Breast Reconstruction at Finesse Plastic Surgery
One in eight women will hear she has breast cancer during their lifetime. Treatment options include surgery, radiation, and chemotherapy. At Finesse Plastic Surgery, our aim is to empower patients to be a part of the decision-making process, especially when it comes to breast reconstruction. We will discuss your goals and develop a personalized treatment plan that helps you achieve them. With modern reconstruction techniques, we can rebuild and reshape your breasts, using implants or your own tissue (flaps). Many patients elect to begin their reconstruction the same day as their cancer treatment, while others choose to delay this step or not proceed with reconstruction at all. We’re committed to giving you the best results possible, so you can feel whole, feminine, and confident.
In order to ensure optimal results, Finesse Plastic Surgery works closely with a team of professionals through every stage of breast cancer treatment. We work closely with our partners at Breastlink to coordinate care and make sure aesthetics are a factor when planning treatment. We collaborate with breast surgeons and oncologists to preserve continuity of care during breast reconstruction, and work with restorative tattoo artists to ensure superior results during the final stages of reconstruction as well. Patient preferences are always our priority. We will take time to discuss your goals and develop a personalized treatment plan that helps you achieve them.
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Reconstruction Options
Lumpectomy
Nearly half of all patients diagnosed with breast cancer undergo lumpectomy (partial mastectomy). This procedure removes the cancer while preserving your natural breast shape. Some patients are happy with the aesthetic outcome of their surgery and decide not to have their breasts reconstructed, while others (up to 30 percent according to studies) are unhappy with the results. Their breasts may no longer be the same size or they may have contour depression where the cancer was removed. For these patients, there are several reconstructive options available to help restore their appearance.
Oncoplastic Breast Reduction
Patients who are candidates for breast reduction surgery or patients who in general would appreciate a smaller breast size are often excellent candidates for "oncoplastic" breast reduction. Ideal candidates for are women who experience neck pain, back pain, grooves in their shoulders from bra straps or rashes under their breasts. Oncoplastic breast reduction surgery is divided into two stages. During the first stage, the breast surgeon removes the cancer. During the second stage, the plastic surgeon steps in and removes additional breast tissue from the infected breast and the other breast in order to create symmetry. Reducing the size of the breasts not only relieves the patient’s back and neck pain, it often results in larger tumor margins, potentially increasing the effectiveness of the cancer surgery.
Oncoplastic Breast Lift
Breast lift surgery, also called mastopexy, is typically performed on patients who are pleased with the size of their breasts, but are unhappy with their appearance. These patients often feel that their nipples are too low or their breasts look “deflated.”A breast lift contours the breasts and places the nipples higher, resulting in a more youthful shape. Oncoplastic breast lift surgery is also divided into two stages. During the first stage, the breast surgeon removes the cancer, then during the second stage, the plastic surgeon tailors the remaining skin and tissue to give the breasts a more youthful appearance while preserving breast volume. Little to no breast tissue is removed.
Fat Grafting
Women with small tumors that create minimal deformities may want to consider a less invasive option, such as fat grafting. This procedure transfers fat cells from one part of the body to the breasts in order to improve their overall shape and contour. The fat is collected using liposuction, usually from the abdomen or thighs. The fat is then processed and injected into the breasts to restore their natural contours. Because the fat has no blood supply, it relies on the surrounding tissue to keep it alive. For this reason, only a limited amount can be injected at any given time. Generally, 50-60 percent of the transferred fat survives, and two or three treatments may be necessary to achieve the desired result. Though this procedure uses liposuction, fat reduction is not its focus. Only small amounts of fat are removed, so rarely see the drastic changes as they would from a cosmetic liposuction procedure.
Mastectomy
If a patient’s breast cancer is widespread or likely to recur, doctors normally recommend a mastectomy – the removal of one or both breasts. Though a small number of women decide not to have their breasts reconstructed after their mastectomy, the vast majority of women do. In some cases, patients decide to delay their reconstruction for months or years after their mastectomy surgery. In other cases, the plastic surgeon may decide the patient is not a safe candidate for immediate reconstruction. Active smokers, the morbidly obese, and poorly controlled diabetics are typically not offered immediate reconstruction because they usually suffer higher rate of complications.
Two-Stage Implant Reconstruction
Worldwide, implant-based reconstruction is the most common reconstructive surgery for women who have received a mastectomy. Implant reconstruction typically requires two surgeries. During the first, a tissue expander is placed under the skin and muscle. A tissue expander looks like a deflated implant and is used to stretch the tissue out. To hold the tissue expander in place, the surgeon may place a soft tissue sling (“acellular dermal matrix”) between the pectoralis muscle and the bottom of the breast, to act like an internal bra.
The process of expansion begins in the operating room. After the expander is placed, fluid is injected through a self-sealing port built into the side. A small needle is passed through the skin, into the port, and saline (the same fluid in an IV bag) is injected. Over time, this creates a pocket that will accommodate the permanent breast implant. The volume that the surgeon is able to achieve during this initial expansion in the operating room will depend on how healthy the skin looks following the mastectomy. The better the skin looks, the more fluid the surgeon will place. In most cases, expansion is possible the day of surgery, with some patients getting up to 1/3 of their goal volume. During the first 2-3 weeks following surgery, no expansion will occur, to give the skin a chance to recover. When the skin is ready, expansion will resume. Every week or two, more saline will be injected until you reach your desired breast size, which may be the same size, smaller or larger than your current breasts. The expansion takes only a few minutes and for most patients there is minimal discomfort.
The second surgery normally takes place 2-3 months after the final expansion. The expander is removed and replaced with a permanent implant. The second surgery is typically an outpatient procedure because it causes less discomfort than the first surgery and patients recover more quickly.
Direct-to-Implant reconstruction
In some circumstances, the surgeon may be able to use implants to reconstruct the breasts in one step, without the use of a tissue expander. Not all patients are candidates, however. Healthy women with small breasts who want to stay the same cup size or go smaller may be candidates. Even if you are a candidate, the plastic surgeon may still decide to place expanders in the operating room if there is concern about the blood supply to the breast skin. Because the blood supply to the skin is significantly compromised during a mastectomy, excess tension on the skin immediately may cause it to die, resulting in exposure of the implant and additional surgeries, such as removal of the implant or a complex flap reconstruction.
Autologous breast reconstruction/flap surgery
During autologous breast reconstruction, tissue is taken from one body part and transferred to the breasts. The tissue, called a “flap,” usually comes from the abdomen and back.
A. The back – Latissimus Flap
The latissimus dorsi is a large, triangular muscle that covers most of the back and helps extend the shoulder backwards. Although it is large, its absence does not significantly affect patients who use this muscle to reconstruct their breasts. During this procedure, the muscle and an overlying ellipse of skin and fat are elevated, leaving only the blood supply attached. The flap of skin, fat, and muscle is passed through a tunnel to the chest, replacing skin and contributing some volume. In most patients, the flap volume is small, so surgeons use an implant to achieve the desired volume. The procedure is generally well-tolerated and patient satisfaction is high. Patients typically stay in the hospital 1-2 nights and take 4-6 weeks off work to recover. Patients normally return to their full level of physical activity after they recover, even when flaps on both sides are used.
B. The Abdomen –TRAM Flap
This procedure is ideally suited for patients who are good candidates for a tummy tuck procedure, have large breasts, or are overweight. It can take up to four hours to reconstruct a single breast using this procedure, and up to seven hours to reconstruct both. Patients usually stay in the hospital 3-5 days, and typically require six or more weeks off work to recover. There is a possibility some of the transferred skin and fat may be lost if the circulation is inadequate to maintain the whole flap. Total flap loss is very rare – less than one percent.
This procedure leaves a long scar in the lower abdomen in the same location as a C-section scar. The surgery also compromises one or both of the rectus (“six pack”) muscles, which decreases core strength.
C. The Abdomen – DIEP Flap
Like the TRAM flap, this procedure utilizes skin and fat from the lower abdomen. However, unlike the TRAM flap, no portion of the abdominal muscles is removed and core strength is unaffected. This operation requires expertise in microvascular surgery because the blood vessels supplying the flap are attached to blood vessels around the breast. Candidates for this operation must have sufficient abdominal skin and fat to reconstruct the breast and achieve their desired size.
D. The Buttocks: SGAP/IGAP flaps
SGAP and IGAP flaps utilize skin and fat from the buttocks and don’t compromise muscle function, like DIEP flaps. Candidates for SGAP flaps are patients interested in using their own tissues for breast reconstruction, but do not have enough skin and fat in the abdominal area. Other candidates are women who have already had a TRAM or DIEP flap performed on one side and are interested in reconstructing of their other breast using their own tissue. The postoperative course is similar to that of the DIEP flap. It requires approximately 3 days of hospitalization, so the patient can recover and the surgeon can monitor the flap.
E. Fat Grafting
Fat grafting uses fat from one part of the body to add volume to another. Fat is collected from the abdomen or thighs using liposuction and then injected into the breasts to correct irregularities or create a more natural transition from the chest to upper pole of the breasts. Fat grafting is may be performed during an implant reconstruction, when the expanders are removed and permanent implants are placed. It may also be performed to correct irregularities that develop after surgery. Only small volumes of fat are removed during this procedure, so even though the areas where fat is removed will look a little flatter, patients shouldn’t expect the dramatic results they see when a cosmetic liposuction is performed. However, surgeons frequently can perform additional cosmetic liposuction procedures during second stage or revision breast reconstruction, for patients interested in body contouring.
Nipple and Areola Reconstruction
If the nipple is removed during cancer surgery ("skin sparing mastectomy"), it can be reconstructed. Most nipple reconstructions occur occurs 3-4 months after the surgeon places the permanent implants. The procedure takes about 45 minutes and can be done in the office or operating room. During nipple reconstruction, the surgeon takes skin from the reconstructed breast, lifts it up, and shapes it into a nipple that projects out from the breast. Three months after the nipple is reconstructed, the patient will be referred to a restorative tattoo artist who specializes in breast cancer patients. She will add color to the new nipple and create an areola. Patients who do not want a nipple that projects can elect to skip the nipple reconstruction and just get a tattoo. With new 3-D tattoo techniques, patients can achieve incredibly realistic results.
Revision of Reconstruction
Our goal is to help our patients achieve the best results possible and have those results last as long as possible. Statistics show that up to half of all patients who have a breast reconstruction will have some type of revision surgery within 7-10 years to improve the result. These surgeries are normally outpatient procedures performed and usually involve a shorter recovery time than the initial surgery. Revision reconstruction should be covered by your health insurance plan and is protected by the Women’s Heath and Cancer Rights Act (WHCRA).
Frequently Asked Questions
Lumpectomy with Oncoplastic Reconstruction: Patients go home the day of surgery and come back for a follow up in the office 1-3 days after surgery. The follow up appointment will be made for you when your surgery is scheduled.
Mastectomy with Tissue Expander/Implant Reconstruction: Once the post-operative pain is manageable you will be able to go home. This may be the same day as surgery or the following day. Your first follow up appointment in the office will be 3-5 days after surgery.
Mastectomy with Flap Reconstruction: Patients stay in the hospital for 1-2 days following a latissimus flap. After abdominal flaps (TRAMs and DIEPs), patients usually stay for 3-5 days.
If you are experiencing shortness of breath or chest pain, this may be a sign of a medical emergency and you should call our office or 911 immediately. Any of the following symptoms should also be reported to our office right away:
- Fever over 101.0F
- Chills
- Redness or bruising on the skin that spreads to a progressively larger area
- Swelling or change in size of one of the breasts
- A sudden increase in drainage
- Uncontrolled nausea or vomiting
You should also call us if your pain getting worse or is not relieved by the pain medication. If in doubt, call us. There is always a doctor on call, 24 hours a day, including weekends.
Pain levels vary from patient to patient, but most patients report tightness and numbness in the chest, as well as pain and stiffness at the bottom of the breasts and under the arms. You may experience shooting pains or tingling sensations on the insides of the arms, and it may be difficult to raise your arms over your head or extend your arms fully.
Take the pain medication as prescribed. Many of our patients take it regularly for the first few days and then gradually decrease the frequency and amount of pain medication they use. We often prescribe Percocet and Valium. Percocet relieves pain, while Valium helps with muscle spasms and tightness. These medications can be taken together, but not at the same time. Both of these medications can cause sedation, so space them out by at least 30 minutes if you are taking them together, and do not take either of them if you feel drowsy or sedated. Please note that Percocet is a controlled substance and must be filled with the original written prescription. If you need another prescription, you must pick it up in person at our office.
What about constipation caused by the pain medications?This is a common symptom of continued use of narcotic pain medication. We advise you to use a stool softener daily until you stop the narcotics. We recommend starting with over the counter Colace, twice daily. If constipation occurs, take over the counter Dulcolax – 2 tablets at night. If this is not effective, the dose may need to be increased; refer to the package instructions. Drinking plenty of fluids and eating a high fiber diet will also help ease constipation. Some patients find prune juice helpful as well. If you go more than 6 days without a bowel movement, you may require the use of an enema.
When should I start the antibiotics and how long do I keep taking them?You should start your antibiotics the evening you get home from surgery and continue them until you are told to stop. Patients who have drains in place will remain on antibiotics until they are all removed. If you run out of antibiotics while your drains are still in, you will need to contact our office for a refill. You will stop taking antibiotics 48 hours after the last drain is removed.
No reconstruction: If we do nothing to reconstruct the breast, you can expect to take a week off work to recover.
Tissue expander reconstruction: Most of our patients take 4-6 weeks off work to recover. Many of our patients are able to work on a computer from home within a few days of surgery. It is usually 2-3 weeks before patients start feeling back to normal.
Flap surgery: Patients who have flap reconstruction typically stay in the hospital for 2-3 days.
Patients who have a mastectomy will be given a prescription for two postoperative camisoles. You can pick these up at the shop in the lobby of the Breastlink Center in Orange, Ginny’s at St. Joseph’s Cancer Center, or Nordstrom’s. Bring one with you to the hospital to wear home. You will also want to bring a loose-fitting layer of clothing to wear over the camisole. Please make sure that during the first 2 weeks after surgery all garments you wear are loose fitting. Tight clothing may interfere with the blood supply to the healing tissues and result in skin loss.
Patients who have a lumpectomy with an oncoplastic procedure will be placed in a bra at the end of the procedure. This garment is provided by the hospital and can be worn for the first several weeks after surgery before you transition back into your own bras.
This will depend on the amount of fluid that comes out of each drain. You will empty the drains 2 or 3 times a day, recording the fluid output in milliliters (CCs). You will keep a record of the output that you should bring to each of your appointments. Typically, the drains are removed after 1-3 weeks, when the drainage is less than 30 milliliters in a 24-hour period for two consecutive days.
Use this machine for approximately 2 weeks after surgery, at night when you are sleeping and during the day when you are resting. This machine helps prevent the formation of blood clots. You do not need to bring this machine to the hospital; they will provide a similar machine for you.
Initially, you will need to come in to the office at least once a week, until the drains are removed and your skin and incisions are healed. During each visit, your care team will tell you when to need to return again and will schedule your next appointment. Once your skin and incisions are fully healed, your visits will become less frequent.
Your surgeon will tell you when you can start showering. Depending on the incision dressings and closure, most patients can start showing again two days after surgery. If you have drains, we ask that you only shower for five minutes or less. The surgical site may get wet briefly and should be dried thoroughly afterwards with a clean towel. Do NOT use a hairdryer on the surgical site, as your sensation changes after surgery and there is a risk of burning or overheating the skin. Drains should be supported while you shower. You can clip them to a necklace (our office can provide you with a lanyard) or pass the loops through an old belt that you don’t mind getting wet.
After your incisions are healed, you will need to wait eight more weeks before submerging or soaking the surgical area. This means you will usually need to wait 10-12 weeks after surgery before bathing or swimming. Your care team will give you specific instructions.
You should avoid lifting anything heavier than five pounds and avoid any upper body exercise during the first 3-4 weeks after surgery. Also avoid any strenuous pushing or pulling movements during this period, such pushing open a heavy door. The range of motion of your arms will probably be limited to some extent. Listen to your body and stop any activity or movement that causes pain.
Start stretching exercises after all the drains are removed. These are outlined on a handout that you will be given in the office. Be patient with your body while it’s healing and expect slow progress regaining full range of motion in your arms. If you are having trouble making progress with range of motion or strength, let us know, and we will refer you to a physical therapist.
Walking is encouraged. You will need to take it easy initially and increase your activity gradually, but walking several times a day will help you regain your strength and energy, as well as being an important prevention strategy for avoiding surgical complications, such as blood clots. A good rule of thumb is that if you are sweating, you are doing too much.
Patients can start taking these medications and supplements after all the drains have been removed.
We will start adding fluid to the tissue expanders after the incisions and skin are fully healed. This can be as early as two weeks after surgery, but may be later. We usually do the expansions at 1-3 week intervals, based on patient comfort.
How does expansion work?We will identify the port in your expander by using a specialized magnet and then place a fine needle through your skin into the tissue expander port. Once the needle is in place, a small volume of saline will be injected in to the expander.
Are the expansions painful?Most patients have numbness in the chest after surgery and do not feel pain at the time of the procedure. A few hours after the procedure, some patients report tightness and discomfort in the chest muscles. This may last a few days, but will gradually improve as your body adjusts to the expansion. Patients are typically expanded about 50-150 cc per visit. Amounts will be determined based on the patient’s comfort level
For pain after expansions, take Valium as prescribed. It is a muscle relaxant, and will help releive tightness and discomfort in the chest muscle after the expansion.
How many expansions will I need? How will I know when I’m done?With each expansion, we will tell you to pay attention to how the new volume feels, and how you fit into your clothing and bras. You will play a large role in determining when the expansions are done.
Breast reconstruction should not delay chemotherapy. If patients experience a complication such as delayed wound healing or infection, chemotherapy may be postponed for a short period of time. We work closely with the medical oncologists and will typically "clear you" to start chemotherapy in the time frame they recommend for your cancer treatment.
Patients typically start radiation therapy two months after their cancer surgery. Patients who have a mastectomy with expander reconstruction will first need to complete the expansion phase. This is normally completed within two months of surgery. In some cases, the expansion may go on for an additional 2-4 weeks, but this will not influence your cancer treatment. We will communicate with your radiation oncologist to ensure that any brief delay will not affect the success of your radiation therapy.
For most patients, the second surgery happens 3-5 months after the initial mastectomy. Patients who require postoperative radiation therapy or chemotherapy will have the second surgery delayed until their treatment is complete. The second stage of reconstruction, where the tissue expanders are removed and the implants are placed, is generally an outpatient procedure with a much shorter recovery time than with the initial mastectomy and reconstruction. You may or may not have drains after the second surgery. Should you have drains, they are usually removed within 5-7 days. Most patients report that there is less pain and “down-time” associated with the second surgery.
How long do breast implants last?It varies from patient to patient. In our practice, we have had patients who have their first implant problem within one year of surgery. We have also cared for patients who have had the same implants for over twenty years. Studies have demonstrated that there is a 93 percent chance your implants will still be intact 10 years after surgery.
What are the different implant choices?Implants come in various shapes and sizes. We will discuss your goals and work with you to choose the proper fill material, shape, size, and texture for you. Fill options include silicone or saline (salt water). We prefer to use silicone when possible because it tends to give a more natural feel and appearance.
The term “gummy bear” implants refers to modern, form-stable implants that look like a gummy bear when cut (the silicone is firmer and doesn't spill out of the shell). Despite the name, gummy bear implants are not as firm as their namesake candy. We use teardrop-shaped (“anatomic”) and round implants. In reconstructive breast surgery, anatomic implants may look more natural in some women. Implants come in smooth and textured forms. Most round implants we use are smooth and most anatomic implants are textured. The anatomic implants are textured so they do not spin out of position.
Is silicone safe?In 1992, the FDA placed a moratorium on the use of silicone implants because they were concerned about possible safety issues. Meanwhile, the rest of the world continued to use them. In 2006, the FDA reconsidered the use of silicone implants for cosmetic and reconstructive surgery. They concluded that the data gathered from 1992-2006 convincingly demonstrated that silicone was safe. Eight other studies performed worldwide supported this conclusion.
Today’s silicone implants are far superior to the implants used in the 80’s and 90’s. The silicone used is similar to the texture of Jell-O. Because of this, it is much more likely to stay inside the shell. Even if the implants were to rupture, the silicone is very unlikely to spread beyond your breasts.
For more information about implant rupture, please read our article: What if Silicone Breast Implants Rupture.
