What is Breast Reconstructive Surgery?
The purpose of breast reconstructive surgery is to restore one or both of your breasts to look as natural and symmetrical as possible. Breast reconstructive surgery is a group of procedures including reconstruction with synthetic breast implants, autologous (from another part of your body) tissue and skin flaps, and fat transfer. It is used to address congenital (since birth), acquired, or cancer-related irregularities.
If you are a breast cancer patient, just as your cancer treatment was personalized and created to treat your specific cancer type, reconstructive surgery is also highly individualized. We will work with your unique goals and expectations.
The Stanford Breast Cancer Program is considered one of the leaders in the field and we are honored to be a part of this team. We are cognizant of the significant benefits of a minimally invasive approach to treating breast cancer. We practice the most advanced evidence-based medicine. Our general surgeons advocate for a nipple-sparing mastectomy (NSM) whenever possible, due to the overwhelming clinical data that has proven no difference in breast cancer recurrence when appropriately selected patients undergo nipple-sparing mastectomies (NSM) vs the traditional total mastectomy. Studies have also shown significant improvements in quality of life and cosmetic results with a NSM vs total mastectomy.
It is important for patients to know that large multi-institutional clinical trials have shown that women with early stage breast cancer (stages 1 and 2), who underwent breast conserving surgery (removing the cancer while leaving as much normal breast as possible), followed by radiation had the same survival rate as those women that underwent total mastectomy. Regardless of the data, many patients continue to elect for a total mastectomy. A total mastectomy entails removal of the entire breast, nipple-areola, and the overlying breast skin envelope. Subsequently, the reconstructive plastic surgeon is left with little skin and soft tissue to recreate the entire breast.
It is important to emphasize that breast reconstruction does not interfere with detection of local or regional breast cancer recurrence. There is also no effect on breast cancer recurrence when comparing patients that have undergone reconstruction vs those patients that have not.
Our mission as plastic and reconstructive surgeons is to restore what was once yours, and if you would prefer, perhaps some additional enhancements to your original breasts to positively impact your recovery and self-confidence. We are dedicated to achieving optimal results and will work with you every step of the way.
All breast implants have a silicone outer shell. This shell can be either smooth or textured. Smooth shell implants have the advantage of more natural movement within the breast capsule your body invariably creates after an implant is placed. However, rotation within the breast capsule is a potential complication with a smooth shell. Textured shell implants stick tightly to the newly formed breast capsule and does not glide naturally within the capsule like its smooth shell counterpart. However, this shell cannot rotate (or turn upside down) within the breast capsule and there is a lower risk for capsular contracture with the textured shells vs the smooth shells. There is an extremely rare association of textured implants and the development of BIA-ALCL (Breast implant associated anaplastic large cell lymphoma), a treatable cancer of the immune system. It is important to discuss the pros and cons of your options with your plastic surgeon.
Saline: your plastic surgeon fills the silicone shell with sterile water in the operating room to your desired size. Saline is much cheaper than silicone, but there is a risk of developing visible rippling, or skin folds over the implant in the future. However, saline implants have the advantage of being able to be filled with more saline after your breast augmentation surgery. This is especially applicable to those individuals undergoing oncologic breast reconstruction after mastectomy and require gradual expansion of the small breast envelope to prepare it for an implant in the future.
Silicone: these implants have varying degrees of consistency. Increased molecular bonds increases the cohesiveness therefore viscosity of the silicone filling. These cohesive silicone implants are also known as “gummy bear implants.” These implants have the advantage of low risk of skin rippling and implant leakage. They are also firmer than the traditional silicone filling that is of liquid consistency, thus are able to hold their shape.
Acellular Dermal Matrix
Your plastic surgeon will use an acellular dermal matrix (ADM), a type of surgical mesh composed largely of collagen from human, pig, or calf skin. Frequently used ADMs include AlloDerm, Strattice, and DermaMatrix. If your plastic surgeon opts to place the implant above the pectoralis major muscle, the ADM will be wrapped around the implant, (like a dumpling), and inserted into your new breast pocket. The ADM will help maintain the positioning of the implant, because the ADM provides a structural framework for the surrounding tissues to incorporate or grow into. If your plastic surgeon opts to place the implant below the pectoralis major muscle, the ADM will be sutured to the outer edge of your pectoralis muscle after the implant has been inserted, and the remaining edges of the ADM will be sutured to the bottom of your breast pocket. The ADM functions like a sling, and again, provides structural framework for the surrounding tissues to incorporate into.
Tissue Flap Reconstruction
These techniques typically produce the most durable and aesthetically pleasing results. They are especially useful in those cases where mastectomy or radiation therapy has resulted in inadequate tissue covering for implants.
Abdominal Flaps: These flaps require you to have excess healthy tissue along your lower abdomen.
DIEP Flap: The deep inferior epigastric perforator flap is a free flap and requires the complete excision of a segment of the lower abdomen. The excised flap of tissue includes the skin, underlying fat, and an artery and vein that penetrates your abdominal muscles before branching out to supply the excised fat and skin. This artery and vein pair is delicately harvested prior to branching. The flap of tissue is then placed into your new breast pocket, and the harvested vessels supplying this flap is then surgically connected to an artery and vein that run up on the underside of the chest wall.
SIEA Flap: The superficial inferior epigastric artery flap is very similar to the DIEP flap. However, the SIEA flap requires a more superficial dissection than the DIEP flap. Thus, it improves the length and degree of recovery required. However, not all women have an SIEA or one that is robust enough to provide adequate perfusion to the flap.
Pedicled TRAM Flap: The pedicled transverse rectus abdominus flap includes one vertical half of your six-pack muscle, and the fat and skin of a segment of your lower abdomen. If your right breast is getting reconstructed, your left rectus abdominis muscle is used. This flap of tissue is excised and elevated from your lower abdomen but is left intact in your upper abdomen. The flap is then tunneled up to your chest and becomes your new breast tissue. This flap is perfused by the superior epigastric artery.
Muscle-sparing Free TRAM Flap: This flap requires the complete excision of a small portion of the rectus abdominus muscle, along with the overlying fat and skin of a segment of your lower abdomen. This flap is perfused by the deep inferior epigastric artery, which is the deeper portion/origin of the deep inferior epigastric perforator of the DIEP flap. This flap does not create a large muscular defect like the pedicled TRAM flap.
Latissimus Dorsi Flap
This flap is an excellent option for patients that are very thin and do not have excess tissue to harvest and transplant. The latissimus dorsi is a back muscle that originates from your lower back and contracts to help move your arm. It is a redundant muscle and not essential for your arm to function. Either a portion of, or the entire muscle on the same side of the breast that will get reconstructed is dissected off the attachments from your lower back and hip. The muscle is then elevated then tunneled under your armpit and then positioned and sutured onto your chest wall. Typically, an implant or tissue expander is placed into pocket created by the muscle flap. The latissimus dorsi muscle is very thin, and because this procedure is usually performed on thin patients, the amount of overlying fatty tissue is not substantial.
Advances in microsurgical techniques create the possibility of harvesting flaps from virtually any part of the body. Other frequently used flaps include thigh-based flaps such as the TUG (transverse upper gracilis), VUG (vertical upper gracilis), DUG (diagonal upper gracilis), and PAP (profunda artery perforator) flaps. These thigh-based flaps essentially provide very effects to a thigh lift. Similarly, the gluteal-based SGAP (superior gluteal artery perforator) flap confers the results of a buttock lift. And the gluteal-based IGAP (inferior gluteal artery perforator) flap confers the same effect as a buttock tuck procedure.
Timing of Breast Reconstruction
Immediate: The reconstruction occurs immediately after your breast surgeon removes the breast cancer. Your plastic surgeon will step into the OR once the breast cancer is removed and reconstruct your breast/s with implants or tissue from another location of your body, or both. If you are having a prophylactic (preventive) mastectomy, immediate reconstruction is always performed. Immediate reconstruction may not be possible if you require radiation or chemotherapy after the surgical removal of your breast cancer. This is usually the case for breast cancer patients greater than stage 2.
Delayed-Immediate: This is a staged reconstructive process. Immediately after tumor removal, a temporary tissue expander (an expandable implant with a silicone shell, where saline can be added with a small needle, or a newer model, where compressed air within the device can expand from an external device controlled by you), or a temporary implant is placed and functions to maintain your breast shape while you undergo radiation therapy. Sometimes your physician will deflate the tissue expander over the course of the radiation treatments to allow for more targeted therapy. The tissue expander is then gradually expanded over time. Reconstruction with an implant or flap is performed 4-6 months after radiation therapy completion.
Delayed: The reconstruction occurs after the completion of breast cancer treatment. This may include lumpectomy, mastectomy, chemo, and radiation. This may occur 6-12 months after your initial breast surgery, or many years later. Your plastic surgeon may advise you to undergo delayed reconstruction if your tumor burden is large or you may opt to focus only on cancer treatment and then address reconstruction separately, later down the road.
Implant Based Reconstruction
This method requires an adequate amount of soft tissue to be present to provide enough covering and support for the breast implant.
- Implant-only-based reconstructive procedures typically require 23-hour hospitalization.
- Flap-based reconstruction involves highly delicate and complex microsurgical techniques, thus blood flow and flap survival is closely monitored in the hospital for 3-4 days.
- Specific instructions personalized to your surgical procedure will be provided as a hard copy.