Breast Reconstruction

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1. What is the history of breast reconstruction surgery?
2. Am I a good candidate for breast reconstruction surgery?
3. What does breast reconstruction surgery involve?
4. How do I plan my breast reconstruction surgery?
5. How do I prepare for breast reconstruction surgery?
6. What results can I expect after breast reconstruction surgery?
7. Where will my breast reconstruction surgery be performed?
8. What type of anesthesia will be used for my breast reconstruction surgery?
9. What should I expect after breast reconstruction surgery?
10. When will I be able to return to work following breast reconstruction surgery?
11. Are there any side effects associated with breast reconstruction surgery?
12. Are there any risks associated with breast reconstruction surgery?

What is the history of breast reconstruction surgery?

During the 20th century, the women’s movement drew greater attention to female problems creating a demand for breast reconstruction surgery. Furthermore, the development of safer breast implants and refined tissue flap procedures have made breast reconstruction surgery a viable option for women who suffer from the consequences of breast cancer therapy requiring breast tissue removal. The American Society of Plastic Surgeons reported that about 62,000 women underwent breast reconstruction surgery in 2004.

Am I a good candidate for breast reconstruction surgery?

Breast reconstruction surgery is usually performed on patients who have had their breast removed due to cancer. Suitable patients must be in good general health and be emotionally prepared to undergo reconstructive surgery. In some cases, patients may have breast reconstruction performed at the same time that the breast is remove in order to avoid emotional stress caused by a dramatic change in physical appearance. However, patients who need radiation therapy to the underarm or chest area should wait until the cancer is entirely eliminated to undergo reconstruction surgery. Furthermore, patients may not want to deal with additional surgery during the time of breast cancer removal. You should keep in mind that breast reconstruction surgery requires significant commitment and may entail several weeks or months of office visits and multiple surgeries. Since breast reconstruction surgery can be performed at the time of breast tissue removal or at a later date, you have a lot of flexibility in determining if and when you would like to get this procedure done.

What does breast reconstruction surgery involve?

There are two methods available for breast reconstruction surgery and they involve: breast expander/implant or tissue flap reconstruction:

1. Implant reconstruction: Implant reconstruction involves replacement of the breast tissue removed with a silicone gell implant. Depending on the amount of skin removed, patients usually require a staged reconstruction utilizing an expander implant to expand the breast skin prior to placement of the final silicone implant. In addition, depending on the amount of inferior breast tissue removed which may violate the inferior breast crease (inframammary crease); patients may require a dermal matrix (created to mimic the deep, tough portion of skin) to recreate this crease. Following placement of the expander and dermal matrix, patients are serially inflated during in office procedure every two weeks until the skin is expanded adequately to tolerate the placement of the desired implant replacement. When patients are expanded to the appropriate volume, patients must wait another month prior to expander removal and final silicone implant placement. During the implant replacement procedure, most patients elect to undergo a contralateral symmetry procedure of the normal breast, which involves a breast lift, and implant placement. Approximately, three months following this surgery, patients then undergo a final nipple areola reconstruction.
2. Flap reconstruction: Flap reconstruction typically requires the use of tissue from the back or stomach to replace the tissue lost during the breast tissue removal. In some cases, when inadequate back or stomach tissue is present, patients may require a silicone implant supplementation of their tissue flap reconstruction in order to appropriately complete their reconstruction. When utilizing tissue flap reconstruction, patients forego the expander phase, as the flap tissue will provide adequate skin. In rare cases, the tissue flap must be detached from their blood supply and reattached to breast tissue vessels by microvascular surgical technique. Reconnecting these blood vessels requires the use of a microscope and more extensive surgery. Approximately three months following this surgery, patients may complete their nipple areola reconstruction and contralateral breast symmetry procedure thus completing their reconstruction.

How do I plan my breast reconstruction surgery?

Because patients feel differently about the timing and method of breast reconstruction surgery, you should discuss reconstructive treatment options with a board certified plastic surgeon. During your consultation, your surgeon will evaluate your health status by obtaining blood work and check your heart with an EKG (for patients older than 40 years of age). If you are performing your reconstruction at a lateral date (delayed fashion), then you will have to obtain a mammography to verify that your treated breast is still in remission and to confirm that you do not have cancer in your contralateral breast. If you are a smoker, you should quit for 1 month prior to your breast augmentation surgery to minimize the risks of implant infection. In addition, it is prudent to quit smoking for 6 weeks following surgery to ensure a well-healed surgical incision line.

How do I prepare for breast reconstruction surgery?

Since your surgery will require general anesthesia, you must take several precautions prior to surgery. First, you will have to avoid eating and drinking after midnight on the day before surgery. This precaution ensures that your stomach is clear of digested foods that could potentially be aspirated into your lungs during induction of anesthesia. Since, you will have anesthetic medications administered throughout the case, you will remain groggy for several hours. You may remain in the hospital overnight and will require a ride to and from the hospital. You should also choose a caretaker who is conscientious to take care of you at least the first night you return home.

What results can I expect after breast reconstruction surgery?

After breast reconstruction surgery, you will regain your breast mound and notice that your breasts appear balanced when you are wearing a bra. However, you should expect to see differences in size, shape and feel between the reconstructed breast and your natural breast. Most women are very satisfied with their improved body image if they enter the reconstruction process with realistic expectations. Patients may also be pleased of improvements of their contralateral breast sagging.

Where will my breast reconstruction surgery be performed?

Breast reconstruction surgeries are usually performed at a hospital operating room or an outpatient surgical suite. Follow-up and staged reconstruction procedures, such as nipple and areola reconstruction, are also performed at a hospital or an outpatient surgical facility as well.

What type of anesthesia will be used for my breast reconstruction surgery?

All reconstructive breast surgeries will require general anesthesia.

What should I expect after breast reconstruction surgery?

Depending of the method of breast reconstruction surgery that is performed, you may remain in the hospital overnight or for a few days. When undergoing tissue flap or expander reconstruction you will have drainage tubes put in place to eliminate excess fluid from the breast pocket dissected. You may feel tired and sore for about 1 week after surgery but pain is well managed with pain medication. Most women are able to resume normal activity within 2 weeks, but it is extremely important for patients to avoid strenuous activity such as heavy lifting (more than 5 lbs.) during the recovery period for up to 4 weeks. Although sensation will return to your breast and nipple area, you should not expect the reconstructed breast to have the same feeling as a natural breast.

When will I be able to return to work following breast reconstruction surgery?

Most patients are able to return to work between 2 to 4 weeks following breast reconstruction surgery. Patients with jobs that require strenuous physical activity will require 4 weeks of recovery period. The recovery period is longest following the first reconstructive operation and less recovery time is needed for subsequent surgeries. Depending on the method of reconstruction used (expander implant versus tissue flap), recovery periods will vary. Patients who use breast expander/implant reconstruction will have a shorter recovery period than patients who choose to have a tissue flap procedure performed.

Are there any side effects associated with breast reconstruction surgery?

Side effects are events that may be experienced by patients as a result of your surgery and should not be considered adverse events. Our patients are counseled regarding these effects and if experienced they are tolerable and often temporary in duration.

1. Numbness: Swelling after surgery usually results in loss of feeling in the breast and nipple area during the first several weeks. However, prolonged numbness is routine following complete removal of breast tissue to treat breast cancer. Tissue flap reconstruction also results in loss of normal sensation by virtue of the nerves being disconnected when transferring tissue from the back or stomach.
2. Scarring: Incisions may be lumpy and red for a few months, but incisions become less apparent over time and can even fade to thin white lines. A bra or swimsuit top can usually cover healing scars. Smokers are urged to stop smoking since smoking impedes the healing process and will result in more prominent surgical scars.
3. Breast/Nipple asymmetry: Breasts may not be the same size and shape and nipples could be positioned unevenly depending on the degree of preoperative asymmetry and depending on whether a contralateral breast symmetry procedure has been performed. In addition, patients must recognize that long term aging of breasts will likely result in residual asymmetry as the reconstructed breast and contralateral normal breast tissue are comprised of different tissue to implant proportion and will age differently by the effects of gravity.

Are there any risks associated with breast reconstruction surgery?

Risks are unwanted events that may occur during or following surgery. These events are recognized as “complications” but their occurrence is minimized by appropriate patient selection, proper surgical decision making, effective surgical technique, and thorough preoperative and postoperative patient management.

1. Hematoma: Hematoma refers to the accumulation of blood in the early postoperative period, which pools into a dissected pocket. Hematomas provide a perfect medium for harboring growth of bacteria. In fact, if the patient has an infection anywhere in the body, the bacteria will travel through the blood stream and resettle in the hematoma; this can lead to an infection and subsequent wound development. In order to avoid a hematoma, drains can be placed in surgery so that any fluid accumulation can be drained. Drains are usually kept in place for 1 to 2 weeks. In addition, patients are evaluated preoperatively to make sure that they do not have a blood clotting deficiency.
2. Seroma: Seroma formation refers to the accumulation of plasma fluid in pockets created by surgical elevation of the soft tissue and disruption of vessels. This fluid may accumulate if the patient’s blood count is low and/or the patient’s nutrition poor. When nutrition is poor, protein levels in the blood are diminished which promotes leakage of this fluid out of vessels. This fluid can be a nuisance to patients often requiring several aspirations in the office prior to its resolution. More importantly, these plasma fluid pockets may harbor bacterial growth and result in a clinical infection. Drains can be placed in surgery and are very effective in preventing seroma formation.
3. Infection: An infection can occur after breast reconstruction surgery especially when expander implant reconstruction is used. An infection may result in disruption of surgical incision lines and may leave the patient with an open breast wound. When implant expander reconstruction is performed an infected implant may be extruded. Prolonged antibiotics and possible removal of antibiotics may be required to fight an infection and to prevent further extension of the infection. Risk of infections are avoided by using sterile technique, using intra-operative antibiotics, and sealing all incisions sites so that bacteria can’t get in through external contact. In addition, infections are less likely in patients who don’t smoke cigarettes or in smokers who quit smoking for at least 1 month prior to surgery. If an infection occurs and the implant has been removed, the patient’s reconstruction will be delayed by at least 3 months.
4. Tissue death (necrosis): Following breast tissue removal (mastectomy), portions of the breast tissue may become compromised due to overly thinning of the breast skin flaps created during the mastectomy. In addition, when tissue flap reconstruction is utilized, it is not uncommon to lose a portion of the transferred fat and skin. This complication will result in secondary procedures, which will require debridement of compromised tissues and revision of surgical incision lines.
5. Capsular contracture: Capsular contracture causes the breast to feel hard and is caused by hardening of a scar around a foreign body such as a breast implant. Although this scar formation is expected and a natural process that occurs when expander implant reconstruction is utilized, when the scar is overly thickened and hardened it results in breast hardening and is characterized as capsular contracture. Patients who develop capsular contracture will require further surgery to either release the scar or to remove the scar entirely.
6. Pulmonary embolism: Blood clots may form in leg veins during any surgery when the patient is under general anesthesia. Patients with a malignancy, such as in patients with breast cancer, have a higher risk of clot formation. Patients with a leg vein clot will complain postoperatively of pain in their calves. Patient’s with this complaint should be taken seriously and treated if a vein clot is diagnosed. Early treatment of patients with a deep leg vein will avoid migration of leg vein clot to the heart and lungs causing pulmonary embolism. Even though pulmonary emboli are rare, pulmonary emboli are the leading cause of death after surgery. Pulmonary emboli must be detected early by performing a CT Scan and should be treated urgently.