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Breast Reconstruction
Overview
Few operations in plastic surgery require
the technical expertise as well as the personal compassion
as breast reconstruction. Dr. Cruise has extensive experience
with breast reconstruction and understands the needs and issues
associated with it. No matter which plastic surgeon you consult
with it is imperative to form a bond and trust with that surgeon. Breast cancer and mastectomy are very emotional. It is a
very difficult time for the patient. Often, the patient feels
like she is in a "fog" and nothing seems real. But the consequences are very real. It is important to take
all this into consideration when planning what is best for
the patient as a whole.
Sometimes it is best to just wait and
reconstruct at a later time. In general, however, it is best
to have the reconstruction performed at the same time as a
mastectomy. This allows the woman to immediately feel whole after the mastectomy. Facing breast cancer is difficult enough. It is easier from a psychological point of view to know and
to see that things are getting back close to normal. Another
significant advantage is that the woman only has to undergo
one anesthesia.
Another fundamental decision the patient
must make, with the help of the plastic surgeon, is whether
or not she wants her breast reconstructed with an implant
or with her own natural tissue. The own natural tissue usually means performing a TRAM flap reconstruction using abdominal muscle and fat. This has
the additional benefit of having a tummy-tuck done at the same time. This is helpful to the patient’s
state of mind. She feels that, even though she just lost something
very dear to her, she gained something in return. Not every
woman is a good candidate for a TRAM flap. Poor candidates
include patients with: significant obesity, heavy smoking
habits, certain abdominal scars, previous abdominoplasty,
significant lung or heart disease and brittle diabetes. Another
choice for reconstruction with natural tissue is using fat
and muscle from the back. This is known as a latissimus
dorsi flap. It can be used with or without an implant.
Another option, which does not involve
using the patient's own a natural tissue, is to use a tissue
expander. It is done by placing an implant under the pectoralis
muscle, usually at the time of mastectomy, and then expanding
it to the desired size over the next 3 months. The expansion
is done during regular office visits and is relatively painless. Once the expanders are filled to the desired size they are
usually removed and replaced with a permanent implant. This
is a quick outpatient procedure. It is often an excellent
choice if both breasts are removed and are being reconstructed
simultaneously. Implant reconstruction, however, does not
create as normal appearing breasts as your own tissue does. If both breasts are being reconstructed, this is not as much
of a problem because at least there is a very good symmetry. If only one breast is being reconstructed this is more of
a problem, especially if the breasts have some sag to them;
most do beyond the age of 30. Here, patients own tissue produces
a more natural result.
To simplify things, the most important
question a patient needs to answer is whether she wants to
use an implant or her own natural tissue. It is a question
she needs to work out with her plastic surgeon. If she decides
to have an implant, she can always have reconstruction with
her own tissue down the road if she changes her mind.
It should be mentioned that breast reconstruction,
no matter which type is decided upon, does not affect the
recurrence of the breast cancer, nor does it interfere with
the radiation or chemotherapy, if it is necessary.
Dr. Cruise has extensive experience in
breast reconstruction using both implants and native tissue. He works closely with the general surgeon who removes the
breast to make sure that the reconstructed breast is the best
possible. With this in mind, Dr. Cruise prefers what is called
a skin sparing mastectomy. This type of mastectomy
is not always possible. It depends on the location of the
tumor and the location of the breast biopsy incision. This
type of mastectomy allows a reconstruction with a much less
conspicuous scar. Even if this type of mastectomy is not
possible, Dr. Cruise has developed techniques that provide
a result that is state-of-the-art.
 Dr. Cruise's philosophy regarding Breast Reconstruction
 Breast cancer and reconstruction are particularly dear to me as I have lost loved ones from it. A particularly difficult time in my life was when a close friend and mother of two died from it. She was only in her early 30s.
The bright side of the story is twofold. First, and foremost, with early detection and better surgical excision of breast tumors, breast cancer has become a very beatable disease. Second, is that breast reconstruction has gotten to the point where the reconstructed breast can be very close to the normal one. This makes the pain and worrying somewhat more bearable to a patient who is going through an extremely difficult period of time.
It doesn't matter if you come to me or any other competent plastic surgeon. What matters is that you go to a plastic surgeon who is involved not only in the reconstruction of the breast but also works closely with the general surgeon who removes the breast so that it can be done in a way that provides the best reconstruction. Personally, I work with very capable oncologic breast surgeons who are able to remove the breast tissue through an incision not much bigger than the areola. This makes my job much easier and allows for much less visible scars. This is not always possible. When it is impossible, I have developed ways to limit the incisions, yet still provide for an attractive breast mound.
Part of the artistic side of breast reconstruction is to try and create a breast with a significant amount of cleavage and projection. I have to be careful because sometimes this is not what the patient desires and I realize that. This is why preoperative evaluation is so important. What is it that the patient wants that really matters. Sometimes the patient wants more cleavage and more projection than she had prior to the mastectomy. Of course, this type of result can not be guaranteed but can often be accomplished. The patient has to understand, however, that this will require a breast lift to the normal breast on the other side about 3 months down the road to obtain the best symmetry possible. Once again, this is the artistic side to breast reconstruction and something I find very satisfying.
One thing the patient must realize is that complete symmetry is not possible, nor is it normal. The vast majority of people who never had breast surgery do not have complete breast symmetry. The goal is to re-create a breast that appears normal in a safe and effective manner.
Benefits
The benefits of breast reconstruction
in the patient with the diagnosis of breast cancer are immeasurable. It provides the patient with a sense of "wholeness”
during a time where she feels like she has very little control. The entire reconstruction process can be looked at as a process
to get her back to normalcy.
With the technical advances available
to Dr. Cruise, breast reconstruction is a safe and reliable
option.
Possible complications
When outlining complications, it is important to distinguish the complications unique to implant reconstruction, and those unique to reconstruction with your own tissue.
Possible complications unique to implant reconstruction are: possible implant failure (i.e. rupture), malposition of implant, capsular contraction (hardening of the tissues around the implant), visible rippling of the implant, extrusion of the implant, and increased risk of infection, because the implant is a foreign body.
Possible complications unique to reconstruction with your own tissue include: loss of part, or all of the transferred tissues, abdominal hernia formation, unfavorable abdominal scar, unfavorable naval reconstruction, unfavorable abdominal contour and unfavorable breast shape.
Possible complications seen with any major abdominal or breast surgery include: infection, wound healing problems, fluid or blood collection and blood clot formation. Blood clot formation within the deep veins of the leg can break off and travel to the lung causing a pulmonary embolism. A pulmonary embolism can be life-threatening.
Sometimes complications cannot be avoided, but Dr. Cruise makes every effort to make sure that what can be done to prevent them is done.
Are
you a good candidate?
Most women, if they are reasonably healthy,
are good candidates for at least implant breast reconstruction,
because implant insertion requires less additional operating
time to perform. If you are in poor health, then either implant
or nothing at all would be your choice. If, however, you are
not in poor health, you have a choice. At this point, the
question becomes: Are you a good candidate for reconstruction
with your own tissue?
In Dr. Cruise's hands, the most natural
appearing and feeling breasts are obtained when your own tissues
are use. This is not to say that implant reconstruction cannot
provide a good result. The reality is that nothing feels more
natural than your own tissue. Also, your own tissue will sag
somewhat over time just like a normal breast does. Some patients
have commented that implants used for augmentation provide
very attractive breasts so why can't they provide very attractive
reconstructed breasts? This is a very good question. The answer
is that even on a woman with very small breasts an implant
used for augmentation still has SOME breast tissue to act
as padding and to hide the implant. With a mastectomy, the
point of the operation is to remove ALL the breast tissue
to adequately treat the cancer. Therefore, an implant under
a reconstructed breast has only skin and a muscle to cover
it. There is no fat and no breast tissue.
Aside from having poor health, there
are some other factors that may make breast reconstruction
with your own tissue unwise. These include being markedly
overweight, prior abdominal surgery, very little abdominal
fat, diabetes, and smoking. All these must be discussed during
your consultation with a plastic surgeon.
Prior to surgery
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Medications. Certain medications thin your blood and should not be
taken within 3 weeks of surgery. The most notable is
aspirin and aspirin containing products. Vitamin E and
many herbal products also thin the blood and should not
be used within 3 weeks of surgery. Dr. Cruise will go
over this more thoroughly prior to the procedure. It
is important to discuss this thoroughly also with your
general surgeon.
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Sleep. It is important to get a good night's rest prior to the
procedure. If you think this may be a problem, please,
do not hesitate to ask Dr. Cruise for something to help
you sleep.
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Smoking. Please do not smoke within 3 weeks before and
after surgery. Smoking has a profound effect on reducing
wound healing capabilities. It significantly increases
the likelihood for infection, wound healing problems,
and scar formation. It also affects your airway, therefore,
making anesthesia much more difficult.
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Eating. Do not eat within 8 hours of surgery and do not drink
within 6 hours of surgery. It is OK to take medications
with a sip of water. Please discuss all medications with
Dr. Cruise, your general surgeon, and the anesthesiologist.
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Washing. It is a important to wash the entire surgical area thoroughly
the night before and the morning of surgery. This includes
cleaning crevices such as the bellybutton and any folds
in an effort to prevent infection.
- State of mind. Remember,
state of mind is critical. It affects not only your attitude
but your immune system and your overall ability to heal. Put your trust in Dr. Cruise and your general surgeon as
they are both well trained and experienced. Excessive worrying
can actually be detrimental and you should discuss this
with Dr. Cruise prior to surgery so that something can be
prescribed to make sure you remain calm.
Anesthesia
ICRS uses only board certified anesthesiologists
to make sure you have the best anesthesia possible. The anesthesiologist
will discuss with you what type of anesthesia is best for
you. He/she will take into consideration your medical history,
the procedure, and your personal wishes.
General anesthesia is the only option
available for breast reconstruction surgery.
After
the procedure
The length of the mastectomy and reconstruction
is variable. If reconstruction is done with an implant, the
entire procedure usually lasts around 4 to 5. If a TRAM flap
is used for reconstruction, the entire procedure usually will
take from 6 to 8 hours. There are many variables that can
change the length of the surgery.
Immediately. Immediately
after the procedure you will wake up in a recovery room, where
nurses will be monitoring you. Around an hour postoperatively
you can have friends and family visit you. You will have dressings
and a surgical bra on. If you have had a TRAM reconstruction
you will also have dressings around your abdomen and you will
be in a flexed forward position. You will be able to talk
but, understandably, you will probably feel somewhat tired. Most likely you will have drains coming out of the surgical
wounds to prevent fluid collections. Approximately 2 hours
after the operation you will be transferred to the nursing
floor.
The remainder of the post operative course
is markedly different between the implant reconstruction and
a TRAM flap reconstruction. The TRAM flap reconstruction is
a much more involved surgery and usually requires a hospital
stay between 4 and 6 days. This is compared to an implant
reconstruction hospital stay which is normally between 2 and
3 days.
With an implant reconstruction you will possibly be up and walking the evening of surgery
and certainly the next day. You are discouraged from doing
active exercise with your arms, as this may cause implant
malposition and/or bleeding. The drains are removed usually
on the second or third day after the operation.
Normally you go home 2 or 3 days after
the operation and are encouraged to walk around slowly. Stairs
for the first week are discouraged. You may shower on the
second post-operative day by just standing in the shower and
letting the water gently roll over you. After the shower,
you should apply bacitracin, surgical gauze, and put on your
surgical bra.
With TRAM flap reconstruction recovery is much slower. You will remain in bed the evening
after surgery but will be encouraged to deep breath and drink
fluids. The next day you will be encouraged to walk around
in a flexed forward position with the help of a nurse. You
will not be able to shower until about day 3 or 4. Depending
on how quickly you will be able to get around on your own,
you will usually go home 4 to 6 days after the operation. Normally the drains from your breast area will be removed
on day 3 and the ones from your abdomen will probably remain
until about 10 days after the operation.
When you go home you will still be walking
in a flexed forward position. You will be able to shower
and do your own dressing changes. Post operative medications
and other protocol will be modified as necessary by Dr. Cruise
with your recommendations.
Typically, it takes about 4 weeks until
you will be able to get around normally without being too
active. It will take about 3 months before you are able to
actively flex your stomach muscles. Keep in mind, because
one of the stomach muscles was used to re-create the breast,
you may never regain stomach strength similar to what you
had before the operation.
Nipple reconstruction and/or breast revision
is performed 3 months later. It is not uncommon to perform
a breast lift on the other breast in order to obtain symmetry. This will be discussed after the TRAM flap. Nipple reconstruction
and breast revision are relatively small procedures and done
with very little, or no pain. They are performed as an outpatient
procedures and have almost no downtime. Breast-lifting of the other breast for symmetry is also an outpatient procedure
but has a about one week downtime period.
Recovery
time
See above as the differences between
reconstruction with implants and reconstruction with your
own tissue are discussed.
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