Before deciding whether to have a mastectomy for breast cancer, BRCA or family risk profile, a well-informed woman should be aware of the newest 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.
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.
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.
SINGLE STAGE 'SCARLESS' RECONSTRUCTION PRESERVING THE NIPPLE
The first edition of Reconstructing Aphrodite was assembled before Nipple Sparing Mastectomy was the predominant technique in our practice.
(Look for the second edition next year!)
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 the breast tissue. In Europe, a technique called "nipple-sparing mastectomy (NSM) " has been used during this 10 year period and in Dr. Eskenazi's practice it has been the predominant implant technique for 5 years. Dr. Eskenazi also pioneered a single stage reconstructive technique for nipple sparing mastectomy that does not require muscle disruption or insertion of foreign cadaver tissue (Alloderm).
This type of reconstruction decreases the scarring because it is done through an incision hidden under the breast. Then the adjustable implant is placed OVER the muscle. There is NO need for expansion at anytime, but a woman can decide her breast size by adjusting the implant size once or twice in the office. An adjustable implant is used to protect the skin from circulation problems in the first few days thus preventing nipple loss, and to aid in decision about breast size postoperatively. There is significantly less pain and bleeding, and women are off pain medicine in a few days. This is because the adjustable implant is placed ABOVE the muscle. This technique often allows reconstruction to be completed with only one operation with general anesthesia and one with local anesthesia. There is no deformity of indentation and motion of the implant every time the chest muscle moves (thousands of times a day). After hundreds of implant reconstruction cases without muscle coverage, Dr. Eskenazi is sure there is no 'bottoming out' with this technique. Alloderm is not necessary to prevent this! Dr. Eskenazi also can perform a breast lift if the circulation allows at the time of the initial mastectomy. To our knowledge she is the only one in the US using this technique.
The technique using an inframammary incision with lift, and implant above the muscle with adjustable implants IS NOT the subcutaneous mastectomy used in the past. It is an oncologically safe operation where the nipple is cored out and sent to the pathologist. In Dr. Eskenaazi's series over >5 years, there have been NO recurrences.
It is ideal for women with BRCA 1&2 and other women with strong family history of breast cancer. It is also ideal for women with DCIS and invasive cancer 2cm away from the nipple. To our knowledge, there is no one else in the country performing this procedure above the muscle without the necessity of cadaver skin graft (Alloderm). In addition, we perform mastopexy/reduction of the breast AT THE SAME TIME as the mastectomy if the skin circulation allows. This technique has taken years to refine, but it is the simplest and most aesthetic implant reconstruction on the market. It is also being used in our practice with DIEP and other microsurgical flaps.
For those women who have tumors which are very large, very aggressive, or involving the nipple, single stage reconstuction removing the nipple is still available (this is the operation used in "Reconstructing Aphrodite").
TRADITIONAL SKIN SPARING MASTECTOMY
This is when the general surgeon who is performing the mastectomy only removes old biopsy scar with or without the nipple. The remaining breast tissue is shelled out from underneath the breast skin, leaving most of the breast skin intact. This remaining skin gives the plastic surgeon more tissue to work with and allows for the most natural looking result. If you are planning a delayed reconstruction, you can still request that your general surgeon leave the extra skin. This will give the plastic surgeon more tissue to work with at a later date, or can be removed easily if you decide not to have reconstruction. Skin sparing mastectomy has been shown to be very safe and has the same cure rates as the old radical mastectomies when all of the skin was removed.
Three weeks after bilateral mastectomy and single stage implant reconstruction.
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.
TRADITIONAL MULTIPLE STAGE RECONSTRUCTION WITH IMPLANTS
Some surgeons prefer to perform a multiple-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 requires more surgery single stage reconstruction.
SURGERY ON YOUR OPPOSITE BREAST
Having symmetrical breasts is very important in obtaining the ideal aesthetic result. Although we do everything we can to make your new breast match your other one, sometimes it is just not possible without altering the other breast. For instance, some patients have a very large and droopy opposite breast, and others may have one that is too small to easily match. These women are good candidates to have surgery on the other breast, such as a breast reduction, breast lift, or breast augmentation. Fortunately, surgery on the opposite breast is covered by insurance. (A new federal law guarantees this!) Dr. Eskenazi ALWAYS operates on the opposite breast (if necessary for symmetry) at the same time as the mastectomy. This makes only one general anesthetic necessary. Also, over the years she has refined reconstructing in the 4th dimension, which is time. It is NOT necessary to 'let the breasts settle,' to wait for symmetry.
BREAST RECONSTRUCTION USING YOUR OWN TISSUE
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 flap (transverse rectus myocutaneous TRAM flap or microsurgical TRAM flap) which uses the abdominal tissue. The photos below depict two different types of immediate reconstruction after mastectomy. The first edition of the book was compiled before microsurgical flap (DIEP, SIEA, TUG, SGAP etc.) but since then we have used these options routinely.
Three weeks after bilateral mastectomies and immediate breast reconstruction with an abdominal flap.
The first figure is an example of a woman who has had both her breasts reconstructed with 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.
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 a 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 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 rare 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.
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.
Examples 7ad (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.
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 usedit 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.
MICROSURGICAL BREAST RECONSTRUCTION
“DIEP” refers to the blood vessel that supplies the skin and subcutaneous tissue of the lower abdomen in the same distribution as the TRAM flap. However, the DIEP flap does not include any muscle in the flap. The DIEP flap is a “perforator flap”: it is supplied by blood vessels that travel within and perforate through the rectus abdominis muscle.
The DIEP vessels are isolated during surgery by teasing apart the rectus muscle fibers to access the blood vessels. The muscle is left in place on the abdominal wall, together with all the motor nerves that provide power to the muscle. In a small percentage of cases, your surgeon may choose intra-operatively to base the tissue on a different blood vessel called the superficial inferior epigastric artery (SIEA). This does not change the tissue used in the flap or your final result, but may significantly shorten your operation time.
COMPARISON OF DIEP (MICROSURGICAL) AND PEDICLED TRAM FLAP RECONSTRUCTION
The DIEP flap can take longer than the conventional TRAM flap: standard operating times are 4-5 hours for a single (“unilateral”) reconstruction, and up to 8-10 hours for a “bilateral” reconstruction (both sides). The time of surgery can be increased by 1-2 hours if the reconstruction is immediate (done at the same time as the mastectomy). An immediate TRAM reconstruction in Dr. Eskenazi’s hands is 3-4 hours for one side and 5-6 hours for 2 sides.
The DIEP flap is a “free flap” and involves “microsurgery”. Microsurgery is surgery that is performed under the operating microscope. The flap tissue from the abdomen is isolated on its microvascular pedicle (one artery and one or two veins that bring blood supply to and from the tissue). The pedicle is isolated and then divided, effectively cutting off the blood supply to the flap. The flap is then transferred to the chest area and the blood vessels are reconnected (the “microvascular anastomosis”) blood vessels in the chest region. With microsurgery, there is a small (3-5%) risk of failure of the microvascular anastomosis. If the blood vessels were to fail or clot off, a return to the operating room would be necessary to redo the anastomosis and to reestablish blood supply to the flap. In contrast, the TRAM flap has virtually no failure rate in experienced hands.
The hospital stay is approximately 5 days for microsurgical patients, 3 days for TRAM patients, depending on the speed of recovery and postoperative pain. This is in comparison to 1 day in hospital for an implant reconstruction.
Blood loss is usually minimal, but in a bilateral reconstruction, and together with a mastectomy, a blood transfusion may be required. Autogenous blood donation (donating 1-2 units of your own blood up before surgery) may be arranged up to 3 weeks before a bilateral reconstruction. Dr. Eskenazi does not transfuse her TRAM patients.
FREE TRAM AND OTHER MICROSURGICAL FLAPS
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.
The SIEA flap contains the exact same tissue as the DIEP flap, but is based on a different blood vessel system. The SIEA flap makes use of the superficial blood supply to the skin and fat of the abdomen, while the DIEP flap uses the deep blood supply.
Approximately only 30% of people have an SIEA vessel that is visible during surgery and that can be used for microvascular anastomosis. This is not known until the time of surgery and cannot be tested preoperatively. As opposed to the SIEA vessels, the DIEP vessels are always present and can always be used.
Advantages of the SIEA flap include a shorter operating time, less surgical dissection, no disturbance of any muscle or fascia, and little to no abdominal discomfort after surgery. Recovery time is often less than for the DIEP flap. Disadvantages include the fact that less than 30% of individuals have this blood vessel, and it may or may not be large enough for microvascular anastomosis.
There are several other types of microvascular free flaps in addition to the DIEP flap that are available for breast reconstruction. These include the TUG flap, S-GAP and I-GAP flaps.
Patients who have had a previous abdominoplasty, previous TRAM or DIEP flap do not have the tissue available for reconstruction using the abdominal skin and fat. Previous abdominal liposuction increases risks of complications with a DIEP flap, but it is not an absolute contraindication. Patients with very low body fat or an inadequate amount of abdominal tissue may not be candidates for the DIEP or SIEA flap to reconstruct a breast mound similar to their other breast. Rarely, the location and number of scars on the abdomen from previous surgery can interfere with the blood supply to a DIEP flap.
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.
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.
RADIATION AND CHEMOTHERAPY
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
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.