Breast Reconstruction

Charlotte Breast Reconstruction Experts – Dr. Graper and Dr. Harper

Breast cancer will affect one in ten American women. Twenty-five years ago, a woman’s only choice was removal of her breast to treat her disease. Now we have two choices; lumpectomy with radiation therapy or removal of the breast, otherwise known as mastectomy. Some patients will also receive chemotherapy if needed. The treatment choices and results have dramatically improved over the years. If one chooses mastectomy, then one has the option of breast reconstruction. This is where the breast is recreated using either one’s own tissues, such as extra abdominal skin and fat known as the TRAM (Transverse Rectus Abdominus Myocutaneous) flap, or using synthetic material such as an implant. Each plastic surgery technique has its own advantages and disadvantages. As highly trained Charlotte breast reconstruction surgeons, Dr. Graper and Dr. Harper perform both breast restoration techniques. If a patient elects to have reconstruction after a mastectomy, then the next decision is whether to have the reconstruction immediately after the breast is removed or wait several months later to begin reconstruction. If one knows they want to recreate the breast, then there is no reason to wait. The risk of recurrence and overall survival rate is not affected by a reconstructive procedure or the timing of such a procedure. If one is not sure of their desire for reconstruction or there are medical considerations like post-operative chemotherapy, then delayed reconstruction is appropriate.

Procedures

Once the decision has been made to begin the reconstruction immediately after the mastectomy then the patient must decide which plastic surgery technique to pursue, autologous abdominal tissue or synthetic implant. The advantage of the autologous tissue (TRAM) is that one is replacing the skin and fat of the breast with very similar skin and fat of the abdomen. Most patients in this age range have had children and have put on a few extra pounds. These traits make those patients good candidates to use that extra tissue and make a very natural breast. So, not only is the breast reconstructed, but the patient gets a modified tummy tuck as well. The new breast will not rupture or get hard like an implant can over time. The disadvantage is that the plastic surgery operation is much longer because it now involves both the breast and the abdomen. Two surgical sites also produce more discomfort and a longer recovery time. Most patients are in the hospital four to six days post-op and require six to eight weeks off work. The implant-type reconstruction is in many ways more simple than the autologous technique. In order to replace the skin and fat of the natural breast, we stretch the skin with a sterile balloon called a tissue expander. The tissue expander is placed under the muscle at the time of the mastectomy, then slowly inflated through a one way valve over the next three months. Once the skin is stretched by the expander, the expander is replaced by a permanent implant with a natural tear-drop shape. Obviously, this involves one more stage than the autologous technique, but each surgery only lasts 60-90 minutes. Most patients go home the day after the mastectomy and tissue expander reconstruction. The second stage where the tissue expander is exchanged for the permanent implant is done as an outpatient. There is much less discomfort with this procedure and many people are back at work in two to three weeks. The disadvantage with implants is that even though the stages are easier, it is a two stage procedure. The implants are more sensitive to infection, but still only 1-2% experience any problems. If the capsule or scar around the implant contracts, then the implant will becomes hard. This can be fixed but requires another minor procedure. Most plastic surgeons prefer silicone implants over saline implants because of the superior look and feel in thin skinned patients, as all mastectomy patients are. There has been a great deal of controversy regarding the safety of silicone implants. Fortunately, all the credible studies have confirmed the safety of silicone implants. Once the breast mound has been created by either plastic surgery technique, then the nipple is reconstructed approximately three months later. The nipple is tattooed when complete healing has occurred. Lastly, a new approach in the last 5 years is that of fat grafting. This is the least invasive technique but requires several stages and an appliance. The appliance is a suction device worn over the breast for 3-6 weeks 18 hours/day to prepare the tissue to accept the fat cells harvested from other donor areas of the body. The fat is injected through small needle punctures in multiple areas of the breast. The device is then reapplied until the tissue is ready for more volume and the fat grafting is done again until the volume of the breast matches the opposite side. These are outpatient procedures with the advantage of removing fat in areas that patients want improvement. It is cumbersome to wear the device but very manageable. These are very specialized procedures and though they are safe, there are many potential problems. We will review these with you so that you will completely understand every facet of the treatment. There is also a back up plan for every step so that if a problem develops we can definitely handle the situation.

Trends

After years of performing breast reconstruction, several trends stand out. The autologous reconstruction seems to offer the best long-term reconstruction in terms of body appearance and ongoing maintenance requirements. This procedure is for motivated patients because it is harder on them than the implant technique. For those patients who, for whatever reason, cannot tolerate the increased initial discomfort and longer recovery time of autologous reconstruction, then the implant procedure is a good alternative. We have found that there is beauty in symmetry. If only one breast is to be reconstructed, then the autologous tissue reconstruction is best because there is skin and fat making up both the reconstructed and non-involved breasts. If both breasts need to be removed, then breast implants are a reasonable choice because both breasts will be made of the same material and can be of a larger size than if the autologous technique were used. This is not a rule, but merely an observation regarding symmetry. When performing breast reconstruction, it makes no sense to make a new breast to match an older, unattractive, drooping breast. For this reason, many patients opt to lift their drooping opposite breast, then match this breast with the reconstructed breast. The insurance companies are required to cover both procedures as of 1999. Some patients take the opportunity to increase or decrease the size of their unaffected breast and then match the improved breast with their reconstructed breast. They often note that they would not have normally made the changes in breast size, but once this problem was forced on them, they made the best of a bad situation and made their breasts the size they had always wanted. Breast reconstruction is a complicated issue with many different nuances. We are well acquainted with all the different aspects of breast reconstruction, and will guide you to the procedure that is right for you. We know what you want.

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“I felt very comfortable with Dr. Graper and his team…very accommodating and very thorough from first consultation, to surgery, to post op follow ups…. They make what could be a very nervous and scary experience a smooth and comforting one.”

ASPS Update on Breast Reconstruction