Breast reconstruction

In contrast to the results of years past, the art of breast reconstruction utilizes latest plastic surgery techniques for cosmetic breast enhancement in conjunction with the most advanced reconstructive plastic surgery modalities. Based on each woman’s desires, anatomy, and oncologic surgical requirements, it may be possible to achieve results that are natural, proportional, and truly aesthetically pleasing.

Dr. Ali Izadpanah is a renowned, highly trained plastic and reconstructive surgeon offering breast reconstruction in Montreal, Quebec and its area.
Dr. Ali Izadpanah has a reputation of delivering breast reconstruction, due to his meticulous, perfectionist and caring approach to each patient.

Dr. Izadpanah has a special focus in his practice which involves the care of breast cancer patients. In order to perform these duties effectively, Dr. Izadpanah works closely with a multi-disciplinary team of physicians, including: a surgical oncologist specializing in breast cancer surgery, radiation oncologists and medical oncologists. Working together and communicating effectively with the variety of doctors involved in a breast cancer patient’s care is paramount to a successful outcome.

Breast reconstruction is an option for the majority of women undergoing unilateral mastectomy (one side) or bilateral mastectomy (both sides).

Immediate breast reconstruction, which begins the reconstructive surgical process during the mastectomy procedure, is possible for most patients.

Concerns

There have been significant advances in breast reconstruction techniques that have enabled women who choose to undergo mastectomy to feel balanced, comfortable, confident and attractive.

With numerous treatment options available to women with breast cancer, or genetic predisposition to breast cancer (BRCA gene mutation), trying to determine the best breast reconstruction options can be confusing.
The appearance, contour, and volume of the breast can be recreated with implants or with a woman’s own tissue. The nipple and areola also are recreated. Because the sensory nerves or milk glands and ducts have been removed or significantly injured, normal breast sensation and normal breast function, as with nursing, do not usually return.

Breast reconstruction can be done at any time after undergoing a mastectomy. The procedure has no known effect on the recurrence of cancer and it does not appear to affect cancer surveillance.

Gaining an understanding of the different types of breast reconstruction and the steps and timing of the surgical process is important, and can occasionally factor into decisions regarding breast conservation surgery vs. mastectomy.

After a mastectomy, there are two primary paths for breast reconstruction:

  • Prosthetic or implant-based reconstruction, which involves the use of tissue expanders and/or breast implants.
  • Autologous reconstruction, utilizing tissue from elsewhere on your own body.

When women chose breast conservation therapy that includes:

  • Lumpectomy.
  • Sentinel lymph node biopsy.
  • Radiation therapy.

Breast Conservation Surgery
(A Portion of the Breast Tissue is Removed)

Lumpectomy: Surgery to remove a tumor and a small amount of normal tissue around it.

Partial mastectomy: Surgery to remove the part of the breast that has cancer and some normal tissue around it. This procedure is also called a segmental mastectomy. Patients who are treated with breast-conserving surgery may also have some of the lymph nodes under the arm removed for biopsy – called lymph node dissection. It may be done at the same time as the breast-conserving surgery or after and always through a separate incision.

Surgical Treatments Removing the Entire Breast

Total mastectomy: Surgery to remove the whole breast that has cancer – also called a simple mastectomy. Some of the lymph nodes under the arm may be removed for biopsy at the same time as the breast surgery or after through a separate incision.

Modified radical mastectomy: Surgery to remove the whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscle.

Solutions

There are choices to be made when a patient faces a diagnosis of breast cancer. Many of these decisions are made during the consultation with the surgical oncologist. Dr. Izadpanah will also review the options and surgical plan from the oncologist and aid patients in the decision making process.

Breast reconstruction after mastectomy can be performed with implants, with ones own tissue (skin / fat / muscle) from one area of the body to the chest), or hybrid surgery – the combination thereof.

Dr. Izadpanah will typically recommend the use of special types of breast implants called tissue expanders for the initial stage of breast reconstruction. These special implants are temporary, placed to aid in stretching the remaining tissues (muscle and skin) to allow creation of the new breast mound and ultimately placement of a soft, natural-feeling silicone gel implant.

The surgical techniques involving use of patient’s own tissues (typically from the abdomen or back) are usually reserved for salvage options – in the case of problems with implants based reconstructions or in cases involving radiation therapy as part of the breast cancer treatment plan.

Implant-Based Breast Reconstruction

Breast reconstruction with breast implants (implant-based, prosthetic) can be performed in one or two primary surgical procedures.

The two main surgeries of the tissue expander implant reconstruction are as follows: first stage, performed most commonly as an immediate breast reconstruction at the time of mastectomy, and the breast implant exchange, most often approximately three months after the first stage procedure. If needed adjuvant therapy (chemotherapy) may impact the timing of the exchange procedure only, as the second stage procedure is generally performed 4 weeks after the last treatment.

Fat Transfer aka Autologous Breast Reconstruction

Autologous breast reconstruction utilizes tissue from ones own body. When the tissue is ample, the reconstruction can be performed without the use of an implant.

The most common “donor site” (the location from which the tissue is moved) is the abdomen, but it can also be transferred from:

  • Back
  • Hips
  • Gluteal region
  • Thighs

A TRAM (transverse rectus abdominis musculocutaneous) flap has been the most common abdomen-based reconstruction, joined by the DIEP (deep inferior epigastric perforator) flap which is performed with microsurgery and preserves the abdominal musculature.

TIMING OF BREAST RECONSTRUCTION:
IMMEDIATE OR DELAYED?

Breast reconstruction can be performed at the time of mastectomy (immediate), or during a subsequent operation (delayed). In most tertiary care centers that provide comprehensive breast care, immediate breast reconstruction is an option for most women.

Delayed Reconstruction

In the following circumstances, delayed breast reconstruction may be recommended:

  • Advanced disease (Stage III)
  • Active smoking
  • Obesity
  • Cardiac disease
  • Lung disease
  • Poorly controlled diabetes
  • Other comorbidities
Immediate Reconstruction

The advantages of immediate reconstruction are: breast cancer removal and first stage reconstruction during one operation, avoiding the visual impact of mastectomy only on body image, and preservation of the anatomic landmarks which can lead to a more natural appearing breast.

Almost all breast reconstruction after mastectomy require several “stages” to achieve the final desired result, although other than the first inpatient surgery (mastectomy and first stage reconstruction), subsequent procedures are outpatient and associated with short recovery periods and minimal downtime.

When bilateral mastectomy is performed, the breast reconstruction process is most often identical on each side, and is associated with greater short term and long term symmetry.

With unilateral (one side) mastectomy and breast reconstruction, surgery on the opposite breast (contralateral (links to other services) breast lift, breast augmentation, or breast reduction) is frequently required to achieve the most balanced results.

The Steps of Breast Reconstruction

  • 1

    With immediate breast reconstruction, the first operation is the most involved, and the majority of the work is performed at this first stage. At the conclusion of the mastectomy portion of the procedure, with implant-based reconstruction, a tissue expander is inserted beneath the muscle, a layer of allograft is placed, and the tissue expander is filled to a safe and comfortable volume, predicated on the mastectomy flap blood supply.

  • 2

    The second stage of the breast reconstruction process is the removal of the expander and placement of a permanent breast implant. Generally this step is performed approximately three months after the mastectomy and first stage breast reconstruction. If adjuvant chemotherapy is required after the mastectomy, this second stage is usually performed 4 weeks after completion of therapy.

  • 3

    The third stage is typically the final stage of the breast reconstruction. This is usually performed between 6 and 12 weeks after the second stage, and relates to the nipple and any small contour adjustments that may be required. The nipple construction is performed using a modified C-V flap design, commonly using skin including the mastectomy scar, and rarely requiring additional incisions on the reconstructed breast.

You’ll receive highly personalized care from Dr. Izadpanah and his entire staff during your journey through the breast reconstruction process. He considers this to be the most fascinating and challenging field of plastic breast surgery in that it combines the artistry of cosmetic surgery and the surgical and technical expertise of reconstructive surgery. A breast reconstruction can give you the restored, feminine figure you desire.

The Procedure

TWO WEEKS BEFORE THE PROCEDURE

  • Do not take anti-inflammatory medications or aspirin.
  • Tell your surgeon what medications you are taking.
  • Report your allergies to your surgeon.
  • Inform your surgeon if you smoke.
  • Other preparatory steps may be suggested by the surgeon.

THE DAY OF THE OPERATION

  • Wear comfortable clothing.
  • Have one or two support bras with front closure.
  • Bring one or two girdles for the belly.
  • Do not put on make-up.
  • Do not wear jewelry.
  • Wash with disinfectant soap.

The procedure will take place under general anesthesia and will take a few hours. Your surgeon will reconstruct your breasts with an extension prosthesis inserted through the crease under the breast or through the scar of the mastectomy. It will be enlarged little by little to relax the skin, and will eventually be replaced by a permanent prosthesis.

Hospitalization varies from a few hours to a few days. Plan to have someone give you a lift home. During your convalescence, stay in bed in a position that does not stretch your wounds, do the breathing exercises recommended by your care team and the other exercises they will advise you to do for your arms. You can relieve pain with medications prescribed by your surgeon.

If your surgeon deems it necessary, you should wear the bras and girdle at all times during the first three weeks and during the day for the following three weeks.

  • No alcohol
  • No tobacco
  • No intense physical activity

THE MAIN SHORT-TERM COMPLICATIONS

  • Hematoma (accumulation of blood around the prosthesis)
  • Infection
  • Opening the incision
  • Ulceration of the skin and exposure of the prosthesis

THE MAIN LONG-TERM COMPLICATIONS

  • Breast hardening
  • Changing the sensitivity of the nipples
  • Rupture of prosthesis
  • Inflatable Prosthesis
  • Prosthesis filled with silicone gel
  • Autoimmune diseases

Before & After

* The photos are not presented as a guarantee of result. The results may vary.
** Images are not of actual clients and are for presentations purposes only.

FAQ

Can my reconstruction be performed at the same time as the mastectomy?

In some instances it can. Almost all patients with stage I breast cancer, in which the cancer has not traveled to the lymph nodes, are candidates for reconstruction at the same time as their mastectomy. In other patients with more advanced breast cancer, it may be best to delay breast reconstruction until all other treatments have been completed.

Will having radiation treatments affect my reconstruction?

It will have an effect. More and more women are receiving postoperative radiation treatments to complete their cancer therapy. Most plastic surgeons now agree that it is best to delay breast reconstruction if radiation treatments are planned. Radiation treatments can negatively affect the body’s ability to heal wounds as well as decrease the overall cosmetic appearance of the reconstructed breast. Also, most women who have had radiation treatments after mastectomy are not good candidates for tissue expansion and implant reconstruction.

How and when is nipple reconstruction performed?

A new nipple can be reconstructed from small flaps of skin on the newly reconstructed breast or from borrowing tissue from the opposite nipple. The darker areolar skin is usually created by a small skin graft or tattooing. This is usually performed about three months after the newly reconstructed breast is completely healed. Nipple reconstruction can be performed at the same time as any other symmetry attaining procedures on the opposite breast, or any small revisions on the reconstructed breast.

A breast reconstruction can give you the restored, feminine figure you desire.

What is my recovery like?

Tissue expansion usually just involves one night in the hospital. The latissimus flap reconstruction will require two to three days of hospitalization. A Tram flap reconstruction can require up to four days in the hospital. Pain is controlled with intravenous medication during hospitalization. For the muscle flap procedures, a special catheter can be placed that ministers and local anesthesia to help control pain. Depending on your type of work and type of reconstruction performed, it can be anywhere from one to four weeks before returning to work. Plan on physical activity being limited for six weeks.

Are any other procedures necessary?

It is very common to perform surgical revisions on the reconstructed breast to obtain the best result. Nipple reconstruction is also desired by most patients. Also, any procedures on the opposite breast to obtain symmetry may be required.

What are the advantages to having breast reconstruction after mastectomy?

The goals of breast reconstruction are to restore the breast shape, size, and appearance to near normal and to achieve breast symmetry when dressed. It eliminates the need for external prosthesis. Many studies have shown that breast reconstruction patients have improved quality of life and psychosocial well-being.

What is a "flap" with regard to breast reconstruction?

A flap is tissue taken from your body with its blood supply used to reconstruct the breast. The flap can be pedicled (meaning that the blood supply stays attached to the body) and transferred up to the chest or free (meaning that the blood supply is disconnected and transferred up to the chest and reconnected again with microsurgery). Common flaps for breast reconstruction are the TRAM flap (tissue taken from the abdomen) and the latissimus flap (tissue taken from the back).

Where do the skin and other tissue come from for natural-tissue breast reconstruction?

Other options include back (latissimus flap), buttock (gluteal flap), and inner thigh (TUG flap).

When can I have breast reconstruction surgery? Can it be done at the same time as my mastectomy?

Breast reconstruction can occur immediately after mastectomy or delayed (at a separate time after the mastectomy). Most women undergo immediate breast reconstruction.

How long after chemotherapy or radiation therapy can DIEP flap breast reconstruction be done?

Usually about four to six weeks after chemotherapy. Usually about six to twelve months after radiation therapy. You have to wait for the acute effects of radiation to the skin to resolve prior to any breast reconstruction.

Will I have sensation in my reconstructed breast?

No, you will not have normal sensation as before.

Compared with an implant, DIEP flap reconstruction provides a more natural look and feel that will mature and change as a woman’s body ages, and that won’t have to be replaced because of rupture or other problems.

What are the benefits of using my own body's tissue for breast reconstruction compared with having a breast reconstructed with an implant?

It is your own body tissue. It will give you a more natural look and feel that will mature and change with you as your body ages. You don’t have to worry about replacing it, as may happen with an implant due to implant rupture, infection, or capsular contracture.

What is microsurgery, and why is it used in breast reconstruction?

Free tissue transfer is the transfer of tissue taken from one part of the body and moved to another part of the body far away by detaching the blood vessels and reconnecting the blood vessels using microsurgery. Microsurgery is surgery performed with use of a microscope to re-connect tiny blood vessels to re-establish blood flow to the flaps.

If I do not want to use, or can't use, my abdomen for a DIEP flap breast reconstruction, are there other flap options?

Latissimus flap (from the back) is a possible option, but what is usually requires an implant, gluteal flap (tissue from the buttocks), and TUG (tranverse upper gracilis) flap using tissue from the inner thigh.

Procedure

Breast Reconstruction

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