I am 35, having a unilateral mastectomy, no chemo, no radiation. I've received two different opinions from board certified plastic surgeons about reconstruction - one said tissue expander (delayed) will achieve symmetry and no Lat flap technique is necessary, the other indicated a Lat Flap with implant(immediate) will achieve symmetry best and the delayed tissue expander option will result in a flat breast. Is this true - how do I choose?
Better Symmetry? Lat Flap with Implant or Tissue Expander and Implant?
Doctor Answers (14)
Options for breast reconstruction
Without more details it would be difficult to give you specific advice, but you might consider these principles in making this decision:
1. Delayed reconstruction is associated with a lower complication rate.
2. Placement of a tissue expander is a simpler operation, with no donor site involved.
3. The latissimus dorsi flap is a more complex operation, with a longer recovery, but has the advantage of a potentially better result.
4. Delayed reconstruction will sacrifice some of the skin of the breast, which may result in central flattening of the reconstructed breast.
Web reference: http://www.bolithomd.com
Lat and Implant vs tissue expander and implant?
Unless your skin is thin, there is not reason to sacrifice your back muscle. Consider an implant alone. Both will achieve symmetry equally and both are based on the quality of the intiial resection.
Latissimus dorsi flap versus tissue expander.
There is no question that immediate reconstruction with a Lat flap and implant will give you the best symmetry and the most natural looking breast. The trade off is that it is a bigger operation and a scar on your back. A delayed tissue expander will never give you as natural a result but it is less invasive surgery with less down time. No procedure is perfect. You have to decide what issue is most important to you in order to make your decision. Best of Luck.
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Best Unilateral Breast Reconstruction for Symmetry
In your question you suggested a choice between skin expander and latissimus dorsi breast reconstruction for achieving symmetry after a unilateral breast reconstruction.
Accepting the limitation to these two choices, I generally would choose a latissimus flap, particularly if your breasts were not to large and the latissimus along could provide sufficient volume to match the non-mastectomy side. My reason for this is that the latissimus dorsi flap provide a soft warm natural breast entirely of your own tissue.
However, if your breast were large than the latissimus alone would not be sufficient, and an implant and latissimus would be needed , or your would need to reduce the non-mastectomy sided breast so that it would match the smaller volume of the latissimus alone.
There are, of course, more options than the one that you have mentioned, and they can often provide sufficient fat and skin tissue flaps to match larger breasts.
A thorough evaluation and discussion of your options with a board certified plastic surgeon is needed.
See nybreastreconstruction.com for more information on these and other techniques.
"Direct to implant reconstruction"
There is no reason in your situation to use a muscle !
You could have a direct to implant reconstruction and have a wonderful breast without expanders or the need to use your LD muscle !!
Choice of reconstruction
If you are going with a tissue expander implant reconstruction, a latissimus flap to me is a life preserver for a secondary procedure if the primary reconstruction fails secondary to radiation. Since you are not having RT I would do the expander and implant.
Timing and choice of reconstruction
If you do not need chemotherapy or radiation therapy, you should consider immediate reconstruction. Immediate reconstruction is done at the time of mastectomy and can give you the best cosmetic outcome. In terms of LD flap/implant vs. tissue expander, if you are undergoing simple, skin sparing mastectomy, you should be okay with tissue expander placement as your first stage. If you are needing more radical mastectomy where you need more skin coverage, then you may need LD flap/implant. However, without examining you and talking with your breast surgeon, it is be difficult to answer. It seems like you need to consult your plastic surgeons again; please ask for pros and cons of each option. Good luck to you.
It is hard to decide when you have received two diverging opinions. Both surgeons should have a good rationale for their recommendations. However, from the limited information provided, I don't see any reason that a delayed or secondary reconstruction would be necessary. In most cases, reasonably good symmetry can be achieved with either tissue expansion/implant reconstruction, or LD/Implant reconstruction. The LD will provide additional soft tissue in the form of muscle and skin and may allow for a greater degree of ptosis (droop) of the reconstructed breast, however, this is at the expense of a longer procedure and a donor site on the back.
Frequently this issue requires addressing the opposite "normal" breast as well. Depending on the size and shape, various options may be better suited. Your best symmetry will likely require a reduction or lift on the opposite side. IF you have a small breast on the normal side an expander may be a reasonable option with a skin sparing mastectomy. However, if you have a larger, ptotic breast, a latissimus flap may be a better option to achieve the look you seek.
There are options in breast reconstruction
1: tissue expander, and implants
2: Latismus Dorsi flap with or without implant, depending on size and type of mastectomy
3: TRAM flap
4: Free flap
All can achieve symmetry, but not perfection.
There are pros and cons for each method, and different risks.
See multiple plastic surgeons and discuss all options available to you.
Between the both of you, you will reach to a decision that you and the plastic surgeon are comfortable with.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.
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