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Breast Reconstruction Information

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Article on Breast Reconstruction
Breast Reconstruction: Personal Story
Average Costs
Breast Reconstruction Information
Options
Tissue Expansion
Breast Reconstruction with Implants
Breast Reconstruction without Implants
Recovery
Questions to ask your Plastic Surgeon
Breast Reconstruction Scars
Satisfaction Rates
Article on Breast Cancer and Silicone Implants

View Breast Reconstruction Before and After Photos
Breast Cancer Links

Breast Reconstruction
by Dr. Bahram Ghaderi
St. Charles, Illinois

There has been a marked increase in the number of women having breast reconstruction surgery immediately following a mastectomy. In the 1980s, about 10 percent of women who had a mastectomy had immediate breast reconstruction. Today, that figure has increased many folds among the 50,000 women a year who undergo mastectomy.

One clear and immediate benefit is psychological. The woman wakes up after surgery and has not lost her breast. This has a positive effect on her recovery and improves the woman's ability to successfully complete the remaining breast cancer therapy.

There are major physical benefits as well. The surgeon who removes the breast can do a skin-sparing mastectomy, removing less skin than usual. This technique creates a better and more natural reconstruction. Also, immediate reconstruction does not interfere with chemotherapy and radiation therapy, if necessary.

The woman who chooses immediate reconstruction is spared the risk and inconvenience of being hospitalized a second time. A federal law was passed in 1998, which requires insurance companies to cover breast reconstruction, including any procedures that are required on the opposite breast to obtain maximal symmetry. A growing number of medical institutions now offer immediate reconstructive surgery for mastectomy patients.

The breast to be reconstructed can be made from a woman's own tissues, most often taken from the abdomen or back, or from an artificial implant. The decision for which procedure is best for you will be a combination of your desires and your plastic surgeon's recommendation based on a comprehensive examination and medical background review. Usually 6 months after the initial reconstruction any procedure required on the opposite breast is performed as well as the nipple/areola reconstruction.

In choosing a surgeon, you should search for a board certified plastic surgeon in your area. They can provide you with more detailed information and recommend a breast reconstruction procedure that best matches your desires and needs.

Learn more about Dr. Ghaderi.
Reprinted with kind permission by Dr. Bahram Ghaderi, a board certified plastic surgeon located at 2900 Foxfield Road, Suite 201, St. Charles, Illinois 60174.
Copyright 2003 St. Charles Plastic Surgery.

Right Breast Reconstruction

Carol's Story:
"In July 2001, I was diagnosed with breast cancer - a recurrence of ductal carcinoma in situ, for which I had been treated with a lumpectomy and radiation treatments in 1999. This news was absolutely devastating!! I had been told all along that I had caught the cancer at a very early stage ("pre-cancer" in some books) and that the type of cancer was very slow growing and non-invasive even though I did have some micro invasions. It could have been forming in my body for 5 or more years, but didn't show up on the mammograms until May 1999."

Photos courtesy of Dr. Bahram Ghaderi, a board certified plastic surgeon located at 2900 Foxfield Road, Suite 201, St. Charles, Illinois 60174.

.
"The recommended course of action was to have a mastectomy and reconstruction. I had no qualms about having a reconstruction - I knew I didn't want to bother with a prosthesis - but the plastic surgeon who had performed the same procedure on my girlfriend was no longer in my insurance network. I was referred to Dr. Ghaderi by my breast surgeon. The initial consultation with Dr. Ghaderi assured me that he was indeed the physician to perform the reconstruction. He answered all my questions as well as those of my husband. The different types of reconstruction were presented to me along with the pros and cons of each type. Because of my radiated skin, the implant reconstruction (a.k.a. "the Toyota") was eliminated from the choices and I decided on an attached flap TRAM."

"The surgery went well with no complications. Dr. Ghaderi gave me a timeline handout of what to expect - what medications would be administered, when I should start walking the halls of the hospital, what emotional feelings I might experience, etc. I found this to be so reassuring - especially the morning when I was in a "weepy" mood. Sure enough, my timeline said that my emotions would come into play on that day."

"The goal of the surgery was to have natural looking breasts when wearing a bra. To fully accomplish this, I was scheduled for a nipple surgery approximately six months later. Part of my upper thigh skin was used for the main portion, the areola, and Dr. Ghaderi used Alloderm, which is a synthetic skin, to make a natural nipple. Since insurance companies sometimes deny paying for the artificial material, Dr. Ghaderi personally called my insurance company to get approval. I truly feel that Dr. Ghaderi accomplished his goal - and more. When I see myself in a bra, I can sometimes pretend that the cancer never existed. His work was even complimented by a plastic surgeon in Canada who commented how nicely the breasts matched each other."

"For anyone who has to go through the trauma of breast cancer, I would advise you to choose your doctors very carefully. I truly feel that my recovery, both physically and emotionally, was less of a nightmare because of the skill and care of Dr. Ghaderi."

Costs of Breast Reconstruction

According to the American Society of Plastic and Reconstructive Surgeons, the average surgeon fee for breast reconstruction is:

Implant alone: $2,841.00
Tissue Expander: $3,413.00
Back Flap procedure: $5,646.00
TRAM Flap procedure: $7,088.00
Microsurgical Free Flap procedure: $9,315.00
Tattoo Nipple Area: $600.00
Nipple Reconstruction: $1,200.00

These fees do not include bills from anesthesiologists, hospitals, or the cost of implants. Most health insurance companies do cover the cost of breast reconstruction after mastectomy. In 1998, the Women's Health and Cancer Rights Act was passed, which requires all health insurance providers who cover mastectomy procedure to also cover the costs of breast cancer reconstruction for mastectomy patients.

Breast Reconstruction Information

Breast implant procedures can be performed on an outpatient basis or at a hospital. Breast implant surgery can be done under local anesthesia or under general anesthesia. Breast implant surgery can last from one to several hours depending on whether the implant is inserted behind (submuscular) or in front of (subglandular) the chest muscle and whether surgery is performed on one or both breasts. If the surgery is done in a hospital, the length of the hospital stay will vary according to the type of surgery, the development of any postoperative complications, and your general health. It may also depend on the type of coverage your insurance provides. Before surgery, your doctor should discuss with you the extent of surgery, the estimated time it will take, and the choice of drugs for pain and nausea. See Breast Implant Information page for more information regarding breast implants.

Your consideration of breast implants, for reconstruction or for augmentation, should be based on realistic expectations of the outcome. You may also want to talk with women who have had this surgery at least a year ago by the same surgeon. Keep in mind, however, that there is no guarantee that your results will match those of other women.

Your results will depend on many individual factors, such as

  • your health
  • chest structure and body shape
  • healing capabilities (which may be hindered by radiation and chemotherapy, smoking, alcohol, and medications)
  • the skill and experience of the surgical team
  • the type of surgical procedure
  • the type and size of implant
You will be given general or local anesthesia, and in most cases, antibiotics. The surgery may last from 1-2 hours for augmentation to several hours for reconstruction or revision.

Scarring is a natural outcome of surgery, and your doctor can describe the location, size, and appearance of the scars you can expect to have. For most women, scars will fade over time to thin lines, although the darker your skin, the more prominent the scars are likely to be. You should ask your doctor about the types of surgical procedures, where your scar will be, and what to expect after surgery.

Options in Breast Reconstruction

The type of breast reconstruction procedure available to you depends on your medical situation, breast shape and size, general health, lifestyle, and goals. Women with small or medium sized breasts are the best candidates for breast reconstruction.

Breast reconstruction can be accomplished by the use of a breast implant, your own tissues (a tissue flap), or a combination of the two. A tissue flap is a section of skin, fat and/or muscle which is moved from your stomach, back or other area of your body, to the chest area and shaped into a new breast.

Whether or not you have reconstruction with or without breast implants, you will probably undergo additional surgeries to improve symmetry and appearance. For example, after your breast has healed from the original implant surgery, you may want to build a new nipple and darken the areola (skin around the nipple). This procedure can usually be performed on an outpatient basis. Ask your doctor to explain the various ways this can be done, such as using a skin graft from the opposite breast or by tattooing the area.

Ask your doctor about the pros and cons of each implant technique. If you decide to have reconstruction for one breast, you may need to think about surgery on the other breast to achieve a similar appearance.

Breast Reconstruction with Breast Implants

Your surgeon will decide whether your health and medical condition makes you an appropriate candidate for breast implant reconstruction. Women with larger breasts may require reconstruction with a combination of a tissue flap and an implant. Your surgeon may recommend breast implantation of the opposite, uninvolved breast in order to make them more alike (maximize symmetry) or he/she may suggest breast reduction (reduction mammoplasty) or a breast lift (mastopexy) to improve symmetry. Mastopexy involves removing a strip of skin from under the breast or around the nipple and using it to lift and tighten the skin over the breast. Reduction mammoplasty involves removal of breast tissue and skin. If it is important to you not to alter the unaffected breast, you should discuss this with your surgeon, as it may affect the breast reconstruction methods considered for your case.

Timing of Breast Implant Reconstruction

The following description applies to reconstruction following mastectomy, but similar considerations apply to reconstruction following breast trauma or for reconstruction for congenital defects. The breast reconstruction process may begin at the time of your mastectomy (immediate reconstruction) or weeks to years afterwards (delayed reconstruction). Immediate reconstruction may involve placement of a breast implant, but typically involves placement of a tissue expander, which will eventually be replaced with a breast implant. It is important to know that any type of surgical breast reconstruction may take several steps to complete.

Two potential advantages to immediate reconstruction are that your breast reconstruction starts at the time of your mastectomy and that there may be cost savings in combining the mastectomy procedure with the first stage of the reconstruction. However, there may be a higher risk of complications such as deflation with immediate reconstruction, and your initial operative time and recuperative time may be longer.

A potential advantage to delayed reconstruction is that you can delay your reconstruction decision and surgery until other treatments, such as radiation therapy and chemotherapy, are completed. Delayed reconstruction may be advisable if your surgeon anticipates healing problems with your mastectomy, or if you just need more time to consider your options. There are medical, financial, and emotional considerations to choosing immediate versus delayed reconstruction. You should discuss with your surgeon, plastic surgeon, and oncologist, the pros and cons with the options available in your individual case.

Surgical Considerations to Discuss

Discuss the advantages and disadvantages of the following options with your surgeon and your oncologist:

Immediate Reconstruction:

  • One-stage immediate reconstruction with a breast implant (implant only).
  • Two-stage immediate reconstruction with a tissue expander followed by delayed reconstruction several months later with a breast implant.

Delayed Reconstruction:
  • Two-stage delayed reconstruction with a tissue expander followed several months later by replacement with a breast implant.
Breast Implant Reconstruction Procedures

One-Stage Immediate Breast Implant Reconstruction
Immediate one-stage breast reconstruction may be done at the time of your mastectomy. After the general surgeon removes your breast tissue, the plastic surgeon will then implant a breast implant that completes the one-stage reconstruction.

Two-Stage (Immediate or Delayed) Breast Implant Reconstruction
Breast reconstruction usually occurs as a two-stage procedure, starting with the placement of a breast tissue expander, which is replaced several months later with a breast implant. The tissue expander placement may be done immediately, at the time of your mastectomy, or be delayed until months or years later.


Tissue Expansion

 During a mastectomy, the general surgeon often removes skin as well as breast tissue, leaving the chest tissues flat and tight. To create a breast shaped space for the breast implant, a tissue expander is placed under the remaining chest tissues.

The tissue expander is a balloon-like device made from elastic silicone rubber. It is inserted unfilled, and over time, sterile saline fluid is added by inserting a small needle through the skin to the filling port of the device. As the tissue expander fills, the tissues over the expander begin to stretch, similar to the gradual expansion of a woman's abdomen during pregnancy. The tissue expander creates a new breast shaped pocket for a breast implant.

Tissue expander placement usually occurs under general anesthesia in an operating room. Operative time is generally one to two hours. The procedure may require a brief hospital stay, or be done on an outpatient basis. Typically, you can resume normal daily activity after two to three weeks.

Because the chest skin is usually numb from the mastectomy surgery, it is possible that you may not experience pain from the placement of the tissue expander. However, you may experience feelings of pressure or discomfort after each filling of the expander, which subsides as the tissue expands. Tissue expansion typically lasts four to six months.

Breast Reconstruction with Implants

After the tissue expander is removed, the breast implant is placed in the pocket. The surgery to replace the tissue expander with a breast implant (implant exchange) is usually done under general anesthesia in an operating room. It may require a brief hospital stay or be done on an outpatient basis.

Post Mastectomy
Stage 1: Tissue Expander
Stage 2: Breast Implant and Nipple/Areola Reconstruction

Breast Reconstruction Without Implants: Tissue Flap Procedures

The breast can be reconstructed by surgically moving a section of skin, fat, and muscle from one area of your body to another. The section of tissue may be taken from such areas as your abdomen, upper back, upper hip, or buttocks.

The tissue flap may be left attached to the blood supply and moved to the breast area through a tunnel under the skin (a pedicled flap), or it may be removed completely and reattached to the breast area by microsurgical techniques (a free flap). Operating time is generally longer with free flaps, because of the microsurgical requirements.

Flap surgery requires a hospital stay of several days and generally a longer recovery time than implant reconstruction. Flap surgery also creates scars at the site where the flap was taken and possibly on the reconstructed breast. However, flap surgery has the advantage of being able to replace tissue in the chest area. This may be useful when the chest tissues have been damaged and are not suitable for tissue expansion. Another advantage of flap procedures over implantation is that alteration of the unaffected breast is generally not needed to improve symmetry.

The most common types of tissue flaps are the TRAM (transverse rectus abdominus musculocutaneous flap which uses tissue from the abdomen and the Latissimus dorsi flap which uses tissue from the upper back.

It is important for you to be aware that flap surgery, particularly the TRAM flap, is a major operation and more extensive than your mastectomy operation. It requires good general health and strong emotional motivation. If you are very overweight, smoke cigarettes, have had previous surgery at the flap site, or have any circulatory problems, you may not be a good candidate for a tissue flap procedure. Also, if you are very thin, you may not have enough tissue in your abdomen or back to create a breast mound with this method.

The TRAM Flap (Pedicle or Free)
During a TRAM flap procedure, the surgeon removes a section of tissue from your abdomen and moves it to your chest to reconstruct the breast. The TRAM flap is sometimes referred to as a "tummy tuck" reconstruction because it may leave the stomach area flatter.

A pedicle TRAM flap procedure typically takes three to six hours of surgery under general anesthesia; a free TRAM flap procedure generally takes longer. The TRAM procedure may require a blood transfusion. Typically, the hospital stay is two to five days. You can resume normal daily activity after six to eight weeks. Some women, however, report that it takes up to one year to resume a normal lifestyle. You may have temporary or permanent muscle weakness in the abdominal area. If you are considering pregnancy after your reconstruction, you should discuss this with your surgeon. You will have a large scar on your abdomen and may also have additional scars on your reconstructed breast.


Post Mastectomy
TRAM Flap
Final Result with Nipple/Areola Reconstruction

The Latissimus Dorsi Flap With or Without Breast Implants
During a Latissimus Dorsi flap procedure, the surgeon moves a section of tissue from your back to your chest to reconstruct the breast. Because the Latissimus Dorsi flap is usually thinner and smaller than the TRAM flap, this procedure may be more appropriate for reconstructing a smaller breast.

The Latissimus Dorsi flap procedure typically takes two to four hours of surgery under general anesthesia. Typically, the hospital stay is two to three days. You can resume daily activity after two to three weeks. You may have some temporary or permanent muscle weakness and difficulty with movement in your back and shoulder. You will have a scar on your back, which can usually be hidden in the bra line. You may also have additional scars on your reconstructed breast.

Questions to ask your plastic surgeon about Breast Reconstruction

Postoperative Care

Your doctor should describe the usual postoperative (after surgery) recovery process, the possible complications that can arise, and the expected recovery period. Following the operation, as with any surgery, some pain, swelling, bruising, and tenderness can be expected. These complications may last for a month or longer, but they should disappear with time.

Medications for pain and nausea can be prescribed. Some women may experience bleeding and some may experience fever, warmth, or redness of the breast, or other symptoms of infection. These symptoms should be reported immediately to your doctor. You should be told about wound healing and how to care for your wound. Drains may be used for a few days.

Post-operative care may involve the use of a post-operative bra, compression bandage, or jog bra for extra support and positioning while you heal. At your doctor's recommendation, you will most likely be able to return to work within a few days, although you should avoid any strenuous activities that could raise your pulse and blood pressure for at least a couple of weeks. Your doctor may also recommend breast massage exercises.

Ask your doctor about a schedule of follow-up examinations, limits on your activities, precautions you should take, and when you can return to your normal routine. (If you are enrolled in a clinical study, your doctor should give you a schedule for follow-up examinations set by the study plan.)

Source: http://www.fda.gov/cdrh/breastimplants/biissues.html and http://www.fda.gov/cdrh/breastimplants/bisurgery.html

Satisfaction Rates of Breast Reconstruction

An article released by the American Society of Plastic Surgeons states that:

Source: http://www.plasticsurgery.org/mediactr/breast_reconstruction_studies.cfm

According to the European Journal of Plastic Surgery:

    Delayed breast reconstruction following mastectomy for cancer is widely accepted because of a high satisfaction rate. Immediate breast reconstruction offers an even more satisfactory solution, especially related to recovery and self-esteem. In our study, immediate breast reconstruction was performed for three indications: breast cancer, high risk for development of breast cancer and chronic cystic breast disease. Forty-eight consecutive patients with a mean age of 48 years were evaluated. In 37 cases malignant disease, in eight patients prophylaxis, and in three patients benign disease were the reasons for mastectomy. In 42 patients, primary reconstruction was performed, using tissue expanders, followed by prosthetic replacement. Of the other six patients, three were reconstructed with a definitive prosthesis and three with a musculocutaneous flap. At the end of the follow-up period, 42 patients had a definitive prosthesis and two patients had their breasts reconstructed with autologous tissue only. Four patients stopped the procedure following infection and extrusion of their implants. These infections accounted for an overall complication rate of 24%. After starting perioperative antibiotic prophylaxis from the 20th patient onwards, the complication rate was reduced to 12%. Thirty-three patients could be interviewed to assess satisfaction: nine patients were very satisfied, 18 were satisfied and six were moderately satisfied with the end result. Thus, 82% of the patients were satisfied.
Source: http://link.springer-ny.com/link/service/journals/00238/bibs/0023004/00230211.htm

The Institute of Medicine reports:

    In the group of 100 women implanted by van Heerden et al. (1987) 85% would recommend implant reconstruction to other women, and 73% rated it 6-10 on a scale of 1-10 (32 women rated it a 10). However, this questionnaire was administered by the operating service during the post-operative period. Spear and Majidian (1998) asked patients to express their degree of satisfaction, and 98% of 42 consecutive women rated themselves somewhat to completely satisfied with their breast implants. Again, this rating was carried out by the operating team, presumably shortly after surgery. A survey by Francel et al. (1993) of 197 implant reconstruction patients, with a 50% response rate, found that 100% of women who had been reconstructed immediately would try it again and 90% of them were satisfied. Of women who had undergone delayed reconstruction with implants, 90% would try it again and 80% were satisfied. This is another example of a survey performed by the surgical group after an unspecified, but clearly short, postoperative interval.
Source: http://www.nap.edu/books/0309065321/html/27.html

Silicone Breast Implants Are Not Linked to Breast Cancer Risk

From the "National Cancer Institute"
October 2000

In one of the largest studies on the long-term health effects of silicone breast implants, researchers from the National Cancer Institute (NCI) in Bethesda, Md., found no association between breast implants and the subsequent risk of breast cancer.

In 1992, because of the lack of sufficient evidence on the long-term safety of implants, the Food and Drug Administration (FDA) restricted the use of silicone breast implants to women seeking breast reconstruction in controlled clinical trials, and Congress directed the National Institutes of Health to undertake a large follow-up study to evaluate the long-term health effects of the implants.

"This is the first part of our analysis of the health risks from the study," said Louise A. Brinton, Ph.D., principal investigator from NCI's Division of Cancer Epidemiology and Genetics (DCEG) in Bethesda, Md. "For women followed for more than 10 years, there was no change in breast cancer risk. Our results do not confirm the findings from several other studies that exposure to implants reduces a woman's risk for breast cancer. This may relate to the longer follow-up in this study as compared with most others."

The average length of follow-up was 12.9 years among the implant patients and 11.6 years among the comparison patients. In previous studies, women with implants were generally followed for less than 10 years.

The participants included 13,500 women who had implant surgery for cosmetic reasons in both breasts sometime between 1962 and 1989 and, for comparison, about 4,000 women similar in age who had some other type of plastic surgery, such as removal of fat from the stomach, or wrinkles from the face and neck. Both groups of women were selected from 18 plastic surgery practices in which the surgeons had performed large numbers of cosmetic breast implant surgeries prior to 1989 and were willing to give the investigators access to their records. The practices were located in six geographic areas: Atlanta, Ga.; Birmingham, Ala.; Charlotte, N.C.; Miami and Orlando, Fla.; and Washington, D.C.

In order to carry out the study, researchers reviewed the medical records from the plastic surgery practices and collected data about the surgical procedures, types of implants, and complications, if any, as well as factors affecting health status, such as weight and medical history. Patients who were located were asked to complete a mailed questionnaire in order to collect information about their health status, factors that might affect their health, and short- and long-term complications that might be associated with the implants. No clinical exams were done on the patients, but attempts were made to verify patient reports of cancer and connective tissue disease from the medical records of the physicians who diagnosed or treated the diseases. For patients who had died, death certificates were collected to verify the causes of death.

Besides the size of the study and the length of follow-up, another unique feature of the NCI study is that the researchers compared the breast implant patients to both the general population and to women who had received other types of plastic surgery. In previous reports, the general population was used as the control group. However, NCI investigators found in an earlier study that women with implants tend to share more breast cancer risk factors with women who had received other types of plastic surgery than with the general population. These risk factors include histories of previous gynecologic operations and operations for benign breast disease. Therefore, they believe that women who received other types of plastic surgery may be a more appropriate comparison group than the general population. However, when compared to either the general population or women with other types of plastic surgery, there was no evidence of a change in breast cancer risk in the implant group.

Of the implant patients in the study, 49.7 percent received silicone gel implants, 34.1 percent double lumen implants, 12.2 percent saline-filled implants, 0.1 percent other types of implants, and 3.8 percent unspecified types of implants. (Double lumen implants have two shells; the inner sac is filled with silicone gel and the outer with saline.) The participants had cosmetic surgery during a time (between 1962 and 1988) when a great number of changes were taking place in the manufacturing of breast implants such as the shell thickness, the type of shell coating, and the gel composition. However, the researchers found there was no altered breast cancer risk associated with any of the types of implants.

One of the controversial issues is whether women with breast implants have more advanced breast cancer at diagnosis than women without implants. In the current study, NCI researchers found a somewhat later stage at detection of breast cancer among the implant patients compared to the controls and a smaller percentage of in situ (early-stage) cancers among the implant patients. However, the differences were not statistically significant and there was no significant difference in breast cancer mortality between the implant and comparison group.

"This is an issue that needs further study," said Brinton. "This would include continuing to follow participants in this study to see if their breast cancer death rate changes with time."

About 80 percent of breast implants in the United States are for cosmetic reasons and 20 percent for breast reconstruction. This study does not include women undergoing breast reconstruction after breast cancer surgery, so it is not possible to predict whether similar results would be found for this population. The majority of the previous studies have also focused on women who received implants for cosmetic reasons.

It is estimated that between 1.5 million and 2 million U.S. women have had breast implants since they first appeared on the market in 1962.

Source: http://surgery.org/article_archive_html_pgs/Oct2000.html

View Breast Reconstruction Before and After Photos


Information provided is for general education about breast reconstruction and cosmetic plastic surgery procedures. This information is subject to change. Smart Plastic Surgery.com does not guarantee that it is accurate or complete, and is not responsible for any actions resulting from the use of this information. General information provided in this fashion should not be construed as specific medical advice or recommendation, and is not a substitute for a consultation and physical examination by a physician. Only discussion of your individual needs with a qualified physician will determine the best method of treatment for you. All board certified plastic surgeons listed are board certified by the American Board of Plastic Surgery and/or the Royal College of Physicians and Surgeons of Canada. Board certified plastic surgeons are verified by the American Board of Medical Specialties.

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