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Breast Reconstruction

Breast Reconstruction is a surgical procedure used to reconstruct the breast mound.  There are a variety of surgical techniques for breast reconstruction.  The technique that is best for you will depend on if you have had radiation, how quick of a recovery you want, whether you want to use your own tissue for the reconstruction, or if you want an implant used in your reconstruction.  These procedures include, but are not limited to breast reconstruction with a TRAM abdominal muscle flap, a DIEP abdominal flap, SGAP flap, IGAP flap, tissue expander/implant, implant, or latissimus and implant reconstruction.  Most breast reconstructions are a staged process.  You may also need procedures done on your non-cancer side for symmetry if you have only had a mastectomy on one side.  You can have an immediate reconstruction at the time of your mastectomy or have a delayed reconstruction at a later date.  The decision to do your reconstruction as immediate or delayed will depend on your type of cancer, and the possibility of needing radiation postoperatively.  If radiation is needed it is always best to have some of your own tissue used for your reconstruction as it will bring a good blood supply with it.  A good blood supply aids in healing, and reduces the risk of infection or erosion.

Direct to implant-This type of reconstruction is usually done at the time of mastectomy, and is usually done in people who are a good candidate for a nipple sparing mastectomy.  This is a quicker recovery than if your own tissue is used in your reconstruction.

Expander/Implant-This is usually a staged process.  It first involves the use of a balloon like tissue expander that is inserted beneath the skin and chest muscle.  Saline is gradually injected into the tissue expander to fill it over a period of weeks or months.  In most cases, once the skin has been stretched enough, the expander will be removed and replaced with a permanent implant.  This will be followed by nipple areola reconstruction.  This is usually a quicker recovery than if your own tissue is used in your reconstruction.

Latissimus/Implant-This technique is a staged procedure and involves the use of a muscle located on the back along with its attached skin which is transferred to the chest area for the breast reconstruction procedure.  A tissue expander followed by an implant is usually done with this to add volume.    The nipple areola complex reconstruction is done as a separate procedure once the implant has settled.  This requires a longer recovery time than if an expander/implant reconstruction is done.

TRAM-This technique involves the use of abdominal muscle (rectus abdominus) and the overlying skin of the lower abdomen which is repositioned to the chest wall region in order to reconstruct a breast mound.  A nipple areola complex reconstruction is done as a separate procedure once the tissue has settled.  This requires a longer recovery time than if an expander/implant reconstruction is done.

DIEP abdominal flap-This technique uses the skin and soft tissue from the lower abdomen which is repositioned to the chest wall region in order to reconstruct a breast mound.  This procedure uses the blood supply and blood vessel from the lower abdomen which is tied into a blood vessel in the chest to keep the tissue alive.  The muscle of the lower abdomen is left intact with this procedure.  A nipple areola complex reconstruction is done as a separate procedure once the tissue has settled.  This requires a longer recovery time than if an expander/implant reconstruction is done.

SGAP flap-This is a skin and soft tissue flap from the buttock which is repositioned to the chest wall region in order to reconstruct a breast mound.  This procedure is based off a perforator from the superior gluteal artery which is tied into a blood vessel in the chest to keep the tissue alive.  A nipple areola complex reconstruction is done as a separate procedure once the tissue has settled.  This requires a longer recovery time than if an expander/implant reconstruction is done.

IGAP flap-This is a skin and soft tissue flap from the buttock which is repositioned to the chest wall region in order to reconstruct a breast mound.  This procedure is based off a perforator from the inferior gluteal artery which is tied into a blood vessel in the chest to keep the tissue alive.  A nipple areola complex reconstruction is done as a separate procedure once the tissue has settled.  This requires a longer recovery time than if an expander/implant reconstruction is done.

Again, Dr. Lovelace will perform a personal consultation with you to determine what the right procedure is for you at our Fort Worth office which is conveniently located to Southlake, Keller, Argyle and Mansfield just off of Heritage Trace Parkway.

What are the other names for this procedure?

Creating new breasts after cancer

What pain will I have?

Mild to high

What will it cost?

Typically this procedure is covered by insurance.  You may owe your insurance deductible  co-pay, or out of pocket expenses depending on your insurance policy.  If you don’t have insurance, a price quote which includes fees for the facility, anesthesia, and surgeon will be given to you at your consultation.

What is the hospital/surgery center time?

The procedure can take between 1-8 hours depending on the procedure you are getting.  You will either go home the same day, or stay up to 3 nights in the hospital depending on your individual needs, and the extent of the reconstructive surgery.

What is the recovery?

Sutures that are placed are usually dissolvable and will not need to be removed.  In some circumstances, a drain may be needed.  These drains help prevent hematomas and seromas.  If a drain is left in place, it is usually removed 1-2 weeks after surgery depending on the output.  You will be placed in a special bra after your surgery, and told to wear this at all times for 4 weeks, and then only at night for 4 more weeks.  You will be expected to start walking immediately after surgery to help reduce the risk of blood clots.  On average patients return to light duty work 1-7 days after surgery.  You will be able to return to non-strenuous activity approximately 1-2 weeks after surgery.   Approximately 8 weeks after surgery, strenuous activity will be allowed without restrictions.  Scars will flatten and fade between 3 months and 2 years after surgery.  No swimming pools, bath tubs, or hot tubs until the incisions are healed, and no scabs remain.  You will be allowed to shower 48 hours after your procedure and wash over your incisions with soap and water.  Final bra size can be determined within 8-12 weeks after your last surgery.  Typically breast reconstruction is a staged procedure, and is not all completed with just one surgery.

What medications should I take or avoid taking with my surgery?

You should not take any blood thinners or anti-inflammatory medications for a week before your procedure, and you should hold all over the counter supplements a week before surgery.  This will help reduce the risk of bleeding intraoperatively, and help reduce the risk of postoperative hematoma (collection of blood).  If blood thinners are prescribed for you by your cardiologist or primary care physician, you should get clearance from them to hold these medications before they are discontinued.  You should hold all hormones 6 weeks before surgery.  Birth control pills should be held 6 weeks before surgery as well.  Of course you should make sure to use alternative forms of birth control during and after this time.  Hormones and birth control pills put you at a higher risk of blood clots.  These clots can go to your lungs and cause serious illness or even death.  We call this a pulmonary embolus.  Steroids should be weaned off at least a month before your surgery, and this weaning process should be set up and cleared by your prescribing physician.  If you are on medications for your cancer you may be asked to hold these if cleared to do so by your prescribing physician to also help reduce the risk of blood clots.  If you are doing chemotherapy, the timing of surgery will depend on your chemotherapy schedule.  If you are doing radiation therapy, Dr. Lovelace will ask that you wait until 6 months after your last dose of radiation before reconstruction is started.  Dr. Lovelace and the staff will go through your list of medication, and let you know what exactly you need to do with those medications preoperatively.  Make sure that you bring all of your medications with you to your consultation.  You will usually be given your prescriptions for your postoperative medication on your preoperative visit so that they can be filled and at your house when you get home from surgery.

Will I need clearances from any other physicians?

Depending on your age and medical issues, Dr. Lovelace and her staff will set you up with your primary care physician, oncologist, cardiologist, etc. for clearance prior to your surgery.  At that time any necessary labs, EKGs, or chest x-rays will be done.  If you have not had a mammogram to your remaining breast within the last year, Dr. Lovelace will request that you get one preoperatively.  If you have had bilateral mastectomies this will not be needed.

What are the risks of Breast Implant Exchange?

The risks of breast implant exchange include bleeding, infection, scarring, hematoma, seroma, possible need for drains, dehiscence, contour irregularities, asymmetry, poor cosmesis, need for further intervention, numbness/hypersensation, intra-thoracic injury, skin necrosis, need for skin excision, breast ptosis over time, stretch marks, weight gain/loss/pregnancy can change result, fat necrosis, capsular contracture, implant visability/palpability/malposition/rupture/bottoming out, cardiac/pulmonary/stroke/DVT/PE events, death, etc.

What are the risks?

We will discuss the risks, benefits, alternatives, and no intervention, as well as patient expectations. Plastic Surgery operations have subjective outcomes which may be dependent upon patient anatomy, procedure performed, and patient expectations. While a specific result cannot be guaranteed, and peri-operative problems may occur, every effort will be made to deliver a good result in a safe and ethical manner.
Breast reconstruction is a challenging process, but may be very rewarding for patients with realistic expectations. A natural breast cannot always be recreated and there will not be exact symmetry. Multiple stages, revisions, and treatment plan changes may be required throughout the breast reconstruction process. Variations secondary to anatomy, lumpectomy, mastectomy, axillary dissection, and radiation therapy all impact the reconstructive method chosen as well as the outcome. The patient will be educated on alternative breast reconstruction techniques such as expander/implant, latissimus, TRAM, and free flaps. We will also discuss immediate vs. delayed reconstruction, and nipple areolar complex reconstruction.
The risks of expander/implant reconstruction include bleeding, infection, scarring, hematoma, seroma, need for drains, dehiscence, contour irregularities, asymmetry, poor cosmesis, need for further intervention, numbness/hypersensation, intra-thoracic injury, skin necrosis, breast ptosis over time, results changing over time, fat necrosis, capsular contracture, implant visability/palpability/malposition/rupture/erosion, cardiac/pulmonary/stroke/DVT/PE events, death, etc.
The risks of flap reconstruction include bleeding, infection, scarring, hematoma, seroma, need for drains, dehiscence, contour irregularities, asymmetry, poor cosmesis, need for further intervention, numbness/hypersensation, intra-thoracic injury, skin/flap necrosis, breast ptosis over time, results changing over time, fat necrosis, capsular contracture, implant visability/palpability/malposition/rupture/erosion, donor site morbidity, longer recovery, longer hospital stay, possible vascular occlusion, flap loss, cardiac/pulmonary/stroke/DVT/PE events, death, etc.

Please contact our office in Fort Worth which is conveniently located to Southlake, Keller, Argyle and Mansfield just off of Heritage Trace Parkway about scheduling an appointment with Dr. Lovelace.