Breast Reconstruction
Breast Reconstruction
This guide serves as a short overview on several aspects of breast reconstruction, including partial breast reconstruction after lumpectomy/partial mastectomy. As a health practitioner, Dr. Tavin believes it's important for medical diagnosis and treatment of any type of cancer to be the primary focus. Therefore, he will always support the recommendations of the cancer doctors even if they might diminish the results of the reconstruction.
Most reconstruction we perform are done at the time of the mastectomy. The mastectomy incision is designed for the breast surgeon and is usually assisted by the cosmetic surgeon in the mastectomy surgery. During this procedure, close attention is paid to the preservation of the fold under the breast and restoration of the outer border of the breast to improve the shape of the reconstruction.
We perform three types of breast reconstructions:
- temporary tissue expander to be replaced by breast implant
- back muscle (latissimus dorsi flap) plus tissue expander
- abdominal muscle (transverse rectus abdominis muscle or TRAM flap)
All patients are offered the option of nipple and areola reconstruction, but not everyone chooses to have it done. Each woman’s decision is her personal choice.
Temporary Tissue Expander
Expander/implant reconstruction is the most common type performed in the US. Most of our patients spend one night in the hospital and can return to work within two weeks. Prescribed muscle relaxants in addition to pain medication are given as the stretching of the overlying pectoralis major muscle by the expander is the chief cause of discomfort.
For women who have a one-sided mastectomy, we typically do a lift on the other side to improve the symmetry at the time of expander replacement. For those who are having both breasts reconstructed, expanders followed by implants provide the best symmetry and give the woman the option to choose her breast size.
Pre-Pectoral Breast Reconstruction
Since the late 1980s plastic surgeons have been placing tissue expanders and breast implants below the pectoralis major muscle to avoid capsular contractures (hard scars) that had been noted to form when implants were placed underneath the skin and fat after mastectomies. A downside of the standard sub-pectoral breast reconstruction is the abnormal motion of the whole breast when the arms are moved (termed animation deformity). How noticeable this is varies from person to person.
Around 2014 a number of plastic surgeons began creating a pocket formed from acellular dermal matrix (cadaver skin from which the donor’s cell have been extracted) above the pectoralis muscle (pre-pectoral) that had the benefit of minimizing development of capsular contracture while avoiding animation deformities. Additional benefits of pre-pectoral reconstruction include the ability to place the implants closer to the breast bone than in sub-pectoral reconstruction and a shorter time period to fill tissue expanders.
Pre-pectoral reconstruction can be performed at the time of the mastectomy or at a later date if issues arise with a sub-pectoral reconstruction. Dr. Tavin was the first surgeon at Plastic Surgery Group of Memphis to perform pre-pectoral breast reconstruction.
Back Muscle Plus Tissue Expander
The back muscle with expander/implant is a technique to help avoid a hard scar from forming in women who have previously had radiation to the breast in conjunction with a lumpectomy/partial mastectomy or will need radiation following the mastectomy.
If post-operative radiation will be necessary, reconstruction is deferred until 6-12 months after the radiation. This combination technique can also create a larger breast than an implant or muscle flap alone. Women usually spend one night in the hospital can return to work in 2-3 weeks.
Abdominal Muscle
The TRAM flap allows creation of a reconstructed breast that can match the natural ptosis or droopiness of the remaining breast. This operation is not a good option to reconstruct two breasts as it eliminates the ability to sit up normally forever. Although I have had many women refer to the TRAM flap as the tummy tuck operation, the appearance of the abdomen after a TRAM flap does not look as good as that after a real tummy tuck.
Women spend about 3 days in the hospital and may need a several weeks to months to return to work.
Partial Breast Reconstruction
Most women undergoing lumpectomy/partial mastectomy do not need reconstruction, but some women have so much tissue removed that they would benefit from surgery to restore shape and symmetry.
This might range from rearranging the remaining breast tissue, reducing the opposite breast, transferring fat to the operated breast, or using the back muscle without an implant. Unfortunately whereas reconstruction after complete mastectomy is mandated by Federal Law, partial breast reconstruction may or may not be covered by the woman’s insurance company. We will always make efforts to obtain coverage in such cases.
Before and After Photos
