PERFORMING BREAST RECONSTRUCTION: Using State-of-the-Art Techniques
Mastectomy for cancer is the most common reason that women have breast reconstruction. In fact, the number of women undergoing this reconstructive surgery has increased dramatically over the past 15 years, and the trend for immediate breast reconstruction after mastectomy has grown from 10% in the 1980s to about 50% today.
At Stony Brook's Carol M. Baldwin Breast Care Center, our plastic surgeons use the state-of-the-art reconstructive techniques, providing a range of different options to patients wanting breast reconstruction.
|Our plastic surgeons can create a breast that closely approximates the form, feel, and appearance of a normal breast.|
Both Alexander B. Dagum, MD, associate professor of surgery and chief of plastic and reconstructive surgery, and Steven M. Katz, MD, assistant professor of surgery, of our Division of Plastic and Reconstructive Surgery—along with nurse practitioner Sharon Valentine, RN, NP—have been actively involved in reconstructive breast surgery for many years.
Patients at the Breast Care Center are able to receive the most sophisticated, compassionate care in a coordinated and timely fashion. This requires very close cooperation among the different physicians of the comprehensive breast service, which includes the oncologic surgeon and the medical and radiation oncologists, all of whom work closely with our plastic surgeons.
Breast reconstruction is an operation carried out to restore breast shape and replace breast tissue lost during a mastectomy or, occasionally, a lumpectomy. The operative goal is to match the opposite breast as closely as possible.
There are many benefits to breast reconstruction. These include restoration of a woman's feeling of being whole again, as well as her self-confidence and feelings of femininity. In clothes, the appearance of the reconstructed breast will be similar to that prior to the mastectomy, and without clothes the breast mound will restore the natural shape of her breast.
On a practical side, breast reconstruction eliminates the need for external artificial breasts (prostheses) which can be uncomfortable and awkward to wear.
It is important to note that reconstructive breast surgery does not interfere with future treatments such as radiotherapy, chemotherapy, or detection of recurrent breast cancer. It also does not increase the risk of recurrence of the breast cancer.
Although breast reconstruction aims to match as closely as possible one's previous breast, patients must bear in mind that this surgery will not precisely restore the breast appearance and shape they once had, nor will it have the same sensitivity or allow for lactation.
The trend at major breast cancer centers, such as the Carol M. Baldwin Breast Care Center, has been to offer immediate reconstructive surgery for mastectomy patients. In fact, now in New York it is required that this surgery be offered to every woman undergoing a mastectomy. However, there are still legitimate reasons to wait and have the reconstruction done later.
Some women are not comfortable weighing all the options while they are struggling to cope with the diagnosis of breast cancer. Breast reconstruction can certainly be performed at a later date. However, the advantages of immediate breast reconstruction are that not only is the patient spared a second major operation and hospitalization, but after the mastectomy, she wakes up with a breast and is spared the psychological feeling of a lost breast.
For most patients, breast reconstruction will require from one to three surgical procedures to achieve the desired result. The first procedure is the most lengthy and complex, while the other procedures tend to be done on an outpatient basis and are more in the realm of perfecting form.
The first procedure involves creation of the breast mound or breast shape. There are many ways this can be achieved.
The type of breast reconstruction to be chosen depends on the desires of the individual patient, as well as the surgical factors that determine the reconstructive possibilities in each case.
The transverse rectus abdominus muscle (TRAM) flap reconstruction is—from the surgeon's viewpoint—perhaps one of the most rewarding ways to reconstruct a breast. From the patient's viewpoint, the TRAM reconstruction is especially attractive because the outcome is very natural, from materials to appearance.
|TRAM flap reconstruction with pedicled/tunneled rectus abdominus muscle and abdominal "skin island" for creation of breast.||Finished TRAM reconstruction (prior to creation of nipple-areola) showing scar lines: the breast scar may vary in appearance; the scar on the lower abdomen generally runs from hip to hip, but is low enough to be concealed under many types of swim suits.|
This operation, popularized in the early 1980s, involves using entirely the patient's own tissue to build the new breast. The skin and subcutaneous fat, which would be taken out with a standard abdominoplasty (tummy tuck), is brought up to the mastectomy site pedicled on the rectus abdominus muscle. It is shaped into a new breast closely matching the opposite breast.
|New York law requires that every woman undergoing a mastectomy be offered reconstructive breast surgery.|
The TRAM operation is lengthier than other reconstructive options and requires slightly more time for recovery, but it yields the most natural-looking breast. Occasionally, skin and muscle will be brought from the back to reconstruct the missing breast. However, with this latter technique, an implant is usually required if a larger breast needs to be made.
The most common way to reconstruct a breast is to use a combination of a tissue expander and an implant. A tissue expander is a small "balloon" that is placed beneath the chest muscle (pectoralis muscle) at the time of the mastectomy. Over the ensuing six weeks, the balloon is then filled with saline through a small port using a syringe and needle. This process allows for the creation and stretching of skin, much like what happens to a woman's belly during pregnancy.
Reconstruction with skin expansion. A, The tissue expander is placed beneath the chest muscle. B, Full expansion with saline occurs after about six weeks. C, At a second operation, the tissue expander is exchanged for a permanent breast implant to match the opposite breast, and the nipple-areola is reconstructed, too.
This remodeling of the skin requires about six weeks. After sufficient skin has been created, a second operation, in which the tissue expander is removed and a permanent breast implant placed, is performed several months later. The current breast implants are made of silicone and filled with saline (salt water). Gell-filled implants, which have a more natural feel, are also available, but are still considered experimental.
Every effort is made to achieve the best possible result from the reconstruction. The results, however, can vary a great deal. Although it is impossible to achieve a perfect match, it is generally possible to achieve a close match that, even in a bathing suit or low-cut dress, looks "the same" as the opposite breast.
Most women are very satisfied with the final result of reconstructive breast surgery, and feel a significant improvement in their appearance and quality of life.
For more information about breast reconstruction performed by our plastic surgeons, please call 631-444-4545.
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