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Whether
you decide to have breast
reconstruction depends on your own
individual case, medical condition, general
health, lifestyle, emotional state, and breast
size and shape. You may consider consulting
your family, friends, breast implant support
groups, and breast cancer support groups to
help you in making this decision. Your general
surgeon, plastic surgeon, and oncologist
should work together to plan your mastectomy
and reconstruction procedure to give you the
best possible result.
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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
plastic surgeon, as it may affect the breast reconstruction methods
considered for your case.
What
Are the Choices in Breast Reconstructive Procedures?
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 prosthesis (a breast implant, either
silicone
gel or saline-filled), 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 breast reconstruction
with or without breast implants, you will probably undergo additional
surgeries to improve symmetry and appearance.
For example,
because the nipple and areola are usually removed with the
breast tissue in mastectomy, the nipple is usually reconstructed
by using
a skin graft from another area of the body or the opposite breast,
in addition
to tattooing the area. Nipple reconstruction is usually done as
a separate
outpatient procedure after the initial reconstruction surgery is
complete.
Breast
Reconstruction Procedures with Implants
The Timing of Your 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.
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. In breast reconstruction following mastectomy,
a
breast implant is most often placed submuscularly.
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.
Stage
1: Tissue Expansion
During a mastectomy, the general surgeon 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, tightness
or
discomfort after each filling of the expander, which subsides as
the tissue
expands but may last for a week or more. Tissue expansion typically
lasts
four to six months.
Stage
2: Placing the Breast Implant
After the tissue expander is removed, the unfilled breast implant
is placed in
the pocket, and then filled with sterile saline fluid. In reconstruction,
following
mastectomy, a breast implant is most often placed submuscularly.
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.
Breast
Reconstruction Procedures without implants
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 breast implant reconstruction. Flap surgery also
creates
scars at the site where the flap was taken and 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.
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.
Post-Operative
Care
Depending on the type of surgery you have, the post-operative recovery
period
will vary. Note: If you experience fever, or noticeable swelling
and/or redness
in your implanted breast(s), you should contact your surgeon immediately.
To
talk to women about breast reconstruction in Canada visit
the
breast reconstruction message boards on www.canadaba.ca
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