesthesiologist and the nursing staff will meet you in the pre-operative area, to discuss your medical condition and answer your questions.

The anesthesia

What kind of anesthesia is used for breast reconstruction surgery?

Breast reconstruction surgery is performed under general anesthesia with intravenous induction and inhalation anesthesia. You will sleep through the entire operation, feeling no pain and remaining absolutely relaxed.

The section about Anesthesia provides complete information on this medical practice along with recommendations and instructions.

How long does breast reconstruction surgery take?

Surgery time for breast reconstruction depends on the technique used, whether it is performed along with mastectomy or post-mastectomy. According to your case, your doctor will inform you approximate time of surgery.

Patient preparation before surgery

You will be asked to remove your underarm hair by using depilatory cream instead of razor. The use of razors prior to surgery increases the incidence of wound infection.
Patient preparation includes treating the surgical site before surgery, using appropriate antiseptic agents for skin preparation.
In the operating room the intravenous therapy or IV will be initiated. The IV is the giving of liquid substances directly into a vein. Through a needle you will receive saline solution, anesthesia, and other medications you may need during surgery.
Once you have moved over the operating table, you will be placed in a supine position with arms in abduction. This means that you will be lying down with the face up and open arms. The elbows are cushioned with pillows to prevent any postoperative discomfort.

Surgical Procedure - Breast Reconstruction

Surgical breast reconstruction after mastectomy consists of two general types of procedures: those involving expanders or implants, and those using your own tissue flap or the person’s own tissue (Autologous) to replace the loss tissue.

You have the following options to consider when choosing a type of breast reconstruction:

Temporary tissue expander subsequently replaced for a permanent implant.
Permanent tissue expander requiring only valve removal.
Latissimus dorsi musculocutaneous flap with implant or expander.
Autologous flap of the latissimus dorsi muscle.
Autologous flap of the transverse rectus abdominis myocutaneous (TRAM).
Free tissue transfer, also called free flap for implant to be attached in the chest. This requires the use of a microscope (microsurgery).

Since mastectomy involves loss of breast tissue, specifics of the breast reconstruction surgery are unique for each patient. Your surgeon will advise you on the type of breast reconstruction or combination of procedures that are most suitable for you. During the procedure selection your doctor will observe the following aspects:

Laxity and thickness of the remaining chest skin.
Condition of the pectoralis and serratus muscles.
Size of the opposite breast.
Availability of flap donor sites in other parts of the body

Breast reconstruction procedures - What types of procedures do exist for breast reconstruction?

Esta técnica o conjunto de procedimientos supone la utilización de tejido autógeno, es decir, del mismo paciente y se emplea en aquellas pacientes con insuficiente tejido mamario. Si bien la complejidad que involucra este tipo de tratamiento, amplía el tiempo de permanencia en quirófano, así mismo, las técnicas de colgajos ofrecen al cirujano la ventaja de trabajar con el tejido del propio paciente, que refleja sus mismas características y además se adapta mejor. El volumen de las mamas es calculado preoperatoriamente y el diseño del colgajo se ajusta a la extensión que refleja el área a tratar, posterior a la mastectomía.

1. Tissue flap procedures
This technique uses autologous tissue, which is your own tissue, to replace this in insufficient breast tissue cases. Although tissue flap procedure requires more time in surgery, this procedure provides the advantage of using the same patient´s tissue. This technique rebuilds the breast so that it is about the same size and shape as it was before mastectomy, and the flap size is adapted to the breast reconstruction site. Pedicled flap

What is a flap? What is a pedicled flap?

A flap is a piece of tissue that is transplanted from one area of the body to another. This flap contains blood vessels, skin, subcutaneous tissue and muscle. In the pedicled flap, tissue is transferred maintaining its original vascular pedicle. The tissue is left attached to the donor site and simply transposed to a new location keeping the “pedicle” intact as a conduit to supply the tissue with blood.

Free flap

In contrast to the pedicled flap, the free flap or free tissue transfer describes the complete movement of tissue from one site on the body to another. Tissue, along with its blood supply, is detached from the donor site and transferred to the recipient site. This requires the use of a microscope (microsurgery) to connect the tiny vessels in the recipient site.

These surgery procedures involve a careful planning, development and transference technique.

Types of breast reconstruction using flaps

Latissimus dorsi musculocutaneous flap with implant or expander.
In The latissimus dorsi breast reconstruction method is a tissue flap procedure in which the surgeon moves muscle and skin from the patient´s upper back or latissimus dorsi muscle to the reconstruction site. An implant may be placed during the procedure or later in another procedure. The advantages with this type of reconstruction procedure are that the flap keeps its original blood supply and also, that this method provides a more natural form to the reconstructed breast. However, patient should understand that this procedure can produce considerable permanent scars on the back and around the new breast.

Autologous flap of the transverse rectus abdominis muscle (TRAM)

The autologous flap of the transverse rectus abdominis muscle, also called TRAM flap is a tissue flap procedure that uses muscle, subcutaneous tissue and skin from the abdomen of the patient to create a new breast. The TRAM flap is tunneled under the skin to reach the inframammary fold. However, patient should understand that this procedure can produce considerable permanent scars on the abdomen area and around the new breast.

Free tissue transfer or free flap
Free tissue transfer, also called free flap method, has become a frequently used option in breast reconstruction after mastectomy. If performed along with mastectomy, the free flap procedure provides a better blood supply and therefore a lower incidence of necrosis. In a free flap reconstruction, tissue from the abdomen or the buttocks is transferred to the breast area. The tissue is completely removed from the donor site and reconnected to a new blood supply using the microscope.

2. Breast reconstruction with implants
Breast reconstruction with implants alone depends on the presence of enough soft tissue so a complete coverage of the implant can be obtained. Submuscular implant placement is associated with a lower incidence of capsular contracture in comparison to the subcutaneous implant placement.

3. Breast reconstruction with expanders

What are expanders?

When your doctor talks about expanders, he means a technique that allows the gradual stretching of the chest tissue to create space for placement of a permanent implant later. This surgery method is known as breast reconstruction with tissue expanders and may involve two phases. In a first procedure, an implant tissue expander is placed beneath the major pectoralis muscle and over the Inframammary fold. This method is performed through a transaxillary approach. Once the tissue expander is placed, through a tiny valve the surgeon injects a saline solution. It requires many visits to the surgeon after tissue expander placement to slowly fill the device through the internal valve. The expansion is performed under sterile conditions and the tissue expander is slowly inflated until it reaches the right size. The expander is left in place for approximately two months and a half, or for the time that may be required.

In the second surgical procedure, the expander is removed through the same incision it was inserted through, and the adequate size silicone gel implant is inserted. The aim is to reach as closely as possible the remaining natural breast size.

The nipple-areola complex reconstruction surgery is scheduled a few months later.

What is the expander like?

There are different types of tissue expanders.The most commonly used is the tissue expander with valve, like a balloon, which is equipped with a tiny valve, through which saline can be pumped. The valve allows controlling the expander filling. Hypodermic needles are used to introduce the saline into the expander.

Nipple-areola complex
How is the nipple-areola complex reconstruction done?
Dr. Nieto considers that nipple-areola complex reconstruction enhances the realism of the breast reconstruction. Some patients may only want to have the shape of the breasts. However, the surgeon has the medical commitment to perform the best possible treatment that more closely resembles the natural shape of the breast. Nipple-areola reconstruction is essential for both physical and psychological reasons. Though, it is important patient understands that even in the most skilled hands, the reconstructed breast will never be exactly like the original.

The nipple-areola reconstruction represents the final stage of a complete breast reconstruction. Construction of the nipple-areola complex usually is performed 2-6 months following reconstruction, when the breast has taken its final shape and position.

Surgery techniques for nipple-areola complex reconstruction

What techniques are used in the reconstruction of the nipple-areola complex?

A variety of tissues can be grafted to the breast mound to create a new nipple.

The nipple-areola complex reconstruction techniques depend on the type of tissue used for reconstruction:

Nipple division of the remaining breast. Nipple reconstruction may involve nipple sharing with the contralateral breast.
Labia minora and labia majora tissues. Skin grafts are taken from other parts of the body in order to reconstruct the nipple-areola complex. This reconstructive technique uses grafts from the genital area. Usually, a graft from the labia majora is used to reconstruct the areola and a graft from the labia minora for the nipple. The skin quality from these tissues provides satisfying results in the nipple-areola complex reconstruction.
Auricular cartilage. Auricular and post-auricular cartilages are used to reconstruct the nipple-areola complex.
Buccal mucosa - When a light pink color of the nipple-areola complex is desired, grafts from the buccal mucosa can be used to reconstruct this area. However, this technique is not frequently used.
Areola tattooing - Many women now opt for nipple-areolar reconstruction by tattooing to simulate areolar shadow. The permanent areola repigmentation and nipple restoration technique employs cosmetically tattooed micropigmentation as a way to restore the natural beauty of breasts. This method provides a very satisfactory replication of the areola.

Treatment of the contralateral breast

Many patients find that breast reconstruction hardly produces a breast that is symmetrical with the opposite breast. Therefore, alteration of the opposite breast to achieve symmetry may be required.

The options for the contralateral breast treatment include the usual surgery techniques for breasts.

In those patients at risk of developing breast cancer in the opposite breast, a prophylactic mastectomy with breast implant reconstruction may be considered, with subsequent submuscular implant placement.

Postoperative Care - What care should I take following breast reconstruction?

Part of the success of surgery depends on the postoperative care. It is very important to follow the surgeon´s recommendations to reach the desired outcome. Dr. Nieto closely observes her patient´s convalescence and healing. Please do not hesitate to contact her if you have questions or concerns. Written instructions will be given for your postoperative care to you and your family.

Postoperative recommendations – Breast reconstruction surgery

1- A surgical or soft bra must be worn for the following 2 weeks both day and night. Please do not remove it.

2 - Your surgeon will give you specific postoperative instructions on how to care for yourself according to the type of breast reconstruction procedure that has been performed.

3 - Drainage tubes will be removed usually after 3-8 days following surgery.

4 - Sutures are removed within the first two weeks following the surgery.

5 - You must rest at home for the first 48 hours following surgery.

6 - You will be given a prescription with antibiotics and pain medication to minimize any discomfort.

7 - Inform immediately to your physician if you develop an unexpected reaction to the prescribed medication.

8 - You must make arrangements for a responsible adult friend or family member to take you home and take care of you during your convalescence.

9 - You have to sleep on your back and keep your head elevated. If you have back or buttocks wounds, you will be given specific instructions for wound care.

10 - Avoid taking any medication that has not been prescribed by your doctor, especially aspirin (acetyl salicylic acid) or aspirin-like products (Ibuprofen, Advil, Motrin or Aleve). These medicines have anticoagulant adverse effects and may increase the risk of bleeding or scarring complications.

11 - You should expect some bruising and swelling as a natural part of reconstruction surgery. This condition will fade within days after surgery.

12 - Avoid any activity for 2 weeks after surgery.

13 - Do not remove your bandages or surgical bra.

14 - Do not raise your arms above your head for two weeks.

15 - You will not be able to drive a vehicle for the following weeks.

16 - Lifting heavy things, animals or children may affect the area of surgery. You must avoid any activity that increases risk of hitting.

17 - Do not allow sutures or dressing to get wet until they have been removed.

18 - You must avoid shaving the axillary area for 2 weeks after surgery.

19 - Do not lie face down for the first 4 weeks or the time indicated by your physician.

20 - Protect yourself from sun exposure for the following 2 months.

21 - Ask your doctor when you may return to normal activities. Most people resume normal activities after 4 weeks.

22 - Exercise can be resumed 3 months after surgery.

23 - Patient must return to the office for general check up as indicated by the physician.

24 - You should keep examining your breasts as usually.

25 - It is important to understand that complete healing and final results after breast reconstruction surgery may take from several months to one year.

26 - You should see your oncologist for breast exam as usually.

27 - Please inform Dr. Nieto if you present heavy bleeding from the wound, severe pain or chest pressure, high fever (more than 38 degrees), significant redness or severe discomfort.