California Breast Reconstruction

Breast reconstruction is a surgical procedure that utilizes different techniques to create a breast that closely matches the shape, size and feel of the breast that was removed. There are two alternatives to consider: immediate breast reconstruction and delayed breast reconstruction.

Immediate breast reconstruction is performed at the same time as the mastectomy, while delayed breast reconstruction is postponed until a later post-surgery date.

Breast reconstruction is most often recommended for patients who have undergone a mastectomy (surgical removal of a breast) due to cancer or a pre-cancerous condition, although these techniques may also be used to correct any type of breast abnormality.

Many women feel insecure about breast abnormalities, especially after a mastectomy. Breast reconstruction offers women an opportunity in renewing a normal appearance to their breasts. This will create a sense of confidence as well as assist the woman in regaining her femininity.

• Immediate Reconstruction
• Delayed Reconstruction
• How is breast reconstruction surgery performed?
• Breast implants
• Flap reconstruction
• Types of flap reconstruction
• How long does breast reconstruction surgery take?
• What type of anesthesia is used?
• Where is the procedure performed?
• When can I return home and resume normal activities?
• How do I prepare for breast reconstruction surgery?
• What precautions are necessary during recovery?
• What are the possible complications after breast reconstruction surgery?
• What results can I expect after breast reconstruction surgery?
• Choosing the right surgeon

Immediate Reconstruction

During immediate reconstruction the general surgeon, who removes the breast, teams up with a Plastic Surgeon, creating the new breast. Immediate reconstruction has several potential emotional and aesthetic advantages. Some patients find that waking up from a mastectomy with two normal breasts helps to alleviate the grief caused by losing a breast. Immediate reconstruction can also preserve a greater amount of skin and reduce scarring. Scars are easier to conceal when less skin is removed during the mastectomy. And, of course, when the reconstruction is performed immediately following the surgery, there is only one recovery to deal with.

Delayed Reconstruction

Though immediate reconstruction offers many benefits, it is not for everyone. Some patients do not want the added stress of researching different reconstruction techniques while they are coping with a cancer diagnosis. Since breast reconstruction can be performed weeks or even years after having a mastectomy, choosing a delayed reconstruction allows patients to take their time exploring their choices. Delayed reconstructions also allow patients to complete other treatments such as chemotherapy or radiation before thinking about breast reconstruction.

If you are considering breast reconstruction, the following information will provide you with a good introduction to the procedure. For more detailed information about how this procedure may help you, we recommend that you consult a plastic surgeon who is board certified or who has completed a residency program that includes instruction in this procedure.

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How is breast reconstruction surgery performed?

There are two major types of breast reconstruction: breast implants and flap reconstruction:

Breast implants

The most common breast reconstruction technique, implants are rubber shells filled with either silicone gel or a saline solution. Breast implants are typically inserted through the use of a tissue expander. In this technique, a silicone balloon or bag is surgically placed beneath the chest muscle.

Through a valve buried under the skin, the surgeon injects a sterile saline solution into the bag, expanding it. The "expander" stays in place for several weeks or months, during which time weekly or bi-weekly injections are administered. Once the skin has expanded sufficiently, the bag is replaced with a permanent implant during a second surgery.

A third surgery may be recommended to reconstruct the nipple and areola. In order to ensure proper placement of the nipple, this operation is normally performed at least three weeks after implant surgery, giving time for the new breast time to settle into its permanent position. The nipple is usually fashioned from a small piece of skin drawn from the breast mound. A separate skin graft forms the areola. About six weeks later, the nipple and areola will be colored to match the other side using a medical tattoo technique.

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Flap reconstruction

This technique creates a new breast using a section of muscle, skin and fat taken from another area of the body. It requires a longer hospital stay and more recovery time than implant reconstruction, and it also leaves scars at both the breast site and the donor site. But because the new breast is made of natural tissue, it looks, feels and ages more like a normal breast -- which many patients prefer. In addition, the use of natural tissue eliminates the complications that can arise when foreign objects such as implants are inserted into the body. Flap reconstruction may also be recommended when the skin won't expand enough to cover an implant.

Flap reconstruction may be performed using a pedicle flap or a free flap. The pedicle flap allows the tissue used in reconstruction to remain attached to its original blood source. The tissue is moved to the breast area through a tunnel under the skin. In the free flap technique, the flap tissue is completely removed and reattached to the breast area, where its blood vessels are connected to those in the chest area through microsurgical techniques.

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Types of flap reconstruction:

Transverse abdominus musculocutaneous flap

The TRAM procedure can be performed as either a pedicle flap or a free flap. A section of muscle, fat and skin is surgically removed from the abdomen and used to form the new breast. Sometimes referred to as "tummy-tuck" reconstruction, this procedure flattens the stomach andreconstructs the breast simultaneously. After the surgery, the abdominal muscles are temporarily weakened, and in rare cases, this weakness becomes permanent. If you are considering future pregnancy, be sure to tell your doctor because this sort of abdominal weakness can affect future pregnancy.

Latissimus Flap

In this technique, a section of the latissimus dorsi (the back muscle arising from the top of the hip to the arm just below the shoulder) is removed to form a new breast. This tissue is often quite thin, so a small implant may be required as well.

Other flaps

If the abdominal or latissimus tissue is unsatisfactory, a flap can be taken from the upper, middle or lower part of the buttock. However, this technique tends to weaken the gluteal muscle, restricting an athletic patient's activities. It also requires the surgical removal of a vein from one leg, since the gluteal blood vessels often aren't long enough to stretch from the chest area to the armpit where they must be reattached. If all other methods are unsatisfactory, tissue can be taken from the upper hip or "love handle" area. This technique is usually a last resort, since this tissue does not lend itself well to shaping a breast. Taking a flap from this area can also leave the hips uneven.

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How long does breast reconstruction surgery take?

Generally, each of the surgeries in the implant process takes from one to two hours. Flap reconstruction surgeries may take two to four hours and the TRAM flap operation could take up to six hours. Free flap procedures are often longer than pedicle flap procedures because of the careful microsurgery needed to reconnect the blood vessels.

What type of anesthesia is used?

Breast reconstruction is performed using general anesthesia causing you to be asleep during the whole procedure.

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Where is the procedure performed?

Breast reconstruction is usually performed on an outpatient basis, in the surgeon's office-based surgical suite, an outpatient surgical facility, or hospital.

When can I return home and resume normal activities?

Tissue expansion and implants are often done on an outpatient basis, allowing the patient to return home immediately. On rare occasions, patients may be slow to recover from anesthesia or have complications that require them to stay overnight in the hospital.

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How do I prepare for breast reconstruction surgery?

During your initial consultation, your surgeon will discuss the changes that you would like to make to your appearance. Since the appearance of your breasts is a matter of personal perception and preference, you will need to discuss your concerns in detail so your surgeon can determine the appropriate alternatives. You also should make arrangements ahead of time for someone to drive you to and from your procedure and to assist you with your daily activities during your recovery period.

Prior to your surgical procedure, the surgeon will perform a complete health history and physical. Depending on your age and state of health, your surgeon may order tests including, but not limited to, an electrocardiograph (ECG), chest x-ray and spirometry (lung function test). Knowledge of your allergies, medications and previous surgeries should be brought to your surgeon's attention at this time. Specific instructions to assist you in preparing for this procedure will be given to you after the health history and physical is complete. Depending on your individual health status, the instructions may include guidelines regarding your diet, alcohol intake, smoking and which medications.

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What precautions are necessary during recovery?

Recovery time varies depending on the type of procedure, but usually takes between four and six weeks. Recovery from flap procedures generally takes longer than recovery from implant procedures. You should be able to do light activities by the end of the first week, including taking short walks to reduce the risk of blood clots in the legs. Refrain from heavy lifting, sexual activity and rigorous sports for three to six weeks. Patients who have had the TRAM flap procedure should refrain from heavy lifting for at least three months, since the abdominal wall is weaken by the procedure and further strain could result in a hernia.

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What are the possible complications after breast reconstruction surgery?

The most common problem following implant surgery is capsular contraction, a tightening of the scars around the implant. In this situation, a second surgery can be performed to loosen the scar tissue. Other complications associated with implants include infection around the implant, necessitating its removal, and leaking, hardening, or shifting of the implant.

You should know that implants deteriorate over time and may eventually need to be replaced. With all free flap procedures there is a risk that the blood vessels will not reattach sufficiently, constricting blood flow and causing the death of the flap tissue. Flaps taken from the buttocks can result in a weakened gluteal muscle, and flaps taken from the hips can result in noticeable asymmetry. TRAM flap procedures can result in abdominal hernia, loss of feeling in the skin below the navel, and a permanent weakening of the abdominal muscles. As with most surgeries, the risks of swelling, bleeding, infection, fluid collection, drug reactions, keloid scarring, and numbness exist. No procedure is without risks; however, the majority of complications known to be associated with a breast reconstruction are minor when the procedure is performed by an experienced board certified plastic surgeon. It is always important to be informed about the possible complications before any surgery. Be sure to discuss any concerns you may have with your surgeon.

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What results can I expect after breast reconstruction surgery?

Most patients report that breast reconstruction enhances their appearance and contributes to their quality of life. Scars will never completely disappear, but they do fade with time. You should also be aware that a reconstructed breast may not duplicate the other breast exactly; it may seem firmer and have a slightly different shape. For most patients, these factors do not detract from their overall satisfaction with the replacement of a lost breast
After surgery you will be tired and sore for one to two weeks. Your doctor can prescribe pain medication to relieve any discomfort. You should also expect some swelling and bruising, which could last for several weeks. Some procedures require the insertion of a drain for at least a week to remove excess fluid from the surgical site. Your stitches will either dissolve or be removed within ten days of surgery.

For the first twenty-four to forty-eight hours after surgery, you can apply ice to the area every fifteen minutes to reduce pain and swelling. After a tissue expansion or implant procedure, you'll be allowed to bathe again beginning twenty-four hours after the surgery. After flap surgeries, sponge baths are advised for about a week.
Having a breast removed can cause great emotional strain. For patients whose mastectomy was due to cancer, the absence of a breast can be a daily reminder of their struggle with a serious disease. Breast reconstruction can give patients a physical appearance similar to that before their mastectomy, or, when it is used to correct deformity, it can create symmetry that in the body that was lacking before the surgery. Breast reconstruction can help restore women's self-confidence, femininity and sense of wholeness, so that they can go on with their lives.

Some insurance companies will pay for breast reconstruction if it is medically necessary, but they may have specific requirements such as a letter from your surgeon, a referral from your general practitioner, and/or photos or other documentation. Be sure to find out what your insurance company requires if you intend to use insurance to pay for this surgery.

We at California Plastic Surgery Specialists are here to help you make an informed and educated decision. The information presented on this website can help answer some of your questions, however for more detailed information related to your specific needs we recommend meeting with a highly qualified and experienced board certified plastic surgeon for a consultation. When you feel ready to meet with a cosmetic surgeont give us a Call Toll Free (800) 449-1884 or you can send us a request for a consultation with a platic surgeon in California.

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