Breast Surgery & Procedures
Breast reconstruction
following mastectomy:
Procedure:
BREAST RECONSTRUCTION TRAM FLAP. Transverse rectus
abdominus myocutaneous flap. breast reconstruction following
mastectomy. Surgical
removal of breast.
LENGTH:
4 to 6.5 hours.
ANESTHESIA:
General 3 to 5 day inpatient hospital stay.
SIDE EFFECTS:
Temporary pain or discomfort, swelling, numbness, dry
breast skin. Permanent scars.
RISK:
Poor or delayed healing, prolonged recovery, fluid accumulated
in abdomen or breast requiring drainage, failure of flap, secondary
surgery, fat necrosis (hard areas in breast due to poor healing in
fat).
RECOVERY:
Tasks of daily living may be resumed immediately. Back to
non-strenuous work (no lifting greater than 10 lbs) in 4 to 8 weeks.
No strong pushing, pulling or repetitive upper body movements for
3 weeks.
EXERCISE:
Resume 1/3 intensity at 3 weeks. Low impact activities @
1/3 duration of exercise, repetitions, amount of weight and pulse
rate. 2/3 intensity at 6 weeks. Full intensity including high impact
(running, horse back riding, high impact aerobics) at 8 weeks.
FADING & SCAR IMPROVEMENT:
6 to 24 months.
BRUISING:
2 to 4 weeks.
SWELLING:
Moderate/Significant 4 to 8 weeks, Subtle/Mild 2 to 3 months,
all of which are dependent upon extent of procedure(s).
DURATION of RESULTS:
Permanent. Need for multiple stages to complete
reconstruction. Usually a full year.
OFFICE VISITS:
1st 5 to 7 days / 2nd visit 7 to 10 days. Anticipated office visits: 7 to 10 the first 3 months, yearly after reconstruction stages completed.
GARMENT WORN:
Abdominal binder 4 to 6 weeks.
PAIN MEDS:
Ibuprofen or Narcotics as needed.
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Delay of Tram - Preparing
the blood vessels of the flap:
Procedure:
Performed 7 to 14 days before mastectomy with reconstruction.
ESTIMATED COST:
$1,000
Nipple Reconstruction:
Procedure/Timeframe:
2 to 3 months after permanent prosthesis
or 6 to 8 months after mastectomy/reconstruction, may be performed
at the time of implant exchange.
LENGTH:
Office Procedure 1 hour, NO DOWN TIME.
OFFICE VISIT:
1st 7 days / 2nd Visit 14 days.
BRUISING:
2 weeks.
SWELLING:
6 weeks REDNESS in SCAR: 6 to 12 months.
ESTIMATED COST:
$1,200 per side.
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Tattoo:
Procedure:
Pigment to the nipple
areolar area, 2 to 3 months after nipple reconstruction.
LENGTH:
Office procedure 1 hour, NO DOWN TIME.
OFFICE VISIT:
1st 6 weeks / 2nd Visit: 3 months / Anticipated
yearly thereafter.
DURATION of RESULTS:
Fading of the tattoo will occur and will
need to be touched up in the future.
ESTIMATED COST:
$650 to $750, Unilateral - $950 to $1,050, Bilateral.
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More Information About Breast Reconstruction
Loss of a breast is a severe physical and emotional event for any woman. Fortunately, procedures are currently available for reconstruction of the female breast following a mastectomy, which helps to correct both the physical and emotional loss associated with a mastectomy.
MOST WOMEN WHO HAVE HAD A MASTECTOMY ARE CANDIDATES FOR BREAST RECONSTRUCTION. The role of the reconstructive surgeon is to work with the general surgeon, the oncologist, and the radiologist involved in your treatment, to map out a plan for optimum management of your breast cancer. If you desire reconstruction, we make every effort to achieve a fully reconstructed breast as safely and as rapidly as possible. In many cases, I will have the opportunity to discuss breast reconstruction with you prior to your mastectomy. Treatment of different types of breast cancer may vary significantly, hence the type of reconstruction and the timing of your reconstruction may also vary. Some patients may be candidates for immediate reconstruction (performed at the time of the mastectomy), while others may be more appropriate for delayed reconstruction. This information sheet is intended to provide only basic information regarding breast reconstruction. The specific nature and timing of your procedure will depend on many factors and will be discussed with you in much more detail at your consultation.
If chemotherapy or radiation therapy is prescribed for you following your mastectomy, reconstructive procedures must be very carefully coordinated with these other therapy methods to insure proper treatment for the cancer. RADIATION AND/OR CHEMOTHERAPY DO NOT PREVENT YOUR HAVING RECONSTRUCTION, however, planned radiation therapy may require delayed, rather than immediate reconstruction following a mastectomy.
In evaluating your specific needs in breast reconstruction, I will review in detail your past medical history, operative reports from your surgical procedure, pathological reports from examination of the tissue removed in surgery, and other information supplied by your general surgeon, oncologist (chemotherapist), and radiation therapist.
If you have had a type of breast cancer which has a high statistical chance of occurring in the opposite breast or you have other significant risk factors such as a very strong family history, I might, in conjunction with your general surgeon, consider removal of tissue in the opposite breast with reconstruction. ONLY A VERY SMALL PERCENTAGE OF WOMEN WITH BREAST CANCER HAVE RISK FACTORS WHICH REQUIRE ME TO RECOMMEND REMOVAL OF TISSUE IN THE OPPOSITE BREAST. In most circumstances, the opposite breast is not approached surgically and is followed just as any normal breast would be.
SHAPE MODIFICATION OF THE OPPOSITE NORMAL BREAST MAY BE NECESSARY TO ADEQUATELY MATCH THE RECONSTRUCTION. When this is necessary, I will discuss with you in detail what type of procedure may be necessary and coordinate this with your general surgeon to assure thorough and adequate follow up of your breast in the future.
In general, there are two types of reconstructive procedures. The first involves AUTOLOGOUS TISSUE ONLY (YOUR OWN BODY’S TISSUES). The second involves some type of PROSTHETIC DEVICE (A TISSUE EXPANDER OR AN IMPLANT). Often these procedures may be combined such that a balance of your native tissues and an implant may be used to achieve the optimal result. There are advantages and disadvantages to every technique. For example, autologous reconstructions require sacrifice of uninvolved tissues with a second wound site, and the associated increase in hospital stay and recovery, while prosthetic reconstructions may deliver a less natural feel and have the added risks of permanent implants (scar contracture, deflation, malposition, etc).
Many factors are considered when choosing a specific reconstructive plan. These include the availability of donor tissues, the need for post-adjuvant therapies (radiation or chemotherapy), your medical history, your smoking history and lifestyle considerations. After discussing all of these options, we can decide which type of reconstruction, if any, is most appropriate for you.
The most common types of autologous tissue reconstructions involve transfer of a muscle flap from either your back or your stomach with varying amounts of skin and fat transferred with the muscle. The TRAM (transverse rectus abdominus myocutaneous) FLAP involves TRANSFER OF LOWER ABDOMINAL SKIN, FAT, AND MUSCLE TO RECONSTRUCT THE BREAST MOUND. The skin and fat used to make up the new breast come from the lower portion of the abdomen and receive their blood supply through the rectus abdominus muscle (the long muscles which run vertically in the mid portion of the abdomen and tense during sit ups). In properly selected patients, the amount of tissue available by this technique is significantly more than that of the back, and A BREAST IMPLANT BENEATH THE TRANSFERRED TISSUE IS USUALLY NOT REQUIRED. The breast is thus reconstructed entirely from your own tissues without using an implant. The TRAM flap reconstruction may be preferable in patients who have lost more significant amounts of tissue with their mastectomy or who have a greater degree of sag in the opposite breast. This technique requires adequate volume of tissue in the abdomen for transfer to the breast.
Another common type of autologous tissue procedure involves TRANSFER OF THE LATISSIMUS DORSI MUSCLE AND SOME OF ITS OVERLYING SKIN FROM THE BACK. The tissue is rotated from the back through a tunnel in the armpit to the area of the chest wall on the side of mastectomy. For small reconstructions, the flap can be used alone, but more often an implant or tissue expander is placed beneath the muscle flap. The skin overlying the muscle from the back is then used to replace the skin lost at the time of mastectomy. This procedure is useful in patients who have lost a significant amount of breast tissue.
Prosthetic reconstruction describes procedures that involve PLACEMENT OF AN IMPLANT BENEATH THE SKIN AND RESIDUAL MUSCLE REMAINING ON THE CHEST WALL, OR UNDER A MUSCLE FLAP TO RECREATE THE BREAST MOUND. Often times, this initial device is a TISSUE EXPANDER, which is an inflatable type prosthesis with a small valve which can be filled through the skin in the office after surgery. This is used to stretch the skin and muscle to accommodate the placement of a permanent breast implant in the future. The tissue expander is slowly filled in the weeks following surgery, and then allowed to remain in place for several months. A second procedure is required to exchange the tissue expander for a PERMANENT SILICONE OR SALINE FILLED IMPLANT. Often times a lifting procedure (mastopexy) may be performed on the opposite breast at this time to help achieve symmetry.
Regardless of the technique chosen to recreate the breast mound, a final procedure is required for RECONSTRUCTION OF THE NIPPLE AREOLA COMPLEX. This is often done in the office or in an outpatient setting several months after the breast mound is completed. Alternatives for nipple areola reconstruction include sharing the nipple and areola on the opposite side if they are large enough to provide adequate tissue for both sides. Nipple-areola sharing can provide an excellent color match. When these tissues are not available, the nipple and areola can be reconstructed using local skin flaps and skin grafts taken from other areas of the body. These then require tattooing to achieve a natural color match.
After I have examined you, based on your specific tissue requirement and the availability of the above listed donor tissues, I will recommend a specific approach for reconstruction to you. In many cases, I will be able to offer you more than one alternative. Each of these procedures has specific reasons for use as well as specific limitations. I will discuss these in much more detail with you. While there are many considerations, the overall quality of the reconstruction is most important. Although each situation varies, in general TWO TO THREE PROCEDURES ARE REQUIRED TO COMPLETE THE RECONSTRUCTION. The first involves transfer of the major amount of tissues for reconstruction of the breast mound, and the second reconstruction of the nipple areola complex or replacement of a tissue expander with a permanent implant. If indicated, modification of the opposite breast can be accomplished at the same time as one of these procedures.
Occasionally, a third touch up type procedure may be required to achieve optimal reconstruction. GENERALLY, ONLY THE FIRST PROCEDURE REQUIRES HOSPITALIZATION, WITH SUBSEQUENT PROCEDURES BEING PERFORMED ON AN OUTPATIENT BASIS.
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AT YOUR INITIAL CONSULTATION VISIT:
During your consultation, after I have reviewed your records in detail and communicated with the other physicians involved in your case, I will examine you thoroughly. The first step to a successful reconstruction is to determine which tissues have been lost, and what tissues are required to reconstruct the breast. I then carefully assess adjacent areas of the body from which I may be able to borrow donor tissue to reconstruct your breast mound. The availability of donor tissue and its quality are obviously critical factors in breast reconstruction.
In this consultation, I would expect you to be frank in discussing your expectations with me. Do not hesitate to ask any questions that you may have. I will be equally frank with you, explaining the factors that could influence the procedure and the results.
I cannot make the decision for you regarding whether to undergo surgery or not. I can only advise you regarding the surgical options and anticipated outcomes I would expect for you based upon your individual anatomy, desires, and realistic expectations. I will define goals in a surgical plan at this initial consultation. Follow up appointments will include time to ask further questions or review the procedure so that you are comfortable with its nature and implications. I will educate you and define the operative scenarios and choices available to you, but you must make the final decision regarding the surgical procedure.
When a decision is made to proceed with reconstruction, preoperative photographs will be taken. These photographs are necessary in the planning, execution and follow up of your reconstruction and are maintained as a portion of your medical record.
When I have determined which surgical procedures will be necessary for your reconstruction, I will discuss with you in detail surgical fees and estimated hospitalization time (usually not more than one week total), and will assist you in communication with your insurance carrier regarding their extent of coverage on your surgery.
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BEFORE YOUR BREAST RECONSTRUCTION:
Our nurse and office manager will make all arrangements regarding scheduling of your surgery and will give you specific instructions as well as reconfirm these with you by telephone and/or letter. Since my schedule and your desires must be coordinated with hospital and anesthesia schedules, please allow my personnel a reasonable amount of time to make these arrangements. They will make every attempt to accommodate your requests.
Good general health is mandatory for a problem free and predictable recovery from any surgical procedure. Wellness and good general health result from proper diet, regular exercise and appropriately timed medical evaluations focused on preventative medicine. Good nutrition, vitamin and herbal supplements, as well as adherence to holistic health principles are important concepts in maintaining wellness. Certain supplements, although generally beneficial, may have adverse effects during surgery. Please advise us about all your medications and supplements, so we may advise you regarding their safety in regard to your surgical procedure.
We believe that good nutrition is an important component to excellent surgical outcomes. Multiple studies show that most Americans aren’t getting the recommended daily intake of necessary vitamins and minerals, much less the optimal amount. These suboptimal levels of nutrients have been linked with major diseases from heart disease to cancer.
We use a three phase healing program with nutritional supplements to help you recover more quickly and with less downtime. We have you start this a week or so ahead of time to ensure that you are boosting your body’s immune system and removing anything that could interfere with anesthesia or increasing bleeding. Immediately following surgery we give you nutrients that help reduce pain and inflammation and detoxify the anesthesia and other medications. The third phase has additional healing nutrients to support your recovery.
Routine laboratory tests including blood counts and blood chemistries, a pregnancy test when applicable, and an electrocardiogram if you are over 50 years old, will be performed prior to surgery. These tests are performed routinely to screen for any abnormalities which might complicate your anesthesia or surgery.
Do not take any aspirin or any drug containing aspirin for at least two weeks prior to your surgery. Aspirin may retard platelet function, a blood component that is important to normal blood clotting mechanisms. There are many drugs which contain aspirin. Before taking any drug, check the label carefully to assure that it contains no aspirin.
Nicotine causes constriction of blood vessels, and can impair circulation to tissues following any surgical procedure, especially those of the skin. Smoking should be discontinued prior to the procedure for a minimum of 2 weeks. You should cease smoking for a minimum of 4 weeks following your procedure.
Do not eat or drink anything 8 hours prior to surgery. Safety in the administration of anesthesia or sedation requires that your stomach be absolutely empty for this interval of time before surgery.
You may shower or bathe normally the evening prior to surgery. Additional antiseptic cleansing of the skin areas will be carried out by our nurses immediately prior to your surgery.
You should wear loose fitting, comfortable clothing the day of surgery. A loose fitting shirt with buttons in front is preferable to any type of clothing which must be put on over the head. Please be sure that you have all of your questions answered prior to going into the hospital. I prefer that you make additional appointments in the office if necessary to answer questions regarding your surgery. On the day of surgery, I will visit with you briefly immediately prior to surgery.
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THE DAY OF SURGERY:
Most major breast reconstructive procedures are performed under general anesthesia. As mentioned above, the major procedure involving transfer of tissues for reconstruction of the breast mound is the most significant procedure. This procedure may take from three to six hours in the operating room, after which you will be in the recovery room for approximately one hour. Subsequent procedures for placement of a permanent implant, nipple areola reconstruction, or revision of the reconstruction may often be performed on an outpatient basis, and may require general or local anesthesia depending on the extent of the operation.
If your mastectomy and reconstruction are performed simultaneously, your surgical oncologist and I will both be present for the entire case and will assist each other during surgery. Often you may require small silicone drains to be placed to collected excess fluid during the healing period. Your nurses will show you how to care for them while you are in the hospital, and they will be removed in the office 7-14 days after your surgery.
Following your operation, a minimal to moderate amount of discomfort occurs in the first one to three postoperative days and improves rapidly. Total hospitalization time for the major procedure is usually between two to five days. I encourage you to be out of bed the day following surgery and walking in the hall as soon as possible. Regaining normal activity speeds your recovery significantly.
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POSTOPERATIVE HEALING:
Postoperative healing requires some mandatory down time as part of the surgical recovery process. Post surgical healing requires the body to repair the surgical wound (whether in the skin, fat, muscle or bone) with scar tissue. The bruise and tissue fluid in the wound are gradually replaced by stronger scar or fibrous tissue over a period of 6-8 weeks. Until the time that the healing area is strong enough to maintain tissue integrity, the wound is held together by the sutures (stitches) placed at the time of surgery. Too much wound tension (stress) before the strength of the healing tissue is satisfactory, can cause disruption of the incision. I place sutures very precisely to account for these healing characteristics to maximize your postoperative activity, comfort and safety. However, your inherent healing characteristics significantly dictate these parameters. Stretching, movement, massage, and return to normal activities of daily living in the early postoperative recovery allow for the optimal return to your full normal life style.
After the initial burst of high energy healing and the “bulking up” of scar tissue, the wound enters a maturation phase, and the scar tissue becomes thinner, less red and stronger. The maturing and stabilization of scar tissue occurs over a period of 6 to12 months. Long-term changes tend to be more subtle, slower, and less evident than short-term changes that occur in the first 6 to 8 weeks.
There are no absolute parameters regarding return to postoperative activities and one must adjust for variation in pain tolerance, invasiveness of surgery and healing variations.
In general, you cannot speed up the healing process, only slow it down by too much activity too soon. Overexertion can lengthen the period of time for pain to decrease, swelling and bruising to resolve, and the final surgical results to be evident. Healing occurs for up to 6 months. The latter changes tend to be subtle and gradual, and therefore not nearly as dramatic as in the initial 6 to 8 weeks.
Please be patient with your own healing. Any change in your appearance affects your perception of self-image and requires an adjustment period of days to weeks. It is normal to have mild feelings of doubt or a low mood during this period in the first 1 to 3 weeks following surgery. These feelings are then rapidly replaced by positive feelings as healing progresses and you adjust to your improved appearance.
Please contact me if any of the following occur: Marked increase in swelling in either breast, marked increase in discomfort in either breast, marked increase in redness or bruising in either breast, or a temperature taken orally above 101 degrees.
At your convenience, please call my office for an appointment to see me the first week following surgery if this has not already been done. Should you have any additional questions or should any problems at all arise, please contact my office at (303) 443-2277.
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LIMITATIONS, RISKS, AND POSSIBLE COMPLICATIONS
OF BREAST RECONSTRUCTION:
With any surgical procedure requiring general anesthesia, a very small risk is encountered from the anesthesia itself. Risks accompanying the procedure are small and include bleeding in one or two out of one hundred cases. Infection may occur in even fewer cases and bleeding or infection may require an additional surgical procedure. If severe infection occurs (extremely rare), it may cause damage or loss of tissue, or require temporary removal of the breast implant if one has been used.
A reconstructed breast can never exactly match the breast which was lost, but certainly provides a breast which becomes incorporated into your body image and precludes the necessity of wearing an external prosthesis, which is never incorporated into your body image. Our aesthetic goal in reconstructing a breast is to have it match as closely as possible the breast which was lost, given the limitation of your tissues and the surgical techniques which are available.
Scars are produced by any surgical procedure and continue to improve in appearance for six to twelve months. Scars will always be present both on the reconstructed breast and the area from which the tissue was taken. With the latissimus dorsi flap, this involves a scar on the back or in the case of the TRAM flap, a scar across the lower abdomen. A secondary revision of scars may occasionally be necessary after one year. My concerns regarding scars are the same as yours --- highest possible quality and least possible visibility. The degree to which we can match your normal nipple and areola with a reconstructed nipple areola complex depends to a large extent on tissue availability, your skin characteristics, color, and healing characteristics. I will discuss specific details and limitations with you during your consultation.
Whenever your tissues are transferred from one area to another, these tissues are partially deprived of their blood supply. I make every attempt to maintain adequate blood supply for survival of the tissue. Nevertheless, a balance between the ability to move the tissue and the risk to its blood supply always exists. If the transferred tissues do not have adequate blood supply in all areas, some or all of the transferred tissues may be lost. The chances that all transferred tissue will be lost are quite small (the range of one or two in one hundred for the latissimus flap and three to four per one hundred for the TRAM flap). Whenever this occurs, we turn to alternative sources of tissues to achieve the reconstruction. Partial loss of transferred tissues may occur in up to 5% of latissimus dorsi flaps or probably 7-10% of TRAM flaps. When partial loss occurs, it may be relatively minor, requiring no additional surgical procedures, or may require relatively minor revision.
Any of these complications are possible, but rare. The vast majority of breast reconstruction patients experience no complications whatsoever.
CONCLUSION:
Techniques for reconstruction of the breast following mastectomy have improved markedly over the past five years. Currently, excepting certain limitations, virtually any breast can be reconstructed with an average of one major and one or two relatively minor surgical procedures, with a total hospitalization time to accomplish reconstruction between two and five days. The requirements for breast reconstruction vary significantly with each individual patient. Decisions regarding breast reconstruction are complex, and require cooperation between you, us, and other physicians involved in your care.
As you review this information sheet, I encourage you to write down specific questions, which you may have for us. At the time of your consultation, I will review all of these items with you.
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