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Breast reconstruction is a surgical procedure that restores shape to your breast after mastectomy — surgery that removes your breast to treat or prevent breast cancer.
One type of breast reconstruction uses breast implants — silicone devices filled with silicone gel or salt water (saline) — to reshape your breasts. Breast reconstruction with breast implants is a complex procedure performed by a plastic surgeon.
The breast reconstruction process can start at the time of your mastectomy (immediate reconstruction), or it can be done later (delayed reconstruction). The breast reconstruction process usually requires two or more operations. You can also expect to several appointments over two to three months after your initial surgery in order to expand and stretch the skin on your chest in preparation for the implant.
Breast reconstruction with a breast implant carries the possibility of complications, including:
Before a mastectomy, your doctor may recommend that you meet with a plastic surgeon. Consult a plastic surgeon who’s board certified and experienced in breast reconstruction following mastectomy. Ideally, your breast surgeon and the plastic surgeon should work together to develop the best surgical treatment and breast reconstruction strategy in your situation.
Your plastic surgeon will describe your surgical options and discuss the advantages and disadvantages of implant-based reconstruction, and may show you photos of women who have had different types of breast reconstruction. Your body type, health status and cancer treatment factor into which type of reconstruction will provide the best result. The plastic surgeon provides information on the anesthesia, the location of the operation and what kind of follow-up procedures may be necessary.
Your plastic surgeon may discuss the pros and cons of surgery on your opposite breast, even if it’s healthy, so that it more closely matches the shape and size of your reconstructed breast. Surgery to remove your healthy breast (contralateral prophylactic mastectomy) can double the risk of surgical complications, such as bleeding and infection. Also, there may be less satisfaction with cosmetic outcomes after surgery.
Before your surgery, follow your doctor’s specific instructions on preparing for the procedure. This may include guidelines on eating and drinking, adjusting current medications, and quitting smoking.
Breast reconstruction begins with placement of a breast implant or tissue expander, either at the time of your mastectomy (immediate reconstruction) or during a later procedure (delayed reconstruction). Breast reconstruction often requires multiple operations, even if you choose immediate reconstruction.
A breast implant is a round or teardrop-shaped silicone shell filled with salt water (saline) or silicone gel. Once restricted because of safety concerns, silicone gel implants are now considered safe.
A plastic surgeon places the implant either behind or in front of the muscle in your chest (pectoral muscle). Implants that are put in front of the muscle are held in place using a special tissue called acellular dermal matrix. Over time, your body replaces this tissue with collagen.
Some women are able to have the permanent breast implant placed at the time of the mastectomy (direct-to-implant reconstruction). However, many women require a two-stage process, using a tissue expander before the permanent implant is placed.
Tissue expansion is a process that stretches your remaining chest skin and soft tissues to make room for the breast implant. Your surgeon places a balloonlike tissue expander under or over your pectoral muscle at the time of your mastectomy. Over the next few months, through a small valve under your skin, your doctor or nurse uses a needle to inject saline into the valve, filling the balloon in stages.
This gradual process allows the skin to stretch over time. You’ll go to your doctor every week or two to have the saline injected. You may experience some discomfort or pressure as the implant expands.
A newer type of tissue expander uses carbon dioxide. This remote-controlled expander releases the gas from an internal reservoir. Compared with the expansion using saline, the gradual expansion using carbon dioxide may decrease the amount of discomfort you feel.
After the tissue is adequately expanded, your surgeon performs a second surgery to remove the tissue expander and replace it with a permanent implant, which is placed in the same place as the tissue expander.
You may be tired and sore for several weeks after surgery. Your doctor will prescribe medication to help control your pain.
Getting back to normal activities may take six weeks or longer. Take it easy during this period.
Your doctor will let you know of restrictions to your activities, such as avoiding overhead lifting or strenuous physical activities. Don’t be surprised if it seems to take a long time to bounce back from surgery — it may take as long as a year or two to feel completely healed.
Generally, you’ll follow up with your plastic surgeon on a yearly basis to monitor your reconstructed breast after the reconstruction is complete. Make an appointment sooner than that, however, if you have any concerns about your reconstruction.
Breast reconstruction may also entail reconstruction of your nipple, if you choose, including tattooing to define the dark area of skin surrounding your nipple (areola).
If you’ve had only one breast reconstructed, you’ll need to have screening mammography done regularly on your other breast. Mammography isn’t necessary on breasts that have been reconstructed.
You may opt to perform breast self-exams on your natural breast and the skin and surrounding area of your reconstructed breast. This may help you become familiar with the changes to your breast after surgery so that you can be alert to any new changes and report those to your doctor.
Keep your expectations realistic when anticipating the outcome of your surgery. Breast reconstruction surgery offers many benefits, but it won’t make you look or feel exactly like you did before your mastectomy.
What breast reconstruction can do:
What breast reconstruction may do:
What breast reconstruction won’t do:
A DIEP flap is a type of breast reconstruction in which blood vessels called deep inferior epigastric perforators (DIEP), as well as the skin and fat connected to them, are removed from the lower abdomen and transferred to the chest to reconstruct a breast after mastectomy without the sacrifice of any of the abdominal muscles.
It is never medically necessary to have breast reconstruction. This is considered an elective procedure, meaning you can choose to have it done or not. Some women choose to have a mastectomy (removal of breast tissue) without reconstruction. Federal law mandates all insurance plans pay for breast reconstruction for breast cancer.
Many patients prefer to have reconstruction done (or at least the process started) at the same time as their mastectomy. Breast reconstruction performed at the same time as your mastectomy is called immediate reconstruction. Delayed reconstruction is a term used if you choose to have the mastectomy done and then wait to have the reconstruction at a later date.
The majority of the surgeries done at Albany Medical Center are immediate reconstruction. With immediate reconstruction, you are decreasing the overall number of surgeries you may need. You have a better chance at an optimal cosmetic result. For many women, there is a psychological benefit to immediately pursuing reconstruction.
The vast majority of women are candidates for reconstruction. There are a variety of reconstructive options and you may not be a candidate for all types. You and your plastic surgeon will discuss which type of breast reconstruction is best for you.
There are three types of breast reconstruction. The first is tissue expander reconstruction, also known as implant reconstruction. The second is autologous tissue reconstruction, also known as free flap reconstruction which is a procedure where your plastic surgeon uses your own tissues, typically from the abdomen but can also come from your buttocks and thighs. The third is a combination of the two methods, using your own tissue from the back, latissimus muscle, plus a tissue expander/ implant underneath.
In addition, Albany Med offers nipple and areola reconstruction and tattooing.
Implants are not lifetime devices; both saline and silicone implants can rupture or leak. If you have saline implants, you will notice a slow deflation of the implant. The body is able to absorb the saline leaking out of the implant and over a few days to a week and you will notice that your implant is getting smaller.
If you have silicone implants, there may be a change in the shape of the implant, however most of the time, there is no change at all. The only way to detect a leak in a silicone implant is through MRI.
Implant ruptures rates, regardless of saline or silicone, are approximately 1% per year; this means that your implant can rupture at any time after being placed.
Placing implants after a mastectomy is very different than putting in implants for cosmetic augmentation. When women have a cosmetic augmentation, their skin and breast tissue is left intact. These healthy tissues are better able to stretch and accommodate the breast implant. During a mastectomy, the breast surgeon needs to remove some skin along with the nipple/ areola complex. This skin deficit does not usually allow for an immediate implant placement. There are some cases where the breast surgeon will leave the nipple/ areolar complex. Immediate implant placement can be done, however we are limited in the size of implant with this option and symmetry with the contralateral breast is not always achieved.
Women who need chemotherapy after the mastectomy are still candidates for implants. Sometimes we need to adjust the surgery date based on your chemotherapy schedule. For example, we will postpone your second stage surgery (to remove tissue expanders and place the implants) until you have recovered from your chemotherapy. Your plastic surgeon and medical oncologist will decide in what is best for you. Women undergoing chemotherapy may also take longer to heal from incisions. The impact of this is normal and expected.
Radiation on implants is something that needs to be discussed carefully with your surgeon. It is true that women who have implants and radiation are at higher risk for complications, such as capsular contracture and implant loss.
Once you have decided to undergo mastectomy and reconstruction, you will need to decide what type of reconstruction you desire. You will then need to contact your surgeons to let them know you are ready to schedule your procedure. A pre-operative appointment will be set up for you in which you will need pre-operative blood work and other studies. Sometimes, you will require medical or cardiology clearance.
If you choose mastectomy and tissue expander/implant reconstruction, you should plan to be in the hospital one to two days with recovery at home of approximately four weeks. You can expect your first tissue expansion at two weeks post-operatively. Exchange of the tissue expansion for implant will occur around three months after your final expansion, but this may vary depending on if you need chemotherapy or radiation.
For implant reconstruction, most women take four weeks off following the mastectomy and placement of the tissue expanders and one week off of work after the second surgery (removal of the tissue expanders and placement of the permanent implant). Many women are able to return to work during the tissue expansion process.
For tissue flap reconstruction, women generally take four to six weeks off of work.
It is safe to resume driving when all drains are out (more about these below), when you are off all prescription pain medication and when you have regained safe range of motion of your arms. For most women, this is about three or four weeks after the mastectomy surgery.
Drains are placed under the skin during surgery to remove what fluids the body produces after surgery. The drain looks like a narrow plastic tubing that connects to a drainage bulb, which is the size of a closed fist. The drains expedite the drainage process and help decrease the chance of a seroma or fluid collection. You will go home with drains. On average, drains may stay in one to three weeks. You will usually have two drains underneath the arms on the side of your mastectomy. If you use your own tissue, you will have two drains in the abdominal area as well. The drains are easy to care for. You and your family members will be taught how to care for them while you are in the hospital. Generally you will need to strip the tubing to make sure the tube stays open and empty the fluid into a measuring cup. You will need to keep track of the 24 hour total of fluid from each drain.
While the drains are in, you cannot take a bath or submerge yourself into water. You may shower with drains. You should limit reaching and excessive stretching of your arms immediately after your mastectomy. Once the drains from your breast are removed, you may be given limited exercises to start, generally range of motion exercises. If you have tissue taken from your abdomen, you will not be able to lift anything more than five pounds (a gallon of milk) or do any strenuous exercises for six weeks. Walking is fine and can actually speed up your recovery.
Revision of the breast can be done after you are healed from the primary reconstruction surgery. There are techniques that the plastic surgeon can do to improve the shape and size of the reconstructed breast to achieve a better symmetry with the other breast; or if both breasts are reconstructed, with each other. Depending on whether implants or a flap was used in the reconstruction, options can include:
Fat grafting- taking fat from somewhere else on the body, usually the abdomen or thighs, using liposuction and injecting it into the breast flap or around the implant. Excision or removal of extra skin or fatty tissue- to make the breast flap smaller or less bulky. Placing an implant under the breast flap- similar to a breast augmentation using saline or silicone implants.
Once you are completely healed from the breast reconstruction and finished with all of the revision surgeries, your other breast is shaped to match the reconstructed breast. This can be done by reducing the size of the breast with performing a breast reduction or possibly increasing the size of the breast with a breast augmentation using implants. If the breast is drooping, we may also lift the breast to match the height of the reconstructed breast. You will never achieve complete symmetry however, we can try to match the breasts as close as possible using all of the above options. These procedures are all covered by insurance.
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A mastectomy is surgery to remove all breast tissue from a breast as a way to treat or prevent breast cancer. For those with early-stage breast cancer, a mastectomy may be one treatment option. Breast-conserving surgery (lumpectomy), in which only the tumor is removed from the breast, may be another option.
The process of recovering from mastectomy is different for everyone. One reason it’s so variable is that not all mastectomies are the same.
Double mastectomy is when both breasts are surgically removed, but there are several types of surgery:
Double mastectomy surgery usually involves a short hospital stay and a follow-up in a week or two. You can also opt for immediate reconstructive surgery, delayed reconstruction, or no reconstruction at all.
These factors affect how long you may stay in the hospital, anywhere from one night to a whole week if you have a complex reconstruction. The various factors also impact when you can resume normal activities, which can be four to six weeks or more.
There’s also an emotional component to mastectomy that may affect your recovery and change over time.
The DIEP flap procedure preserves all the abdominal muscles. Only abdominal skin and fat are removed similar to a tummy tuck. A flap is tissue taken from your body with its blood supply used to reconstruct the breast.
It can take about 6 to 8 weeks to recover from DIEP flap reconstruction surgery. Your doctor may recommend that you wear a compression girdle for up to 8 weeks after surgery.
Your risk of hernia is much lower with a DIEP flap than with any type of TRAM flap. This is because a DIEP flap uses no muscle to rebuild your breast. Still, after any abdominal surgery, there is some risk of hernia. Hernias can be painful and can cause a noticeable bulge in your abdomen.
for women who carry their weight in their tummy area, losing weight following diep flap usually doesn’t result in their flap breasts shrinking. you sound so lean that any weight loss will take away the tiny amount of fat reserve you have no matter where it is now located.