IMMEDIATE BREAST RECONSRUCTION AFTER MASTECTOMY

Before deciding whether to have a mastectomy for breast cancer, a well-informed woman should be aware of her options for immediate breast reconstruction. Those patients who have large tumors (over 5 cm) which may involve the chest wall, or those patients who the general surgeon feels may have positive margins (cancer still present at the edges of the removed tissue) after the mastectomy, may not be candidates for immediate reconstruction. Virtually everyone else is a candidate for some sort of immediate reconstruction, regardless of her breast size, body weight, or age. Additionally, Congress recently passed a law that guarantees every woman's right to be informed of her options AND to have her medical insurance cover a breast reconstruction as well as any surgery on the opposite breast if needed. There are numerous advantages to an immediate reconstruction. First of all, a woman who has an immediate reconstruction wakes up after her mastectomy with a breast, instead of a bare chest. The presence of a reconstructed breast in the immediate post-operative period helps improve a woman's psychological well-being which may improve overall recovery. Immediate reconstruction virtually always decreases scarring on the breast and often allows the reconstruction to be completed with no visible scar on the breast after the nipple reconstruction has been completed.

SINGLE STAGE BREAST RECONSTRUCTION

Over the last 10 years or so there has been an increasing awareness among general surgeons that it is not necessary in most cases to remove the breast skin along with the breast tissue. This is called a "skin-sparing mastectomy" and it allows for a " single stage reconstruction." This type of reconstruction virtually always decreases the scarring on the breast and often allows reconstruction to be completed with only one operation with general anesthesia and one with local anesthesia. Initially, the nipple and the breast tissue are removed leaving the rest of the breast skin to be filled by the abdominal fatty tissue, back tissue, or a breast implant. If the opposite breast needs to be altered for symmetry, this is also done during the initial operation. A few months later, the nipple is reconstructed and some minor revisions may also be performed in a smaller operation which is usually done on an outpatient basis under local anesthesia.

DIFFERENCES BETWEEN AN IMPLANT AND A FLAP RECONSTRUCTION

Almost all of the women who you will see in Reconstructing Aphrodite have had single stage breast immediate reconstruction with either an adjustable implant (Spectrum or Becker) or a TRAM flap (transverse rectus myocutaneous flap) which uses the abdominal tissue. The photos below depict two different types of immediate reconstruction after mastectomy.

Figure 1 Preoperative view	Figure 2 Three weeks after bilateral mastectomies and immediate TRAM flap breast reconstruction.

The first figure is an example of a woman who has had both her breasts reconstructed with TRAM flaps. You may notice that there is a circle scar around the site where the nipple was. The nipple and breast tissue are removed and replaced with fat and a circle of skin from the abdomen. Other scars on the breast are not always necessary, and depend upon the location and extent of the biopsy scar, as well as the need to remove lymph nodes.

Figure 3 Three weeks after bilateral mastectomy and single stage implant reconstruction.	Figure 4 Three months after bilateral mastectomy and single stage implant reconstruction.

Figure 3 is a women a few weeks after single-stage reconstruction with implants at the same time as the removal of both of her breasts. In implant reconstructions, the straight line scar of some length is necessary to close the area where the nipple and biopsy scar were removed. The nipples are reconstructed 6-8 weeks later.

There are several differences between an implant reconstruction and one using the patient's own tissue: women who undergo breast reconstruction using an implant have a faster recovery and require no scars on other parts of their body such as on the abdomen or the back. The surgery takes about 2-3 hours including the mastectomy, and the hospital stay is one night. There is usually no blood transfusion required. However, implants may need some maintenance surgery at a later date due to hardening (encapsulation), leakage, or other complications. Implants may appear quite natural, depending on the skill of the plastic surgeon, but never feel as natural as a reconstruction out of the patient's own fatty tissue.

The advantages of using the tissue from the abdomen or a TRAM flap (transverse rectus myocutaneous flap) are the absence of need for maintenance surgery at a later date and the more natural feel and appearance.A breast made out of abdominal tissue is warm and soft, it moves like a normal breast and gains and loses weight with the patient. Another advantage includes the "tummy tuck" procedure which allows a woman to loose the fullness in her lower abdomen that may be due to a split between her abdominal muscles after pregnancy (rectus diastasis), and therefore is resistant to diet and exercise. Patients who undergo this procedure have a scar longer than a hysterectomy scar but also have a flat stomach after the surgery.

The disadvantages of a TRAM flap include longer surgery (3-6 hours including the mastectomy), longer recovery, and postoperative pain in the abdomen. The hospital stay is 3-5 days and the recovery period is 4-12 weeks, depending on the patient.

An additional problem is the possible need for a tightening of the abdominal repair at a later date. This is relatively rare and may be dependent on the technique a plastic surgeon uses to close the area where the abdominal muscle is removed.

RECONSTRUCTION WITH IMPLANTS

The available options include both silicone, saline-filled implants and a combination of silicone and saline. The FDA allowed silicone implants to remain on the market for women who are diagnosed with breast cancer. This means that even during the height of the "silicone controversy" the FDA believed the benefits outweighed the potential risks for women with breast cancer.

The reason for this is that the silicone feels and looks more realistic than saline. This is relevant to mastectomy patients because the skin over the implant is quite thin and there is no breast tissue or fat to cover the saline implant to make it feel and look more normal breast.

SINGLE STAGE RECONSTRUCTION WITH IMPLANTS

If an immediate reconstruction is performed using a skin-sparing mastectomy, the reconstructed breast can be very close to the size and shape of the opposite or normal breast after the first operation. A skin-sparing mastectomy is done by removing the nipple and biopsy site and leaving all the remaining skin to be filled with an implant or a flap.

Figure 5

In order to perform this surgery in a single stage, a postoperatively adjustable, expander/implant must be used. These products contain a small injection dome which is implanted beneath the skin and allows the surgeon to inject saline into the device to expand and fine tune the size and symmetry of the implants after the surgery. This process is done in the surgeon's office and is usually complete after 6-8 weeks but could take up to 6 months (particularly is a patient requires chemotherapy postoperatively. Once the expansion process is finished, the small injection dome is removed and a nipple is created. This second procedure usually requires only local anesthesia, and is done on an outpatient basis.

TWO STAGE RECONSTRUCTION WITH IMPLANTS

Some surgeons prefer to perform a two-stage procedure using both a temporary tissue expander and a breast implant. The tissue expander is inserted in the first surgery and it is used to stretch the chest skin. This makes the breast too big for a while, and then the expander is removed and replaced (in the second surgery) with an implant of the right size. A reconstruction done this way usually requires at least one more operation than one done with a skin-sparing mastectomy and a post-operatively adjustable implant. Delayed implant reconstruction, done months or years after a mastectomy, usually requires that the skin be stretched with a tissue expander which means that it typically requires more surgery (two stages) than an immediate reconstruction.

IMMEDIATE RECONSTRUCTION WITH A TRAM FLAP

This is performed using the extra skin and fat from the lower abdomen which is transferred to the breast area. Part or all of one of the rectus abdominus muscles must be transferred as well to provide the blood supply the the new breast. If both breasts are reconstructed with TRAM flaps, both rectus muscles must be used. On the outside, the operation looks identical to a tummy tuck (abdominoplasty). The operation takes about 4 hours in skilled hands (6 hours for bilateral TRAMs), and requires a 3 - 5 day stay in the hospital.

Figure 7a Preoperative view	Figure 7b Postoperative View
Figure 7c Preoperative View	Figure 7d Postoperative View
Examples 7a–d (above) illustrate the difference between immediate and delayed reconstruction using the abdominal tissue. This patient had a mastectomy and then developed a precancerous lesion in the other breast several years later. At that time her right breast was removed and the skin was filled with abdominal fat. Her left breast reconstruction, being delayed (performed at later date without a skin-sparing mastectomy), required skin from the abdomen since the breast skin was discarded in the earlier mastectomy. As is evident, there are no scars on the right breast (the immediate reconstruction) whereas there are significant scars on her left breast (the delayed reconstruction). These scars will fade over time.

[FLASH MOVIE HERE]

In the case of a heavy smoker, a patient with a gall bladder scar, or a very thin patient, it is sometimes necessary to perform the TRAM flap using microsurgical technique. This is done by sewing the small artery and vein from the TRAM flap to an artery and vein in the armpit or chest area. This is called a microsurgical or free TRAM. This procedure is lengthier and riskier than the traditional (pedicled) TRAM but can improve circulation to the flap. Recently, another type of microsurgical abdominal flap has been advocated but the results are less reliable than the free TRAM and the surgery takes longer.

What happens if someone is too skinny for a TRAM flap but does not want to have an implant reconstruction? It is rare that a woman's abdomen is too thin for a TRAM flap. If she had a previous tummy tuck a TRAM flap is not an option. If she has had liposuction in her abdomen there may not be enough fatty tissue. When a woman is too thin options for reconstruction include implant, latissimus or back flap with or without an implant, or flaps from other parts of the body.

For very small-breasted women, the back muscle and skin alone might suffice without an implant (the latissimus flap) but more often an implant must be placed beneath the back flap to achieve the appropriate volume to match the other breast. If buttock skin is used it must be transferred from the gluteal area to the breast using microsurgical technique. It is a demanding operation and usually leaves a significant scar or depression in the buttock area. Due to the type of fat in the buttock area, the breast that results is often less natural appearing than one from the abdomen. It is also possible to use tissue from the outer thigh, but this is done very rarely.

NIPPLE RECONSTRUCTION

An example of a nipple made out of breast skin and tattoo using no grafts.

Nipples are made using tissue that is already on the breast for the nipple and tattoo pigment to color the nipple and surrounding areola. It is also possible to take a small graft from the opposite nipple for those women who have a relatively large nipple on the opposite side. It is my opinion that the nipple graft with tattoo for the areola gives the most natural result. It virtually never leaves a detectable scar or disturbs sensation in the normal nipple. Other options include a skin graft from the groin or labia area, which often needs to be tattooed at a later date. Not all surgeons do their own tattooing at the time of the nipple reconstruction, but rather refer their patients to a nurse or cosmetician who is familiar with cosmetic tattooing.

Figure 9:

The nipple on the patient's right (Figure 9 was reconstructed with a small graft from the opposite nipple and tattoo for the areola. This does not affect sensation in the normal nipple and is used when the normal nipple is large and can afford to have a very small piece removed.

There is an important issue that arises if a woman who has been treated with lumpectomy and radiation has a recurrence of cancer in her breast and needs a mastectomy. There is a much higher complication rate if implants are used after radiation therapy. For this reason it is most often recommended that a woman use her own tissue to make a breast after having radiation. For some women this simply is not an option, but it should be used in those cases where it is available. The fact that radiation therapy limits reconstructive options down the line must be considered initially prior to choosing radiation.

Immediate reconstruction rarely delays chemotherapy at all, and if it does it is only a week or two. Thus, if a women has been told she needs chemotherapy she can still have both chemotherapy and radiation subsequently.