After a bilateral mastectomy has been performed, what breast reconstruction options will provide the most natural look?
Options for Reconstruction After Bilateral Mastectomy?
Doctor Answers 15
Since this question has come up frequently
My answer is what I tell my patients about their options in breast reconstruction
Breast reconstruction is performed to reconstruct the breast after breast cancer. Facing reconstruction surgery along with a diagnosis of cancer can be overwhelming. However, with today’s technology and medical approaches there are options today that weren’t available years ago. Breast reconstruction is often possible immediately following a mastectomy, so that the patient can combine surgeries and have the reconstruction underway. In this manner, the patient is spared the trauma of awakening without a breast.When breast reconstruction is planned at the same time
Of the mastectomy the results can be more natural and with less scarring. SKIN SPARING MASTECTOMY can be designed with the
General surgeon, where most if not all the breast skin is spared the mastectomy, except for the nipple and areola. Sparing the breast skin maintains the same texture, color and the shape in the reconstructed breast.
When adjustment is desired for the opposite, normal, breast, then incisions are designed symmetrical to both the mastectomy, reconstruction and the opposite breast.
Some important facts about breast reconstruction:
• The reconstructive patient must have realistic expectations—the goal is to improve appearance, not attain perfection.
• Reconstruction at the same time as the mastectomy can be an emotional advantage for the patient, and a reconstructive advantage.
• Some surgeons feel that it is advantageous to perform reconstructive surgery approximately three months after the mastectomy, to give the tissues time to heal and soften. However, most physicians feel that this is an antiquated view.
• Reconstruction of the areola and nipple, if desired, is usually performed in a separate surgery.
• Your surgeon may suggest completion of any chemotherapy or radiation therapies (if necessary) prior to any reconstructive surgery for locally advanced breast cancer.
PREPARING FOR SURGERY
You and your physicians, the general surgeon and the plastic surgeon must make many important decisions – whether the reconstruction will be performed at the same time as or after the mastectomy, the technique to be used, if implants are to be placed, whether they will be used for both breasts, and the fill material, size, shape, and texture of the implants. Remember that different doctors use different techniques and usually recommend the one(s) in which they are trained and experienced. Educate yourself so that you can be a part of this decision-making process.
Many techniques are available. Which technique is used depends on the patient’s desires, the amount of tissue available, and the other breast’s appearance.
If there is sufficient tissue (skin), a silicone or saline implant may be placed beneath the pectoral muscle. When the reconstruction is delayed till after the mastectomy, then often, a tissue expander is necessary prior to implant placement to regain the skin removed by the mastectomy..
This balloon-like device with a reservoir is placed under the pectoral muscle. Over a period of a number of weeks,about twelve sterile saline is injected into the reservoir, gradually stretching the skin. Some expanders can be left in to serve as an implant; other expanders must be removed and replaced with an implant after the skin and muscle are expanded.
TRAM FLAP RECONSTRUCTION:
A large flap of lower abdominal skin and fat, along with a part of one or both rectus muscles, is rotated through the abdomen or separated and reattached to the chest wall and shaped. The major advantage of this procedure is that there is no need for an implant because of the abundance of tissue available. The patient also benefits by getting a "tummy tuck." However, this is a major procedure, which can require four to six days in the hospital. This procedure is not recommended for patients who do not have excess abdominal fat, and excess abdominal skin.
LATISSIMUS DORSI FLAP:
The muscle in the back, along with overlying skin and fat, is rotated around the side to the chest wall and shaped. Since there is usually insufficient tissue to completely reconstruct the breast, an implant may be necessary to achieve the volume required. When Skin Sparing Mastectomy is performed the Latissimus Dorsi flap can be adequate to fill a moderate size breast.
Tissue from the abdomen or buttocks, along with the blood vessels, is completely removed and transplanted to the chest wall to form a breast. The blood vessels are joined to the blood vessels in the armpit under the microscope.
Nipple and Areola
Reconstruction of the nipple and areola are usually performed in a separate surgery once the reconstructed breast has healed. The nipple can be more accurately positioned in this manner. Local tissue from the breast reconstruction may be used. If desired, cosmetic tattooing can be performed later to match the color of the nipple and the areola to the other breast.
Breast reconstruction is usually performed under general anesthesia. However, the type of anesthesia used is dependent on the procedure to be performed, the doctor’s choice, and the patient’s medical history or desires.
Length of Procedure
The breast reconstruction will vary tremendously depending on the type of procedure performed and the complexity.
Level of Pain/Discomfort
Generally with a breast reconstruction there is moderate pain and soreness for a week or two, which may be controlled with prescribed pain medications or Extra-Strength Tylenol.
PRE- AND POSTOPERATIVE INSTRUCTIONS
The following suggestions are intended to make you feel more comfortable and help you heal:
• Stop smoking, discontinue the use of alcohol, and stop taking vitamin E and any medications containing aspirin or ibuprofen (two weeks pre- and postoperatively ). Check with your doctor regarding any other medications (including homeopathic/herbal products) that you are currently taking.
• Dressings – this procedure requires a supportive bra or dressing, to wear for four to six weeks after surgery. You may want to purchase a second garment to wear while you launder the other. Do not wear an under wire bra for six weeks.
• You must sleep on your back, with your upper body elevated, for at least the four week.
• Restrict upper-body activity for four to six weeks.
The initial healing period for a breast reconstruction can take from one to two weeks, however recovery from a combined mastectomy and reconstruction or from a flap reconstruction could take up to six weeks. The normal sensation of your breast will be changed but some feeling could return over time. There is scarring with this procedure, but with proper care, and compliance with instructions, the scars should fade over time. Remember that the goal of breast reconstruction surgery is to offer improvement.
RISKS / COMPLICATIONS
Although problems are unlikely, you need to be aware of what can happen and what action you should take.
Complications that can occur with this surgery are bleeding, infection, hematoma (collection of blood under the skin) and scarring. Other risks of surgery include pulmonary emboli, deep venous thrombosis. Loss of flap in total or partial. Weak abdominal wall, and hernia. If an implant is used "capsular contracture" or tightening of the scar around the implant can occur. There is always a potential for the need for further surgery.
NEW YOU…ONLY BETTER
Many women feel that the reconstructive surgery helps them with their self-esteem. After a diagnosis of cancer, for many-- lives are changed. Reconstruction surgery can help to put a bit of normalcy back into the lives of these courageous women.
Tissue flaps produce the best reconstructed breasts, but...
Tissue flaps from the lower belly, such as TRAM and DIEP flaps, produce the best, softest, most natural, and most lasting and maintenance free reconstructed breasts, but the surgery and recovery period are longer than most other methods, and you have to accept a long scar across your lower belly, and belly button.
Options for reconstruction after bilateral mastectomy?
They also provide other advantages - after radiation, you have an increased rate of complications including wound problems, infections, thinning of the tissue, and decreased vascularity to the skin/tissue of the area. The best method to reconstruct a breast following radiation therapy is with a flap. The flap, which is skin, fat, and sometimes muscle, will serve to bring in healthy, well-vascularized tissue to the chest/breast area that will significantly ameliorate the radiation issues compounding the problem. Microsurgical perforator flaps (such as the DIEP flap and SGAP/IGAP flap) are the newest and most-innovative procedures in breast reconstruction today. As these are muscle-sparing flaps, the pain, morbidity, and complications such as those above, of these procedures are much less. They are highly-complex procedures that few plastic surgeons performed and consult with one who is well-versed, trained, and skilled in these procedures if you are interested.
There are many options to breast reconstruction including implant-based and flap-based procedures. The complication rate with implants following radiation is reported as high as 60-70% in some studies. Flap reconstruction is usually recommended, but there are several centers who perform implants following radiation with great success and results. I typically prefer flaps, such as the DIEP flap. Other flaps are the conventional TRAM, latissimus flap, SGAP/IGAP, and, TUG.
You are a candidate for other procedures, if you are willing to continue with your journey for a reconstructed breast. Flaps such as those above, including others, are available. The decision to continue with this will be your decision and what you are willing to go through. There are risks and benefits with everything that we do in Surgery - discuss the various options with a board certified plastic surgeon who will educate you on all of the options and help you to decided if breast reconstruction or which procedure will be best for you. Hope that this helps and best wishes!
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Natural Breast Reconstruction
The most natural reconstruction option, is one that is not known by most plastic surgeons. Yet. It is fat transfer to the breast with the external expander BRAVA. This process uses your own fat to rebuild entire breasts. We use no incisions and no foreign objects, and in most cases, it is an outpaitent procedure. We are pioneers in the use of large-volume autologous fat transfer.
For anyone who has gone through a cancer diagnosis, the difficult task of
undergoing major surgery, and sometimes the unpleasantness of radiotherapy or
chemotherapy, the thought of one or more major traumatic operations to reconstruct
her breast is exhausting. The fact that this fat grafting technique is now an option is a
giant breath of fresh air.When one adds the additional benefit of body sculpting through
the liposuction, hope for a normal, natural life begins to take hold.
Breast reconstruction can involve implants, the body's own tissue (a flap) or a combination of these options
After a mastectomy for breast cancer or for risk-reducing surgery (BRCA gene positive women or those who wish to reduce their personal risk of breast cancer), there are a variety of options for breast reconstruction:
- Nipple-sparing mastectomy - provides the most natural results and allows reconstruction of the entire breast in a single operation
- Implant-based reconstruction - I specialize in a single-stage approach using adjustable permanent implants
- Flap-based reconstruction - using the body's own tissue to build a new breast, usually making use of extra skin and fat from the lower abdomen (DIEP or SIEA flap) or the inner thigh (TUG flap). Tissue is transplanted Microsurgically in my practice, sparing major muscles of the body like in the TRAM or the LD flap.
- Sometimes, a combination of a flap + an implant is done with the procedures staged 6 months apart. This will bring healthy new tissue to an area in need of a flap (for instance, after radiation or severe infection) and the implant will "augment" the flap, similar to a breast augmentation.
I encourage you to seek a Board-Certified Plastic Surgeon who specializes in breast reconstruction and who can offer you the full spectrum of options, including implants and Microsurgical procedures.
The goal in my practice is to achieve above all else a NATURAL reconstruction that best matches a woman's particular aesthetic goals. Please visit my website for more educational background information.
Karen M. Horton, M.D., M.Sc., F.A.C.S., F.R.C.S.C.
This requires your visiting a Board Certified Plastic Surgeon or surgeon who does a lot of these and can explore all your options. They will need to examine you and offer advice based on your previous therapy and what options are best for you now.
Bilateral Mastectomy Reconstruction
The two major categories for breast reconstruction are 1) implant-based and 2) autologous (using your own tissue). With proper patient selection, we obtain outstanding results with both modalities. However, reconstruction is a process that requires some steps to achieve the best results.
Options will include Saline/Silicone Gel implants, Autologous reconstruction with DIEP or SIEA or TRAM flaps, etc. There are pro's and con's to each option. No single reconstruction is the best for everyone. If you have excess tissue in your lower belly (i.e. have you ever thought you might beneft from a tummy tuck?), then you may be a good candidate for a DIEP free flap (reconstructing your breast using your own tissue without the need of an implant).
We often visit with out of town patients to help them with their reconstructive journey. And we work with several outstanding breast surgeons to facilitate immediate reconstruction for out of town patients. Please visit our breast reconstruction website listed below to learn more about your options.
Most Natural Look after Bilateral Mastectomy
In my opinion, the most natural look and feel will come with use of your own tissue for reconstruction. In order to perform this procedure, you must have an adequate donor area to provide you with your desired cup size. The most common donor site is the abdomen, where we typically perform a muscle preserving DIEP Flap. Other donor sites include the buttocks (GAP Flap) and Inner Thighs (TUG Flap).
If you are not a candidate for tissue reconstruction, I would then recommend a silicone gel implant breast reconstruction with 2nd stage fat grafting to provide a smooth contour. However, if your cancer treatment involves radiation, this procedure would be contraindicated.
I wish you a safe and happy reconstruction process.
Breast reconstruction options
There are many forms of breast reconstruction options including using autologous tissue usinf perforator flaps, other forms of free flaps, as well as pedicled flaps like a TRAM. Other forms of reconstruction include tissue expanders and then exchanged for implants.
the most natural look is with your own tissue, but that will depend on your doner site availability. it also means a longer operation. i generally suggest that you start with expander /implant reconstructions. they are easier on you and symetry is fairly easy to achieve. all reconstruction choices have their own set of complications. find an experienced surgeon in your community and he will help you with your choices