RECONSTRUCTIVE PROCEDURES

IMPLANT-BASED RECONSTRUCTION

Breast reconstruction can be classified into two categories: implant reconstruction and flap reconstruction (using your own tissue for breast reconstruction instead of implants). 80-90% of women opt for implant reconstruction because flap reconstruction is a much more invasive type of surgery involving both the breast and the site where the flap is taken from that requires a much longer procedure time and hospitalization, as well as extensive recovery after surgery.

The main benefit of implant-based reconstruction is that no large additional scars outside of the breast are needed and the post-operative recovery is often easier, with a typical two- to four-week recovery period.

Implant-based reconstruction for mastectomy can be done in either one stage, where a permanent implant is placed at the time of mastectomy, or in two stages, where a temporary implant called an expander is placed at the first stage and switched to a permanent implant at the second stage. The decision on which approach to use is based on pre-mastectomy breast size and shape, patient goals, and intra-operative assessment following mastectomy.   Implant-based reconstruction may also include fat grafting at the second stage of reconstruction in order to help give the most natural appearance of the breast following reconstruction.

DIRECT-TO-IMPLANT RECONSTRUCTION

As implant-based breast reconstruction has evolved, two-stage reconstruction with an initial expander is no longer is often no longer necessary. Many plastic surgeons are now realizing that selected patients may be able to have one-stage surgery with an implant placed at the time of mastectomy, which is known as direct-to-implant reconstruction or a “One and Done” approach. The benefits of this approach are that women can avoid the need for a second surgery for the exchange and get to their final reconstructive outcome more quickly.

CHOOSING YOUR IMPLANT TYPE

Breast implants can be filled with either saline or silicone. Both silicone and saline implants come in round and teardrop shapes. They also come in different levels of projection across different volumes. Silicone implants have a range of ‘gumminess’, which affects the feel of the implant as well as the shape and how long the implant lasts.

OVER- OR UNDER-THE-MUSCLE

OVER-THE-MUSCLE

Pros: Patients can have a more natural-appearing upper part of the breast, less chronic pain and functional issues from cutting and disconnecting the pectoralis muscle. Patients who have had prior radiation or are expected to have post-mastectomy radiation will also be able to have better shape and symmetry with over-the-muscle implants.

Cons: With over-the-muscle implants, patients may potentially experience more rippling along the top of the breast, and mastectomy skin flap irregularities can be more visible. In addition, some surgeons may not offer this technique depending on their experience and training.

 

UNDER-THE-MUSCLE

Pros: Under-the-muscle implants are a more familiar technique for many surgeons, based on their prior training. Patients are less likely to have rippling or visible edges of the implant along the top of the breast, and potentially can have better screening for future recurrence if the cancer is right on top of the chest muscle.

Cons: With under-the-muscle implants, patients can experience more short- and long-term pain, and frequently have “hyperanimation deformity” along the top of the breast with pectoralis movement. In addition, the implants are often displaced towards the armpits/sides or appear flattened along the top.

FAT GRAFTING

Fat grafting can be done as a part of reconstruction following mastectomy. When fat grafting is used for post-mastectomy reconstruction, it is typically done as part of the second stage of reconstruction, where fat is injected throughout the mastectomy skin flap and sometimes the chest wall muscles to help increase the size of the reconstructed breast and make the shape appear more natural. In both cases, fat grafting entails standard liposuction (typically of the abdomen and/or thighs) in order to obtain fat to use for the reconstruction. The fat is then specially processed in the operating room to get it ready for transfer. After that, it’s carefully transferred back to the breast or mastectomy skin flaps in small amounts throughout the area to prevent lumpy areas within the breast (“fat necrosis”).

WHAT ARE THE RESULTS?

Drs. Anne and Ziv Peled were the first to publish data about this type of surgery. They have found that over 80% of women have sensation that is similar to what they had before surgery, with many women reporting that they often forget they even had mastectomies and reconstruction surgery because their reconstructed breasts feel so much like their breasts prior to surgery.

A sensation-preserving double mastectomy and implant reconstruction takes about three to four hours of surgery, with a one-night hospital or surgery center stay. For recovery after surgery, most women can return to their daily lives and activities within two weeks, with complete recovery in most cases in four to six weeks.

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