There are many things to consider after a breast cancer diagnosis, and if a mastectomy is necessary, it’s important to explore all your reconstructive options prior to having your surgery. Board certified plastic surgeon Dr. Edward P. Miranda of San Francisco says a significant amount of women who have breast reconstruction undergo a second surgery after their mastectomy simply because they are not informed of or offered immediate breast reconstruction. If you have health insurance, check with your provider: Your reconstruction and implants are probably covered under your plan.
Meeting With Your Doctor
At most major medical centers, a woman is referred to a plastic surgeon prior to her mastectomy. However, according to double board certified plastic surgeon Dr. Tracy M. Pfeifer of New York, this does not always happen. In certain communities and geographic areas women are not referred to plastic surgeons to discuss their options. “The plastic surgeon should explain the options, not the general surgeon,” she says.
Choosing Your Doctors
Pfeifer says choosing general and plastic surgeons who work together frequently often leads to better aesthetic results. The plastic surgeon should perform breast reconstruction frequently, or in the best scenario, only perform breast reconstruction. Ideally, the doctor should also be board certified by the American Board of Plastic Surgery.
The procedure of breast reconstructive surgery after a mastectomy is best understood by examining the two most important factors – timing and types of reconstruction. There are two major types of breast reconstructions: reconstruction with a prosthetic (“implant reconstruction”) and reconstruction using the woman’s own tissues (“autologous reconstruction”).
Many reconstructions are done well after the mastectomy (“delayed reconstruction”); others are performed at the same time as the mastectomy operation (“immediate reconstruction”). Miranda says both are viable options and the choice often depends on medical factors like the need for radiation after surgery and patient preference. “The advantage of immediate breast reconstruction is combining the initial reconstructive surgery with the mastectomy—eliminating one surgical procedure because the plastic surgeon and the breast oncologic surgeon work together,” Miranda explains. “If radiation is planned I generally recommend avoiding implant reconstructions as they have a high complication rate after radiation,” he cautions.
Implant reconstructions are performed with immediate placement of a permanent breast implant at the time of the mastectomy. In some cases, tissue expansion is necessary first, which involves stretching the skin for about three months to create a shaped pocket for the implant to sit in. New anatomic-shaped silicone implants include a form-stable type known as “gummy bears” which promise safety, longevity and a realistic look and feel. The cohesive gel implant was tested in an eight year clinical trial with 1,800 women and found to keep its shape even when severed in two.
In reconstruction that utilizes the woman’s tissues, her own skin and fat are used to create a new reconstructed breast. Traditionally this was done with the TRAM flap – taking skin, fat and muscle from the abdomen and using it to recreate a breast. The downside is using the TRAM flap sacrifices an abdominal wall muscle and weakens the abdomen.
More advanced procedures can offer results that are often better. Options include free flap breast reconstruction using skin and fat from areas like the lower abdomen (“DIEP flap”), upper inner thighs (“TUG flap”) or buttocks (“SGAP flap”). Each of these free flaps has the advantage of not sacrificing one or both abdominal rectus muscles – the ones that are responsible for a six-pack.
The advantage of using either the TRAM or DIEP flap is that it gives the effect of having an abdominoplasty, also known as a “tummy-tuck” – as excess skin and fat is removed to create the breast.
The final stage of reconstruction is to reconstruct the nipple areolar complex. The nipple is reconstructed using local tissue flaps and the areola is created either by a tattoo or a skin graft.