What is Breast Reconstruction Surgery?
Breast reconstruction, also known as reconstructive mammaplasty or postmastectomy surgery includes a variety of procedures performed to restore the form and shape of the breast, following mastectomy or lumpectomy surgery.
Individual anatomy, aesthetic goals and the need for any postsurgical chemotherapy or radiation are factors which will determine your treatment options. Discussing your cancer surgery with a plastic surgeon before undergoing mastectomy is crucial, because the proposed cancer removal surgery may significantly affect the choices and the results of any type of breast reconstruction.
Treatment Options
A mastectomy may leave insufficient tissue on the chest wall to cover and support a breast implant. Breast reconstruction following radiation therapy with a breast implant may require a flap procedure prior to tissue expansion. During the flap technique, the surgeon repositions your own muscle, fat and skin, creating or covering the breast mound.
Following mastectomy surgery, the most popular option is the tissue expander and implant.
You may also be given the option of deciding between silicone and saline breast implants.
Fat transfer is sometimes used to fill in deformities left by lumpectomies and mastectomies.
In very carefully selected patients, nipple-sparing mastectomy with autologous breast reconstruction provides good results. Your surgeon will tell you if you are an appropriate candidate for this procedure.
You must also consider the following:
The Procedure
General anesthesia is commonly used during your breast reconstruction procedure, although local anesthesia or intravenous sedation may be desirable in some instances.
For your safety during the surgery, various monitors will be used to check your heart, blood pressure, pulse and the amount of oxygen circulating in your blood. Your surgeon will follow the surgical plan discussed with you before surgery.
There are three basic options for breast reconstruction:
Most breast reconstruction methods involve several steps, requiring hospitalization:
This is normally a two-or three-step process.
During the initial procedure, your surgeon shall insert a tissue expander beneath the skin and chest muscle, forming a skin-muscle envelope.
The tissue expander is a modified saline implant with a valve, allowing more saline to be added after the first surgery.
Serial injections of saline through the skin into the valve slowly fill the implant and will subsequently expand your breast mound, over two to six months. The skin-muscle envelope is slowly stretched until it reaches the size you want for the final implant.
During the next stage of the procedure, the expander is removed and replaced with a softer breast implant (saline or silicone).
Sometimes, with saline implants, the expander is kept in place for a longer period, allowing the size of the reconstructed breast to be changed (by increasing or decreasing the amount of saline) without implant removal. With a silicone implant, your breast size cannot be changed without another surgery.
Acellular Dermal Matrix (ADM) is a sheet of tissue that has had its cells removed leaving a framework of collagen and elastin for support and cover. This tissue is specifically prepared to allow your body tissues to gradually grow into this material, ultimately replacing it with your own collagen and blood vessels.
In the case of breast reconstruction:
The Acellular Dermal Matrix acts like a hammock under the mastectomy skin-muscle envelope that supports the tissue expander and can also improve implant placement. This framework of molecules allows your body's cells to grow into the matrix, promoting the regenerative process that takes place during tissue expansion. ADM is usually combined with your chest muscle to cover the expander and maintain its position, and subsequently the position of the implant.
The ADM procedure can be less invasive than other techniques, permitting a larger breast mound to be created at the time of the mastectomy and decreasing the number of office visits needed to reach the desired implant volume. When ADM is used, the expander can often be replaced with the final implant sooner than with other tissue-expansion techniques. In rare circumstances, an expander is not needed and the final implant can be placed into the created hammock at the time of the mastectomy with no further surgery required.
The use of ADM products has enabled plastic surgeons to offer immediate breast reconstruction to more patients and to improve the overall results of breast reconstruction. Whether or not you're a candidate for this technique depends on the quality of your mastectomy skin envelope.
ADM has been available since 1994 and has become popular in breast reconstruction within the past ten years. Different ADM products have different properties and your surgeon may recommend one over the other, depending on your situation.
In certain circumstances, especially if you have radiation-damaged tissues, your surgeon may recommend the use of your own tissue, which can provide coverage or replacement of the damaged tissues with healthy, non irradiated tissue.
Reconstruction using autologous tissue and skin (from your own body) can look and feel more like a natural breast than reconstruction with implants. However, these procedures are more complex and invasive, usually prolong the hospital stay and leave scars in the areas from which the tissue was taken.
Autologous fat grafting or fat transfer is another option for treating radiation-damaged tissues or small areas of contour irregularities.
If you are undergoing immediate breast reconstruction, your surgeon may perform a skin-sparing mastectomy to keep as much of your breast skin intact as possible. The tumor and clean margins (areas free of cancer cells) are removed along with the nipple, areola (pigmented skin surrounding the nipple), fat and other tissue that make up the breast. What remains is much of the skin that surrounded the breast. This skin can then be used to cover a tissue flap or an implant.
The major benefit of a skin-sparing mastectomy is that it avoids using skin from other parts of your body for reconstruction, which can be a different color, texture and thickness compared with natural breast skin.
This is a newer procedure that removes the tumor and clean margins as well as the fat and other tissue in the breast, but leaves the nipple and areola intact, improving the overall look of the reconstructed breast. Not all women are candidates for this and there may be other complications. The nipple will likely lose sensation and some projection. In some cases, the tissues may break down and some or all of the nipple and areola may have to be removed later.
There is still debate as to the risk of leaving the nipple and areola in terms of breast cancer recurrence and this should be discussed with your surgeon, who can assess your individual risk based on your tumor type, family history and other factors.
Nipple reconstruction can be performed when the permanent implant is inserted as the third step in the reconstruction process.
Recreating the nipple and areola gives the reconstructed breast a more natural look and can help hide scars. The nipple is normally recreated by lifting a flap of skin from the reconstructed breast itself and folding it in such a way as to create a small piece of tissue with projection. The areola is usually created by tattooing the area or by grafting skin from the groin area, which has a tone similar to the skin of the areola. The scar from where the skin is taken can be hidden in the bikini line.
Many surgeons prefer to delay the nipple reconstruction until the breast implant has settled into its final position, since this may affect the final position of the reconstructed nipple.
After your procedure is completed, you will be taken into a recovery area, where you will continue to be closely monitored. Occasionally, drainage tubes may be used for a short time following surgery.
Incision Scars
How your scars look when fully healed depends on your age, genetics, the way your body heals, and how your incisions and underlying tissues are sewn together.
Even the best reconstruction cannot eliminate mastectomy scars, but when immediate reconstruction is performed, most of the breast skin is preserved to hold the implant or tissue flap and mastectomy incisions may be hidden in the inframammary fold under the breast or around the areola. When hidden around the areola, the small scars are covered when the areola is tattooed later on.
Flap reconstruction does leave a lengthy scar at the donor site, but scars on the abdomen or buttocks can be hidden by bathing suits and underwear. In some cases, lateral or vertical incisions from the nipple are required to accommodate reconstruction. These scars become less noticeable over time, but never disappear completely.
If you have a mastectomy without reconstruction, your surgeon will remove most of the breast skin through a long incision across your chest. The resulting scar is permanent. If you have reconstruction later, it will be done through this mastectomy scar, which is reopened to accommodate the implant or tissue flap. The mastectomy scar remains on the reconstructed breast, but grows pale over time.
Most breast reconstruction procedures take at least two to six hours to complete but may take longer.
Am I a candidate for surgery?
Some common reasons why you may consider breast reconstruction are:
If you are in good general health, have a positive attitude and realistic expectations, you are most likely a good candidate for this procedure.
Advantages of Breast Reconstruction Surgery:
Disadvantages of Breast Reconstruction Surgery:
Preparation for Surgery
Prior To Your Arrival
Before traveling to Cyprus, as part of your surgery preparation you will complete a detailed specific questionnaire and will submit a recent Chest X-Ray and photographic images of the problem areas which you wish to have treated.
Initial Consultation: Once the images have been received by us, we will schedule a consultation with your chosen surgeon, via Skype or telephone. This will allow you to ask any questions regarding the procedure and will also allow your chosen surgeon to assess your condition and determine your eligibility for your chosen procedure.
During your initial consultation, you will have the opportunity to discuss your cosmetic goals. Your chosen surgeon will evaluate you as a candidate for breast reconstruction and clarify what a breast reconstruction procedure can do for you. Understanding your goals and medical condition, both alternative and additional treatment options may be considered. You should be prepared to discuss your complete medical history. This will include information about:
If you are planning to lose a significant amount of weight, be sure to tell your plastic surgeon. The surgeon may recommend that you stabilize your weight before undergoing surgery.
If you think that you may want to become pregnant in the future, discuss this with your surgeon. Pregnancy can alter breast size in an unpredictable way and could affect the long-term results of your surgery.
Your treatment plan
Based on your goals, physical characteristics, and the surgeon’s training and experience, your surgeon will share recommendations and information with you, at this point including:
In advance of your procedure, your surgeon will ask you to:
Ten days prior to your arrival in Cyprus, you will receive all the necessary pre operative instructions, to prepare yourself both physically and mentally for your chosen cosmetic procedure.
Before your departure to come to Cyprus your records will be reviewed thoroughly by our surgeon. This includes Chest X-ray and a complete medical and surgical history.
Getting your house ready before your surgery
It is also important to get your house ready for after you come home from the hospital. At first it will be harder for you to move around, so arrange your furniture and household items ahead of time to make it easier for you during your rehabilitation.
Remove all your throw rugs or anything on the floor that may cause you to trip.
Move phone and electrical cords close to the walls.
Move necessary personal items you need to reach to shelves and tables that are above your waist level.
Preparation for the hospital
Here are a few things to keep in mind as you pack and prepare for the hospital and recuperation:
Getting dressed in the morning helps you feel better, so be sure to bring some comfortable clothing to the hospital:
Upon Arrival
After traveling to Cyprus, a new set of blood tests, E.C.G and chest X-ray will be taken as well as an in person physical examination. To help detect and track any changes in your breast tissue, your plastic surgeon may also recommend a baseline mammogram before surgery.
The surgeon and anesthetist will meet with you and go through your medical and surgical plan.
During this consultation, your surgeon will discuss your surgical procedure and answer any further questions. Your plastic surgeon will proceed to examine measure and photograph your breasts for your medical record. Your surgeon will also consider and further discuss:
Day before surgery
Your doctor or nurse will give you more instructions based on the type of prep.
You should not eat or drink anything after midnight the evening before your surgery.
Morning of surgery
Bring all your medicines, if any in their original containers with you to the hospital.
You will meet with the anesthesiologist. This doctor will talk to you about general anesthesia. This is a controlled sleep while the surgery is being done so you will not feel any pain or remember the surgery. You will have an IV or intravenous line put in to give you fluid and medicine during your surgery.
Your plastic surgeon shall consult with you once again and shall make any markings he needs on your chest, indicating the incision marks for the proposed procedure.
Recovery after surgery
When you wake up after your surgery, you will be in the recovery room. You will stay there until you are awake and your pain is under control. Most patients return to their room after a couple of hours.
You will receive oxygen through a thin tube called a nasal cannula that rests below your nose. A nurse will be monitoring your body temperature, pulse, blood pressure, and oxygen levels.
You will have some redness and swelling after the surgery. As the anesthesia wears off, you may experience some pain. Typically, the most pain is experienced within the first 48 hours after breast reconstruction surgery. Your pain level will decrease each day and may be effectively treated with various pain medications.
After your breast reconstruction procedure, you shall be placed in a surgical dressing that can include a support bra or garment. You may have drains coming out of your underarms to assist in healing (and from your stomach if you had an autologous reconstruction using tissue from your abdominal area).
If you have an autologous flap breast reconstruction:
If you have a breast implant reconstruction:
Some discoloration and swelling will occur initially, but this will disappear quickly. Most residual swelling will resolve within a month.
Hospital discharge and home instructions
The length of your hospital stay will depend on your general health, the type of operation you have and how your recovery progresses. You may spend anywhere from one to six nights in the hospital. Flap procedures require a stay of 3 - 6 days, depending on the type of flap procedures performed and the blood supply to that flap.
Your incisions will most likely be covered with bandages following flap reconstruction surgery but may simply have been closed with skin glue or tape following implant reconstruction.
Your surgeon may recommend an elastic bandage or a soft bra to minimize swelling and support the reconstructed breast(s).
Make sure you are clear about what is expected of you before you are discharged from the hospital or surgical center. Having a loved one or patient advocate with you is a good way to help make sure you take it all in.
Your diet is slowly increased from ice chips to liquids to solid foods as your intestines start functioning.
Before leaving the hospital, our surgeon and staff will help you adjust to recovery in every way possible. You will receive specific instructions and precautions from your surgeon and nursing staff and they will show you safe techniques of simple activities like getting in and out of bed, bathing, going to the bathroom, managing steps at home and getting in and out of a car.
Life After Surgery
These guidelines give you an overview of what you may expect as part of your care after you leave the hospital. Be sure to follow your doctor’s discharge instructions if they are different from what is listed here. This will include information about wearing compression garments, care of your drains, taking an antibiotic if prescribed and the level and type of activity that is safe. Your surgeon will also provide detailed instructions about the normal symptoms you will experience and any potential signs of complications. It is important to realize that the amount of time it takes for recovery varies greatly among individuals.
Implant-based reconstruction is the simplest and least painful and has the shortest recuperation time. Typically, most women are able to do most routine activities within two to three weeks.
Flap-based procedures, which require surgery in two areas, are more demanding and recuperation varies, depending on which flap procedure was performed.
You shall be instructed to wear a support bra.
You will be permitted to shower between one and seven days after surgery.
If you have external sutures, they will be removed in about a week. If your surgeon used tissue glue or tape, it will fall off on its own in a week or two.
You may be able to return to work within a few days to a week, depending on the nature of your job.
For many flap reconstructions, your restrictions may include not lifting anything heavier than five pounds for up to six weeks. You should refrain from lifting, pulling or pushing anything that causes pain and limit strenuous activity or upper body twisting if this causes discomfort.
Your Activity
It is fairly common to feel weak and tired immediately after discharge from the hospital. The body needs time to recover from the stress of surgery.
Walking is permitted and encouraged beginning the same day of surgery. At home, start short, daily walks and gradually increase the distance you walk.
Going up and down stairs is permitted. Initially, have someone assist you.
You may lift light objects (less than 10lbs.) after your discharge. This may be increased gradually after 2 weeks. If lifting an object causes discomfort, you should discontinue the activity. This restriction helps prevent hernias at the sites of your incisions.
Showers are permitted 2 days after surgery. Wash over your incisions gently with soap and water. Be careful to rinse well. Pat the incisions dry.
Driving is not permitted for 2 weeks after surgery or your first follow-up visit with your surgeon. If you are taking prescription pain medications or narcotics, DO NOT DRIVE.
Sexual intercourse may be resumed as your comfort level permits.
People with sedentary jobs have returned to work as early as 2 weeks postoperatively. A physically demanding job may require 4 weeks before returning to work. This may be determined by you and your employer. Some people have residual fatigue several weeks after surgery.
It is common to feel a lump at the sites of the operation. This lump is a combination of normal fluid and scar tissue forming in this area. It usually goes away slowly over the first month or two following surgery.
Your bowel habits
You may have different bowel habits after your surgery. Loose stools are common for the first week or two after surgery. If you have watery diarrhea, call your surgeon. This may be a sign of a bowel infection. Severe constipation should be avoided. See the section below on medicines for constipation.
Your diet
There are generally no dietary restrictions following cosmetic surgery. Avoid foods that cause diarrhea or digestive discomfort. You will eventually be able to resume your regular diet. A dietary supplement or drink can be used.
Medications
Your medicines: Take the medicines you were taking before surgery, unless your surgeon has made a change.
Your surgeon will order a prescription pain medicine for you after surgery. As your pain lessens, over the counter pain medicines such as acetaminophen or ibuprofen can be used. They can also be used instead of your prescription for mild pain.
Prescription pain medicines can cause constipation. Your doctor may order a stool softener to prevent this. You should be back to your normal bowel routine in about 2 weeks. If the stool softener does not work, take Milk of Magnesia. If you still are not getting relief, call your surgeon.
Call your surgeon right away if you have:
Long-term
Your surgeon will encourage you to schedule routine mammograms at the frequency recommended for your age group. Following breast reconstruction, you should continue to perform breast self-examination.
How Long Will the Results Last?
For implant-based reconstruction, both saline and silicone implants are safe and effective when used according to their labeling. Saline and silicone implants have lifetime warranties from their manufacturers; however, the longer you have implants, the more likely you are to experience complications. Recent data suggest that over 95% of implants are intact after seven years, but other data demonstrate that half of women who receive implants for breast reconstruction will require removal or exchange within ten years after implantation.
For patients who are having reconstruction of a single breast, changes in that breast will, over time, be different from that in the other breast. The patient's own natural breast tissue is more likely to sag and lose elasticity compared with an implant-reconstructed breast, which tends to stay youthful, with less drooping over time.
For patients who undergo a bilateral mastectomy and bilateral reconstruction with implants, it is quite common for them to have well-projected, young-appearing breasts with no sagging even in their eighth decade of life.
Breast reconstruction using tissue flaps are subjected to the same forces of gravity as natural breast tissue. The tissues may not age the same because the tissues are from other parts of the body.
The skin and fat from the buttocks region or upper back is much thicker and more fibrous and does not tend to droop or sag as much over time as breast tissue.
The skin and fat of the abdomen is very similar to that of breast tissue and does tend to droop or sag over time, similar to natural breast tissue.
Follow-Up
Follow-up after surgery is extremely important and our surgeons at Salus are committed to providing all the post surgical care you need. For safety, as well as the most beautiful and healthy outcome, whenever you notice any changes in your breasts do not hesitate to contact your surgeon. In order to identify and treat any complications as they may arise, close, lifetime follow-up is essential.