Breast Reconstruction Rehoboth Beach

• Type of mastectomy: one side, both sides, nipple removal, nipple sparing
• Body type: breast size, skin quality (sagging), breast unevenness, height and weight
• General medical condition: history smoking, weight loss/gain
• Cancer treatments: radiation therapy
• Genetics: risk factors for developing breast cancer in opposite breast
• Individual goals and expectations

There are many breast cancer patients who are cancer free after their breast cancer treatments who maybe interested in breast reconstruction in order to restore one or both of their breasts to near normal shape, appearance, size and symmetry following previous mastectomy and reconstruction, mastectomy with no reconstruction or lumpectomy. There are many factors that would affect what would be the best reconstruction option to produce a satisfying outcome. It is important to choose a board certified plastic surgeon who has a lot of experience in post mastectomy breast reconstruction surgery.

• Mastectomy deformity without reconstruction
• Post mastectomy deformity with reconstruction
• Breast deformity and asymmetry after lumpectomy with or without radiation exposure

The “other breast”

One of the goals of breast reconstruction is to strive for symmetry in the situation where only one breast is affected, treated and reconstructed. There are different options to treat the “other breast”:

• Opposite side mastectomy decrease the chance of future breast cancer
• Breast lift, breast reduction or breast augmentation to improve symmetry of size, shape or position
• Fat transfers are also used in breast reconstruction of either breast

• You have breast cancer and desire breast reconstruction after breast cancer procedure to restore your breast to near normal appearance, shape, size and symmetry
• You are in good medical condition and nonsmoker
• You fully understand options of treatment, risks and outcomes with realistic expectations

Although breast reconstruction is intended to restore your breast to a near normal appearance, the results are highly variable:

• There will be visible scars on your breasts that will always be permanent
• A reconstructed breast will not have the same sensation or feel of the breast it replaces
• Usually the results of the reconstructed breast will look better in clothing because of the visibility of these scars
• Certain surgical procedures will leave scars at the donor site, commonly back, abdomen and buttock

• Listening to your concerns, goals and realistic expectations
• Evaluation of general medical conditions, medications, allergies, previous surgeries, exposure to smoking
• Examination of breasts; measurements taken; assess size, skin thickness, quality and laxity; assess for asymmetry
• Photographs taken
• Discuss all options for breast reconstruction: breast implants, own tissue (autologous), how many stages, opposite breast surgery options (mastectomy with reconstruction, breast lift, breast reduction, breast augmentation), fat transfers
• Outline a breast reconstruction treatment plan for either one or both breasts
• Discussion of details, risks and expected outcomes of the breast reconstruction procedure

If you are considering breast reconstruction, there are many things to take into consideration about what type of breast reconstruction might be best for you. You need to learn about the available breast reconstruction options as well as timing of the procedure in order to make an informed decision on your treatment plan.

Breast reconstruction approach and options

• Immediate reconstruction after single or double mastectomy, nipple removal or nipple sparing
• Delayed reconstruction after single or double mastectomy
• Reconstruction with implants
• Reconstruction with tissue expanders
• Reconstruction with your own tissue with or without implants or tissue expanders
• Opposite side breast surgery with breast lift, breast reduction or breast implants

Immediate breast reconstruction: The advantages of immediate breast reconstruction include 1. Fewer procedures and associated recovery periods 2. Avoiding having to live with mastectomy defect and the absence of your breast. The disadvantages would include the additional risks associated with reconstruction and a longer recovery.

Delayed reconstruction is usually recommended if your breast cancer treatment may require other treatments immediately after the mastectomy such as chemotherapy and radiation. Once your breast cancer treatments are completed, reconstructive options could be discussed.

Breast reconstruction with implants

Implant based breast reconstruction is considered if the mastectomy or radiation therapy has left sufficient skin and soft tissue on the chest to provide coverage over a breast implant. For patients with insufficient or poor quality skin on the chest or for those who do not want implants would consider a flap reconstruction utilizing their own tissue most commonly from their lower abdomen.

Immediate breast reconstruction above muscle (prepectoral) is performed at the same time of the mastectomy to recreate an immediate breast mound. As the mastectomy is being performed, the plastic surgeon will prepare the breast implant by wrapping it with a biological mesh known as acellular dermal matrix (ADM) which is designed to help maintain a correct anatomic position above the pectoralis muscle and an extra layer of healthy tissue on top of the implant. After the mastectomy is done, the implant covered with the ADM is attached to the chest wall muscle with several sutures to maintain a proper position.

The main advantage to this prepectoral implamt reconstruction is the shorter recovery and less associated discomfort and risks with not having to cut the muscle. In addition, the breast implant is not affected by the contraction of the muscle.

Immediate breast reconstruction below muscle (submuscular) is performed at the same time of the mastectomy to recreate a breast mound. The only advantage of having a muscle on top of the implant is decreasing the likelihood of rippling or wrinkling of the implant. Because you are cutting the muscle, the recovery is longer and there is more discomfort associated with this procedure.

Tissue expander breast reconstruction is performed either at the same time (Immediate) or at a later date as a separate procedure following the mastectomy (Delayed) and may be considered if the mastectomy has left an insufficient amount of skin on the chest wall to support a full size breast implant. By avoiding placement of a full size implant at the time of the mastectomy, there will be less pressure on the skin flaps to allow safe and predictable healing after the breast cancer procedure. A tissue expander allows the skin to be stretched out over a period of time to support a breast implant. About one month after the initial procedure, the tissue expander is inflated with saline solution through a small needle. This is a short office visit that is repeated once every 2-3 weeks as many times until a volume is reached that is satisfactory to the patient’s desire for breast size. Sometimes the amount of available skin and its ability to stretch will play a role in the final size of this expansion. The second procedure takes place approximately one month after the final expansion where a permanent breast implant is placed. At that time, additional procedures such as fat transfers or opposite side breast surgery such as breast reduction, breast lift or breast augmentation may be performed.

This type of breast reconstruction approach will require two separate procedures over a course of 2-3 months depending upon if chemotherapy is required after the initial procedure. The technique of the tissue expander reconstruction is very similar to the implant based breast reconstruction in the use of a biologic mesh support system wrapping around the tissue expander and placed either above muscle (more common and preferred) or below muscle.

Breast reconstruction with latissimus dorsi muscle flap is performed either immediately after mastectomy or delayed after all other breast treatments are completed. The latissimus muscle is a very large muscle in the back that along with its skin provides a reliable soft tissue coverage over the chest when there is not enough healthy skin to cover an implant or tissue expander. The latissimus flap is recommended for patients with insufficient skin or unhealthy radiated skin on the chest wall. This procedure can be performed as either a single stage immediate reconstruction with a breast implant or a two stage reconstruction using tissue expander to implant exchange.

Breast reconstruction with abdominal based, thigh based or gluteal based flaps utilizes skin and soft tissue from the lower abdomen, outer thigh or buttocks to create a breast mound without the need of a synthetic breast implant. The risks and recovery are greater and longer than implant based reconstruction but there is fewer long term problems associated with flap based procedures. Abdominal based flap procedures include pedicled TRAM flap, free TRAM flap, DIEP flap and SIEA flap.

• Anesthesia risks
• Bleeding
• Infection
• Altered sensation/ numbness
• Pain
• Poor healing of incision
• Scars
• Skin necrosis
• Flap necrosis
• Implant complications- scar tissue contracture, rupture
• Asymmetry
• Irregular skin surface
• Abnormal firm lumps under skin
• revision procedures

The most common breast reconstruction following single or double mastectomy performed in our practice is a two stage tissue expander with acellular dermal matrix. After consultation and outlining of treatment plan discussing details, risks and expected outcomes of the procedure, a surgery date is given. No aspirin or blood thinners 7-10 days prior to your surgery.

Surgical markings are placed on your chest to provide guidance for both the mastectomy and the reconstruction.

The mastectomy that is performed is either nipple removal, skin sparing or nipple sparing depending on the discussion with your breast cancer surgeon. The skin flaps are inspected by the plastic surgeon and if determined to be satisfactory, the reconstruction plan is performed. If the condition of the skin flaps is not satisfactory, the reconstruction may not be performed at that time.

The tissue expander is wrapped with the biologic mesh support and placed onto the chest wall and secured with multiple sutures. The new breast pocket is reinforced with additional sutures to support the tissue expander or implant. The surgical pocket is washed with antibiotic solution and all bleeding is controlled with an electrocautery device. Drains are placed and the incision is closed with dissolvable sutures. A loose dressing is placed.

The patient is usually kept overnight for observation and discharged home the following day with instructions and a return visit to the plastic surgeon with 48-72 hours after the procedure to check all incisions.

Recovery period is approximately 3 weeks to light activity with driving and 6 weeks for full activity.