- Am I Ready for Breast Reconstruction?
- Breast Flap Reconstruction
- Latissimus Dorsi Flap Breast Reconstruction
- TRAM Flap Breast Reconstruction
- Tissue Expander and Implant Reconstruction
- Schedule a Consultation
For many women diagnosed with breast cancer, a mastectomy may present the best option to increase their long-term survival chances. After a mastectomy, patients can choose to have a reconstruction after other adjuvant treatments have been completed, such as chemotherapy or radiation. Dr. Cherup prefers this path. There are some recent statistics that show long-term survival may be improved by this path. Some patients who have a mastectomy and do not need chemotherapy or radiation elect to have reconstruction immediately after the mastectomy, especially if they are having bilateral mastectomies. Breast reconstruction recreates the size and shape of the patient’s natural breast. For some patients, it actually offers a breast profile that is greatly improved.
How Do I Know If I Am Ready For Reconstruction?
Your oncologic surgeon who performs the mastectomy will suggest to you when to have your reconstruction. A consultation with our Pittsburgh plastic surgeon, Dr. Lori Cherup, is very necessary as early in the process as possible to define your health and any risks for surgery it poses. Smoking, being overweight, or multiple medical issues such as hypertension, diabetes, or a need for anticoagulation will affect Dr. Cherup’s decision process regarding timing for you. Your family and job responsibilities — and how much time you are willing to be absent from them — will greatly affect the decision regarding timing and type of reconstruction. Rest assured, you and Dr. Cherup will come to the correct decision for you.
Breast Flap Reconstruction Surgery
Reconstruction using your own tissue is a good option for patients who are large in weight, need one large breast created, who can benefit from a tummy tuck, have loose abdominal or back skin and have more than two months to devote to healing from reconstruction. Flap reconstruction always requires a hospital stay — usually three to six days. Long scars from the donor site on your back or lower abdomen will be necessary.
Dr. Cherup does not perform “free flap surgery” requiring microvascular reconstruction. This surgery, called a DIEP, SGAP, or free TRAM flap, is usually performed at university hospitals. Dr. Cherup will happily refer you if you and she decide this is your best option for reconstruction.
Latissimus Dorsi Flap Surgery
This surgery is a good option for patients who want to match a larger breast; need a large skin paddle, because a lot of skin had to be removed during the mastectomy, and have some loose skin on their back. An ellipse of skin carried by the latissimus dorsi muscle is moved from the back to the front chest to recreate the breast skin — a small implant is usually necessary to provide some volume. The back is closed as a straight line scar; it is hidden under the bra chest band. The breast on the front can be large but will have scars in the horizontal mid-breast plane. Two or four days in the hospital is usually necessary, as well as three drains, which will not be removed for at least a week.
The final result is healed in one month and may require one small revision.
Postop problems include a widened back scar, a chronic seroma in the back skin, and less than optimal breast scars. All of these problems can be improved with a revision.
Tram Flap Reconstruction
The transverse rectus abdominis muscle flap was developed 30 years ago to utilize excess abdominal fat to make a breast. The breast is made totally from one’s own tissue, and does not require implants. This operation is good for patients with a looser, fatter abdomen, often the result of pregnancies or weight gain. Very obese patients are not good candidates because of increased complications of hernias and deep venous thrombosis. A large paddle of skin and fat with one of the rectus muscles as a carrier is moved onto the chest to recreate a breast. The abdomen is closed and benefits from a tummy tuck. The patient benefits from a very full large breast. This surgery requires four to seven days in the hospital and at least a six to eight week recovery. Many patients believe it takes four months to fully recover from the surgery.
Postop problems include anemia from blood loss, and an incisional hernia in the lower abdomen where the rectus muscle is moved. The anemia is usually treated with transfusions and iron pills. Any hernia that might develop can be repaired in the future with a fairly small operation.
Tissue Expander and Implant Reconstruction
Tissue expander reconstruction requires acceptance of implants as the primary means of reconstruction. The silicone implants that we have now are the fourth generation of implants that have been developed since 1960. They are durable, safe, and have significantly less complications than implants before them. We have new shapes and sizes of implants that can produce a more natural looking and feeling breast. Implant-based construction is good for patients who want their surgeries to be done on an outpatient basis, who do not want a very large breast (like a DD cup) and who want to continue to work or take care of their families during the healing period.
Eighty-five percent of breast reconstructions done in the United States are expander/implant surgeries. During the consultation, Dr. Cherup will measure your existing chest wall, your native breast and its droopiness parameters, and discuss your desires. Previous scars from biopsies, lumpectomies, or the mastectomy itself will be examined. She will determine how they will affect the final outcome. Previous radiation can affect the success of the expansion. The tissue expander size and diameter will be chosen. If the reconstruction is to be started immediately after a mastectomy is performed, an allograft dermal matrix such as AlloDerm or Strattice may be used over the expander, attaching the bottom edge of the pectoralis muscle to the chest wall.
The first stage of the reconstruction involves making an incision in the inframammary fold that allows the expander to be placed under the pectoralis muscle. Upper abdominal skin can be advanced upward into the created breast to provide more breast skin. Dr. Cherup does this frequently. AlloDerm or Strattice may be used to provide more cover for the expander. This surgery lasts about two hours, and the inframammary incision is closed with a subcuticular suture.
Two weeks later, the expansion begins with a small, non-painful in-office procedure. Usually 50 to 100 cc of saline is added to the expander at a session. Within six weeks, the expander is fully expanded. The expander can be exchanged for implant within four weeks of full expansion. Prior to this second surgery, Dr. Cherup will discuss with you the options for the exact size and shape of silicone implant to be used. Dr. Cherup prefers to use Allergan or Sientra silicone implants, whether they be anatomic shaped or round. Sometimes additional work must be done on the chest wall pockets to make the shape perfect at this second surgery. Often a mastectomy or perhaps a small augmentation is necessary with the native breast in order to gain symmetry. Rest assured, Dr. Cherup will continue to achieve the best surgical outcome and the best improvement in your whole body profile that you will allow her to pursue.
Schedule a Breast Reconstruction Consultation
If you have questions about breast reconstruction, or you would like to schedule a consultation with Dr. Cherup, please call (412) 220-8181 or (877) 441-0639.