What is Breast Reconstruction?The diagnosis of breast cancer is a difficult time for most patients, who are often frightened and confused about their treatment. At Florida Plastic Surgery Group, we encourage patients to ask questions and become well-informed regarding their treatment and reconstructive options. Fortunately, breast reconstruction—and particularly newer reconstructive techniques—allows for the creation of more natural-feeling and aesthetically-pleasing breasts. There are a number of reconstructive options available to patients, and our plastic surgeons are pleased to offer the entire spectrum of reconstructive options. Our breast reconstruction team will help guide you through the process one step at a time. Our doctors believe that patients, their desires, and anatomies are all unique. Therefore, they will explain all the options and listen to your particular wishes to create a personalized approach to your reconstruction.
The FACTS – Breast ReconstructionIn all the studies to date, breast reconstruction does not interfere with any prescribed cancer treatment (i.e. chemotherapy or radiation therapy). Breast Reconstruction has a documented psychological advantage to healing. Breast reconstruction can be performed immediately after mastectomy or can be delayed. Patients needing radiation treatment have a better aesthetic result if reconstruction is performed in a delayed fashion. Insurances are required by law to cover procedures to restore symmetry on your other breast.
Who is a Candidate for Breast Reconstruction?Women in good health who have undergone or are scheduled for any surgical procedure aimed at removing or preventing cancer of the breast are candidates for reconstruction of their breasts.
How Do I Prepare for My Breast Reconstruction Surgery?We will work with your general surgeon, medical oncologist, and/or your radiation oncologists to ensure your safety during the process. Pre-operative blood work is generally needed prior to surgery. Smoking can result in significant complications, including wound healing problems due to the decrease in circulation to the skin. Therefore, we ask all patients undergoing breast reconstruction surgery to quit smoking prior to and after surgery.
What Are My Breast Reconstruction Options?Women interested in breast reconstruction have several different options for rebuilding the breasts. Below, we have highlighted the techniques available at Florida Plastic Surgery Group. The most appropriate approach for your specific needs and goals can be determined during a consultation with one of our plastic surgeons.
- Oncoplastic Breast Reconstruction
- Autologous Breast Reconstruction
- Delayed Reconstruction
- Implant Based Reconstruction
- Latissimus Muscle with Implant Reconstruction
- Mastectomy-Only with Breast Prosthesis
- Perforator Flap Breast Reconstruction
- TRAM Flap Reconstruction
- DIEP Flap Reconstruction
- Profunda Artery Perforator (PAP) Flap Reconstruction
Oncoplastic Breast ReconstructionIn some cases of breast cancer, a full mastectomy is not required. In these instances, a lumpectomy may be all that’s necessary to remove the threat of cancerous tissues. With that in mind, a lumpectomy that results in the removal of a significant portion of breast tissue, or one that must be performed in a conspicuous location, can cause a contour deformity. Here at Florida Plastic Surgery Group, one of the most advanced forms of breast reconstruction we offer is oncoplastic breast reconstruction, a technique that can address many of the aesthetic concerns caused by lumpectomy procedures. Oncoplastic breast reconstruction is designed to “fill in” the affected area of the breast with healthy breast tissue, ultimately concealing the defects that can result from a lumpectomy. Advantages:
- Minimizes the residual aesthetic effects of large amounts of tissue removal or scarring that can result from lumpectomy procedures.
- Depending on the extent of your unique needs and the timing of the oncoplastic breast reconstruction procedure, an overnight hospital stay may not be required.
- In some cases, oncoplastic breast reconstruction can be performed in tandem with the lumpectomy procedure. This typically means that a second major surgery should not be required.
- For some patients, the best, most symmetric results from oncoplastic breast reconstruction are often accomplished by performing a breast lift or a breast reduction. These procedures are frequently considered part of the breast reconstruction process and therefore may be covered by insurance.
- There is no guarantee that breast shape and volume will be fully symmetrical.
- There is no guarantee that further surgery will not be required.
- Post-lumpectomy radiation is often necessary following a simultaneous lumpectomy/oncoplastic breast reconstruction and may have an effect on results.
Autologous Breast ReconstructionThere are a number of breast reconstruction methods that utilize your body’s own tissue to restore the breasts after a mastectomy. Skin, fat, and/or muscle are transferred as a composite flap to recreate the shape of the breast. Oftentimes, nipple reconstruction can be performed during the treatment, recreating your entire breast in a single-stage procedure. A perforator flap is a specific type of reconstruction in which muscle is not taken, but simply separated to help transfer your body’s tissue to the chest.
Autologous Reconstruction Methods
- Pedicled TRAM
- Muscle-Sparing TRAM
- Perforator FLAPS
- SIEP (Superficial Inferior Epigastric Perforator)
- DIEP (Deep Inferior Epigastric Perforator)
- SGAP (Superior Gluteal Artery Perforator)
- IGAP (Inferior Gluteal Artery Perforator)
- PAP (Profunda Artery Perforator)
Delayed ReconstructionAt Florida Plastic Surgery Group, reconstruction of the breast mound can also be performed at a later date following your mastectomy. Reasons to delay breast reconstruction include feeling you are not ready for a reconstructive procedure or if it is likely that you will have radiation treatment in the future. Advantages:
- Allows more time to consider options.
- Radiation tends to change the immediate reconstruction and can diminish the quality of the final aesthetic result.
- Awaken with a flat mastectomy scar on chest
- Although results are often good for delayed reconstruction, we can often achieve better results with immediate reconstruction.
Options for Delayed Breast Reconstruction
- Mastectomy Only with Breast Prosthesis
- Reconstruction using an implant with or without tissue expansion
- Reconstruction using an implant and your own tissue
- Reconstruction using only your own tissue
- TRAM Flap
- DIEP & Other Perforator Flaps
Implant Based ReconstructionEither saline or silicone breast implants can be placed under or above the pectoralis muscle to reconstruct the breast. Although silicone implants are softer and have a more natural-looking appearance, our doctors leave the choice of implant type up to each patient. In some cases, by using cadaver dermis tissue, our plastic surgeons can reconstruct your breast in a single stage. In other cases, a tissue expander needs to be placed under the muscle and expanded over the months leading up to the final implant placement. Nipple-areola reconstruction can also be performed to complete your reconstruction if a nipple-sparing mastectomy was not able to be performed. Advantages:
- Provides an upper-breast fullness for a more youthful look.
- The recovery from implant placement is generally faster than flap reconstruction methods.
- There are no additional scars on the body.
- It can be matched on the opposite breast.
- The extra volume can help correct ptosis (loose skin) of the breast.
- Since an implant is a foreign body in the breast tissue, there is an increased risk for infection around the implant.
- Less natural breast shape.
- Wrinkling or rippling of the implants may occur.
- Breast tissue may form a capsule around the implant, causing the breast to become firm and sometimes painful.
- Expander placement does require two stages for breast reconstruction and several visits to the office to fill the expander.
Latissimus Muscle with Implant ReconstructionFor our patients at Florida Plastic Surgery Group seeking breast reconstruction, the latissimus muscle and skin can be removed from the back and tunneled to the front of the chest wall to form a new breast mound. This technique is commonly combined with either silicone or saline breast implants. The most common patients for this procedure are undergoing delayed reconstruction after their breast(s) have been irradiated.
- Gives fullness to the upper-breast, often resulting in a more youthful appearance.
- With the flap covering the implant, there are fewer radiation-related complications.
- It can be matched on the opposite breast with an implant placement, and health insurance will cover the opposite-breast symmetry.
- Because the flap provides additional tissue, most patients can undergo reconstruction in one stage without the need for expansion.
- A higher risk of infection surrounding the implant since the implant is a foreign body placed in the breast tissue.
- The breast tissue could develop a capsule surrounding the implant. This may cause the breast to feel firm and even painful.
- Fluid can collect in the back donor site area in about 15% of patients after the drains are removed.
Mastectomy-Only with Breast ProsthesisThis breast reconstruction method removes the breast with or without axillary lymph node sampling. After your incisions have healed, you can then be fitted for a breast prosthesis. Advantages:
- No further surgery is needed
- 1-2 hour procedure
- 1 day in the hospital
- Flat scar across the chest
- A prosthesis is sometimes described as hot and uncomfortable
Dr. Desai and his staff are incredible. I had a bilateral mastectomy, never a lot of fun, but he and his team made the experience a positive one. They have the perfect combination of professionalism and compassion. My results are more that I could have hoped for, complete with 3D tats. His team made me feel like family, and I’ll miss seeing them.
January 29, 2015
Perforator Flap Breast ReconstructionOne of the newer advances in autologous breast reconstruction is the development of perforator flaps. Perforator flaps allow our plastic surgeons at Florida Plastic Surgery Group to transfer fat and skin, recreating a natural-looking breast without sacrificing muscle. Since the muscles are spared, patients often have less pain at the donor site, faster recovery, and a lower hernia rate.
DIEP FLAP (Deep Inferior Epigastric Perforator)The tummy skin and fat are transferred to the chest wall with the necessary blood vessels. The blood vessels necessary to keep the flap alive are microsurgically dissected through the muscle. The rectus abdominus muscle is left intact and the blood vessels are reconnected to the chest under the microscope. Advantages:
- Since the abdominal muscles are left intact, patients generally have a faster recovery.
- The risk of hernia is very low and the strength of the abdominal wall is maintained.
- Patients obtain a flatter appearance to the abdomen (i.e tummy tuck).
- Due to the complexity of reattaching the small blood vessels, the DIEP flap surgery takes more time.
- If blood flow to the flap is interrupted, some or all of the flap may be lost, requiring further surgery.
SIEP FLAP (Superficial Inferior Epigastric Perforator)The tummy skin and fat are transferred to the chest wall with the necessary blood vessels. The abdominal wall fascia and integrity are left untouched along with the abdominal muscles. Advantages:
- Since the fascia is left intact, the SIEP flap is even less invasive than the DIEP flap.
- The risk of hernia is eliminated since there are no fascia incisions.
- Patients essentially obtain a tummy tuck as part of the procedure, which can give the abdomen a flatter appearance.
- Only a small percentage (5%) of patients have the particular anatomy required for the SIEP flap to be a viable option.
- An interruption of blood flow to the flap may result in the loss of some or all of the flap, which would necessitate further surgery.
SGAP / IGAP FLAP (Superior & Inferior Gluteal Artery Perforator)The skin and fat from the upper buttocks is occasionally used for breast reconstruction in patients that have very little abdominal tissue or have had abdominal operations that eliminate the DIEP flap or TRAM flap as an option. The gluteal muscle is spared and the blood vessels are reattached to the chest with the aid of a microscope. Advantages:
- Patients often have a more rapid recovery since the muscles of the abdomen are left intact.
- There is a very low risk of hernia and the abdominal wall’s strength is maintained.
- Due to the complexity of reattaching the small blood vessels, the SGAP flap surgery takes more time and has a lower success rate than the DIEP flap.
- If the flow of blood to the flap is interrupted, part or all of the flap could be lost, which would require additional surgery.
- Fat from the buttocks is less pliable and soft, making it more difficult to shape the flap.
- The buttock donor site will have some change in contour creating asymmetry, which is usually covered by clothing.
TRAM Flap ReconstructionTRAM is an acronym for Transverse Rectus Abdominus Myocutaneous, and simply describes the area of the stomach where tissue is used for breast reconstruction. During this procedure, the skin, fat, and rectus abdominus muscle are transferred as one unit to recreate the breast mound. There are two types of TRAM procedures: pedicled and free TRAMs. In the pedicled TRAM, the tissue is taken from the abdomen and rotated with the blood supply to the breast. With the Muscle-Sparing Free TRAM, the abdominal tissue is disconnected and transferred to the breast pocket. The blood supply is connected under a microscope to a new source under the arm or chest. Advantages:
- Your abdominal tissue does not have to be replaced.
- Creates a very natural-looking breast.
- Tummy tuck appearance to the abdomen.
- Can give an excellent cosmetic result, especially for women with larger breasts with moderate ptosis.
- The reconstructed breast changes with you as you gain or lose weight.
- More complex procedure requiring longer operative time.
- 5% risk of abdominal hernia.
- 1-2% chance of re-operative procedure for inadequate blood flow to flap or loss of flap.
- Slightly increased risk for DVT (deep vein thrombosis) or blood clots in legs.
- Slightly increased risk of blood loss and need for transfusion.
DIEP Flap ReconstructionBreast reconstruction should involve a complete team of individuals including a general surgeon, your plastic surgeon, your surgical team, an anesthesiologist, and possibly a breast radiologist. Our team at Florida Plastic Surgery Group will create a customized approach for your DIEP Flap (deep inferior epigastric artery perforator flap) breast reconstruction. If you are considering DIEP Flap breast reconstruction, our practice has created microsurgical centers for breast reconstruction at two different hospitals and has performed the DIEP Flap surgery successfully on many patients. During this procedure, DIEP flaps are harvested by taking the skin and fat from the abdomen and carefully dissecting the blood vessels that keep it alive. After the skin and fat is detached from the lower abdomen, it is placed onto the chest and artistically molded to recreate the breast. Microsurgery is used to attach arteries and veins to help restore the blood flow. Microsurgical breast reconstruction has a high success rate (> 95%) and provides soft, pliable skin and fat to help create a natural look and feel. The main advantage of the DIEP Flap technique is that while skin and fat are removed, the muscle left behind remains completely intact. This procedure preserves your abdominal wall strength and minimizes the chance of developing an abdominal wall bulge. Most insurance companies do cover the DIEP Flap breast reconstruction and we pre-authorize all the procedures prior to surgery to ensure insurance coverage.
Who is a Candidate for DIEP Flap Breast Reconstruction?Patients who are non-smokers and who have a moderate amount of abdominal wall skin and fat are often excellent candidates for DIEP Flap breast reconstruction. You may be asked to obtain a special CT SCAN to evaluate your blood vessels prior to surgery.
Recovery After Your DIEP Flap Breast ReconstructionPatients are usually monitored every hour for the first two days to ensure adequate blood flow to the flaps. Patients are also encouraged to walk on the first day and take blood thinners to prevent clotting. The total hospitalization time ranges from 4-7 days depending on the speed of your recovery. Patients are asked to wear an abdominal binder for 6 weeks and to avoid any heavy lifting until the healing process is complete. To learn more about DIEP Flap breast reconstruction and how our plastic surgeons can help you achieve your post-mastectomy goals, please contact a member of our staff to schedule a consultation.
PAP Flap ReconstructionTissue from the thighs may provide an alternative autologous option for patients who are poor candidates for abdominally-based breast reconstruction (i.e., TRAM, DIEP, SIEA flaps) either due to previous surgery or insufficient tissue at the abdominal donor site. The profunda artery perforator (PAP) flap, in particular, utilizes a modified horizontal or vertical thigh lift incision to harvest skin and fat from the upper inner and/or posterior thigh, which can be used to restore breast volume, shape, and projection after mastectomy. Similar to the DIEP flap, PAP flap breast reconstruction requires microsurgical expertise to perform. Patients who are non-smokers and have a moderate amount of excess skin and fat along the upper inner thighs are often excellent candidates for PAP flap breast reconstruction. You may be asked to obtain a special imaging study (i.e., CT Angiogram) to evaluate your blood vessels prior to surgery. The duration of hospitalization, activity restrictions, and timeline for recovery are similar to that for other microsurgical breast reconstruction procedures. Advantages:
- Provides an alternative autologous donor site for patients who are not candidates for abdominally-based breast reconstruction.
- Tissue quality is more consistent with native breast tissue than abdominal skin and fat.
- Improved contour along the upper inner thigh (i.e., thigh lift appearance).
- Muscle-sparing procedure with functional preservation of the thigh adductor muscles.
- Can give an excellent cosmetic result, especially for women with small-to-moderate breast size with minimal ptosis.
- The reconstructed breast changes with you as you gain or lose weight.
- Requires positional (i.e., sitting) restrictions during the first 5 to 7 days.
- Small risk (1-2%) of re-operative procedure for inadequate blood flow to flap or loss of flap.
- Flap volume is typically more limited when compared to the abdominal donor site (i.e., more appropriate option for small-to-moderately sized breast reconstructions).
- Slightly increased risk for DVT (deep vein thrombosis) or blood clots in legs.
- Slightly increased risk of blood loss and necessitating for transfusion.