What Is Breast Reconstruction?

The treatment landscape for breast cancer has significantly evolved. Patients now often have the choice between a mastectomy or breast-conserving therapy (lumpectomy combined with radiation). Furthermore, a sentinel lymph node biopsy is conducted to assess whether the cancer has extended beyond the breast tissue. Your surgical and medical oncologists will finalize your treatment plan. Your general surgeon might refer you to a plastic surgeon to discuss breast reconstruction options. Regardless of the treatment plan, you have the right to explore breast reconstruction options. Even if you are a breast cancer survivor seeking reconstruction post-mastectomy, you have the option to pursue it.

Why Women Choose Breast Reconstruction

The diagnosis of cancer can be both overwhelming and terrifying. Patients often face fears for their lives and a strong desire to remove the cancer as quickly as possible. They are introduced to a team of doctors, including medical oncologists, surgeons, and radiation oncologists, which can be overwhelming. One study found that only 40% of patients who undergo mastectomy opt for breast reconstruction. The decision to undergo breast reconstruction is deeply personal, with various factors influencing it. Some women may not prioritize reconstruction, while others may want to avoid additional surgery.

Concerns about costs and insurance coverage for what is perceived as a "cosmetic" procedure can also play a role. In 1998, Congress passed the Women’s Health and Cancer Rights Act, which mandates that all insurance companies cover post-mastectomy reconstruction and procedures to ensure breast symmetry. Although the choice to undergo reconstruction is personal, the increasing number of women choosing reconstruction highlights its importance, safety, and satisfaction. Ideally, the initial stage of reconstruction can be performed during the mastectomy to reduce the number of procedures and enhance cosmetic outcomes. Numerous studies have validated the safety and patient satisfaction associated with breast reconstruction.

Patient Choices and Operative Technique: Implant vs. Autologous

There are several options for breast reconstruction with continuously improving techniques that enhance cosmetic outcomes. Reconstruction performed at the time of mastectomy is termed “immediate” reconstruction, while reconstruction done after mastectomy is called “delayed.” The two main methods for reconstructing the breast are using breast implants (alloplastic) or using a patient’s own tissue (autologous). The preferred procedure depends on the patient’s preference, the stage of cancer, and anatomical considerations. Ultimately, the patient decides whether to use an implant or their own tissue for reconstruction. Both methods have their advantages and disadvantages, which are detailed below.

At SVIA, formerly known as Bay Area Aesthetic Surgery, practitioners use the latest techniques and technologies for both implant (alloplastic) and tissue-based (autologous) reconstruction. SVIA follows the principles of "onco-plastics" to maximize both oncologic care and aesthetic results, ensuring comprehensive surgical options for informed decision-making.

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Your Consultation

Your initial consultation will last about an hour. Your medical and breast history will be thoroughly reviewed during this time, and all your questions will be answered. The consultation aims to provide you with all the necessary information to make an informed decision regarding the different types of breast reconstruction (implant vs. autologous) and to determine the best method for you.

Types of Reconstruction

  • Onco-Plastics: Patients undergoing mastectomies can benefit from the collaborative approach of "Onco-Plastics," which involves coordination between the general surgeon and plastic surgeon to deliver optimal oncologic and aesthetic outcomes. For patients with large or ptotic (sagging) breasts, special incisions can be used to remove the tumor while reshaping and rejuvenating the breast. This method involves designing skin excision patterns for easy tumor access, promoting healing, and minimizing visible scarring.
  • Implant: Implant reconstruction can be either a two-stage or one-stage procedure. In the two-stage reconstruction, a temporary saline implant called a tissue expander is placed under the pectoralis major muscle during the first stage. Additional coverage and support are provided by using acellular dermal matrix, a cutting-edge technique in breast reconstruction. Patients typically spend one night in the hospital for pain management. The implant is gradually expanded during follow-up visits until the desired volume is reached. The second stage, performed about three months later, involves replacing the expander with a final silicone implant. The final silicone implant can be placed during the first surgery for some unique cases. Nipple reconstruction and areola tattooing are performed as office procedures once the final size and shape are set.
  • Autologous: Some patients prefer autologous reconstruction, which uses the patient's tissue, over implants. This method offers long-lasting results and avoids implant-related complications. The most common type of autologous reconstruction is the abdominal-based flap, such as the transverse rectus abdominis myocutaneous (TRAM) flap. This technique uses the skin and fat from the abdomen to create a new breast, often resulting in a "tummy tuck" scar. The procedure can last a lifetime, providing a natural and durable outcome.
  • Pedicle-TRAM: The pedicle TRAM flap is an early and common method of abdominal-based reconstruction, relying on the superior epigastric vessels for blood supply. This flap remains connected to the muscle and is tunneled into the breast cavity to recreate the breast. Although it sacrifices the entire rectus abdominis muscle, it offers ease of harvesting and avoids the need for microsurgery. However, it may result in mild abdominal wall weakness and is not suitable for bilateral reconstruction.
  • Free-TRAM: Microsurgery has revolutionized flap reconstruction, allowing for the disconnection and reattachment of tissues using a microscope. The free TRAM flap, which preserves the dominant deep inferior epigastric vessels, requires careful dissection and microsurgical techniques. This method sacrifices only a portion of the rectus abdominis muscle, preserving abdominal integrity and allowing for bilateral reconstruction.
  • Deep Inferior Epigastric Perforator (DIEP): The DIEP flap represents the latest advancement in muscle-sparing techniques. This perforator flap spares the entire rectus abdominis muscle, resulting in minimal abdominal morbidity and the best preservation of abdominal integrity. The procedure is technically challenging but significantly benefits patients seeking autologous reconstruction.
  • Other Types of Autologous Reconstruction: In cases where abdominal-based flaps are not feasible, alternative options include using tissue and muscle from the inner thigh (transverse upper gracilis free flap or TUG-flap), back (latissimus dorsi muscle flap), or buttocks (gluteal flap). These methods are considered when the TRAM flap is not available due to prior surgeries, insufficient tissue, or other medical conditions.
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Your Breast Reconstruction Procedure

Breast reconstruction typically involves three stages. The initial stage, performed at a hospital, focuses on immediate reconstruction following mastectomy. The second stage, usually three months later, shapes and sizes the breast to its final form. This may involve lifting, reducing, or augmenting the uninvolved breast for symmetry. The final stage, involving nipple reconstruction and areola tattooing, completes the process. Each stage has varying recovery times, with the first stage requiring the most extended recovery period.

Your Recovery

Breast reconstruction is a multi-stage process, usually taking three stages to complete. The first stage is the most extensive and involves the longest recovery period. Subsequent stages have shorter recovery times. Patients typically need one to two weeks off work after the first stage, while later stages may require five to ten days off. The entire reconstruction process takes approximately six months. Rest assured, personalized post-operative care instructions will be provided to ensure a smooth recovery.

A Wealth of Healing Care

Breast reconstruction is a viable option for women following mastectomy due to breast cancer. It offers psychological benefits and does not compromise disease-free survival. Advances in surgical techniques provide multiple options, from newer silicone implants to refined microsurgical free flap reconstructions. The Women’s Health and Cancer Rights Act of 1998 ensures insurance coverage for reconstruction and symmetry procedures. We encourage you to consult with a plastic surgeon trained in breast cancer reconstruction to explore your options.

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Contact SVIA Plastic Surgery

To explore your breast reconstruction options, schedule a consultation at SVIA Plastic Surgery in San Francisco. Our dedicated team is committed to advancing reconstructive care for breast cancer patients through research and community outreach.

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