Mastectomy or Lumpectomy and Breast Implants for ADH?

I have ADH and thinking of getting a Nipple Sparing Mastectomy (NSM), but my doctor wants to do a Lattisimus Dorsi Flap (LDF) with tissue expanders and then have a second surgery for silicone breast implants. I have breast implants that are over the muscle right now and my lesion is right against my chest wall. I don't know if I should do a lumpectomy and new breast implants, or NSM with Alloderm instead of the LDF because I really don't want my back muscle removed. Any suggestions would be greatly appreciated.

Doctor Answers 8

Best Options for Breast Reconstruction

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The decision of what type of surgery to perform to remove the breast cancer is best answered by a surgeon who specializes in removing breast cancer and has examined your breast, imaging studies, and pathology results.  Sometimes, internal rearrangement of breast tissue (oncoplastic surgery) can be performed following a lumpectomy.  If you undergo a mastectomy, then the plastic surgeon will reconstruct the breast.  Most of the time, this is done immediately following the mastectomy.  Before surgery, your plastic surgeon will discuss options and recommend a preferred technique to achieve an optimal result based on your individual situation.  If your team believes you are a candidate for a nipple sparing mastectomy, there should be enough skin to obviate the need for a latissimus dorsi flap.  The presence of breast implants will not adversely impact your breast reconstruction.  The current implants above the muscle may be removed and a tissue expander or permanent implant may be placed under the pectoralis major muscle supported by AlloDerm to have optimal implant coverage and inframammary fold support.  In some cases, it is possible to place the new implants immediately following the mastectomy, thus obviating the need for a second surgery in most cases.  

LD flap with expanders common

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AlloDerm is essentially cadaver skin minus any living cells.  It is used as a scaffold through which a persons living cells can grow into.  It has many uses, but, in use his in breast reconstruction.  AlloDerm does not help in mastectomy recovery.  It does however help in breast reconstruction. In this application, AlloDerm was used to cover the lower portion of an implant that spans from the lower border of the pectoralis muscle to the breast fold.  Because AlloDerm is a foreign substance in can always get infected and as such your doctor and you need to pay close attention to the signs and symptoms.  AlloDerm has also been used in nipple augmentation as well as augmentation of other body parts.  Its efficacy is really not known in these realms because it is not common.  Some providers may use AlloDerm for these applications but please note that its most widespread use is particularly in breast reconstruction as well as repair for abdominal wall hernias.  Please speak with a board certified plastic surgeon if you have any specific concerns regarding your care.

Alloderm a better option than muscle flap for breast reconstruction

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In my view, the Alloderm option is preferable for circumstances like yours, as it can give good long term results without the major recovery involved with the latissimus flap. Lumpectomy can leave a deformity so that has issues as well. Your own surgical team is in the best position to advise however.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 59 reviews

Breast reconstruction

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You should express your concerns with your physician. If you indeed have ADH and not a carcinoma you should discuss the options of lumpectomy with a surgical oncologist.  I have found that often the cosmetic result of lumpectomy is often very good.  Should you require radiation therapy then you should consider removing the implants and having Fat Grafting.

Hard decision

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Hello Melinda,

You present a difficult question for anyone even a surgeon who can examine you. There are advantages to both your options here:

Expander/Alloderm - This is lesser surgery and does not involve operating your back.

Latissimus Dorsi Flap - This is more reliable and provides more tissue for reconstruction.

You could always opt for the lesser surgery and use the Lat flap to fix things if they did not work out properly. I hope you do well with your surgery.

John P. Di Saia, MD
Orange Plastic Surgeon

Breast reconstruction

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Although your treatment options for the ADH is predominantly determined by your oncological surgeon and oncologist, the final decision should be predominantly determined by what you desire your endpoint to be. That is where your reconstructive surgeon is the key. If the mastectomy with nipple sparing is equivalent to a lumpectomy in terms of cure rate for your risk category and you need rediiation with the lumpectomy, you should look a year down the road as to what you want to look like and at what cost. As a plastic surgoen, we prefer to work on non-irradiated tissue. Your case is especially biased since you already have implants. This presumes that you are accepting of implants and that your breast tissue is probably relatively scarce compared to your implant volume.

Do you need to use the LD muscle? I suspect that a nipple-sparing mastectomy will also allow maximum skin-sparing and that you effectively already have a mastectomy-like situation except that the implant is on top of your muscle and you still have some breast tissue. While a LD flap might add bulk and make for a more natural feel, you might save it for the future since you could probably get a fairly good size implant under the muscle as an immediate reconstruction, or if concerned about the flaps, place an expander without the LD flap. You can always add the flap later if necessary.

A lumpectomy may produce a segmental deformity that would be hard to reconstruct and the radiation will probably make the implant reconstruction more problematic.

Robin T.W. Yuan, MD
Beverly Hills Plastic Surgeon

Lumpectomy and new implants vs nipple sparing mastectomy with Alloderm

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Dear Melinda,

I agree with Dr. Pfeifer's post and would like to elaborate.

As our dealings with breast cancer have changed over the years - so have our breast reconstruction. Fortunately and unfortunately, depending on your philosophy, this remains a complex topic where no one solution is always applicable to everyone.

In the "old"days, a properly done "breast cancer operation" meant removing the entire breast, its skin, its axillary tail and all the lymph nodes in the arm pit. This "radical" Halstead mastectomy was "reconstructed" with a skin graft on the former site of the breast. In the 1960's, Dr. J. Urban in New York added removal of the lymph nodes along the central chest bone to this operation.

Subsequent changes to mastectomy, were termed "modified" since they were a change from the radical mastectomy. All reconstructions to modified mastectomies depended on the possibility of post-operative radiation which may complicate the use of an expander to implant approach and potentially the availability of local flaps (rectus - TRAM, LD etc).

In MY opinion, these days, in MOST women, the performance of a mastectomy which preserves the breast fold and nipple combined with an Alloderm sling and silicone implant placement yields the best cosmetic result and fastest recovery compared to other techniques. So - the question SHOULD BE WHY are other techniques being mentioned?

Be aware that the surgeon performing the mastectomy has a huge impact on the final outcome. Oftentimes, he/she also picks the plastic surgeon they prefer working with (for a variety of reasons - technical, easy to schedule with etc).

I would meet with more than one surgeon and see what you are being offered before going forward.

I hope this was helpful.

Peter A. Aldea, MD
Memphis Plastic Surgeon

Lumpetomy or mastectomy for atypical ductal hyperplasia

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Hi Melinda Cheryl. The decision about how to treat atypical ductal hyperplasia must be undertaken with your breast oncologic surgeon. You could manage it either way, lumpectomy or mastectomy, and the decision is usually driven by your other risk factors for the development of breast cancer in the future. For example, you have a greater chance of developing breast cancer if you have a strong family history or are BRCA gene postive. It is good that you are considering your reconstruction options before your surgery but the first thing to decide is the proper treatment for your ADH. If mastectomy is your choice, then consider your options for reconstruction. There are many ways to reconstruct the breast, each of which has its advantages and disadvantages; surgeons also have favorite methods for various reasons. I would suggest having a consult with 2 or 3 board certified plastic surgeons to discuss the various options, focusing on the pros and cons of each. Find out why, in your case, your plastic surgeon is recommending the lat muscle surgery. Once you know the pros and cons of the different methods, you can choose the technique that matches most closely your goals and priorities. Also, be sure and bring someone with you to these consults-it helps to have a second pair of ears during the visit. Hope this helps.

Tracy M. Pfeifer, MD, MS

Tracy Pfeifer, MD
Manhattan Plastic Surgeon
4.8 out of 5 stars 29 reviews

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.