Many women require surgical removal of the breast (mastectomy) for a variety of conditions (cancer, severe fibrocystic disease). With modern techniques, reconstructing the breast is often an appealing option. Using either a woman’s own tissues or implants, Dr. Kunkel is able to create a breast that may be very natural in appearance. Breast reconstruction is almost always covered by insurance and can make an enormous difference is a woman’s self-image. A consultation will provide you with information on the many options available for breast reconstruction.
Techniques for surgery to treat breast cancer continue to evolve. In some situations the breast cancer surgeon may recommend removal of an entire breast. In other situations the breast cancer surgeon may recommend removal only of the part of the breast that has the cancer. What technique is chosen to reconstruct the breast depends on many factors, including the type and location of the cancer, the size and shape of the breasts, what the woman ultimately wants to achieve with her reconstruction, as well as her overall health history. The different types of reconstruction techniques are discussed below.
Tissue expander – This is the most common technique used for breast reconstruction. At the first operation, Dr. Kunkel inserts a temporary device called a tissue expander beneath the skin at the mastectomy site. Saline (salt water) is injected into the tissue expander at the time of the surgery. The amount of saline added during surgery varies depending on how loose the tissues are, the quality of circulation to the tissues, and the patient’s expectations. As the woman is seen in the office over the next several months saline is gradually added to the tissue expander. This is easily accomplished through a device called a port that is built into the expander. The woman comes into the office every two or three weeks for this and it takes just a few minutes to do. Over time the tissue expander is filled to a size and shape that she thinks fits her overall frame. Once the final size of the expander has been reached, the woman undergoes a second operation to replace the tissue expander with a longer-term implant, either saline or silicone. This operation usually takes about an hour or two and the woman goes home the same day.
Direct-to-Implant – Some women are candidates to skip the tissue expander entirely and just have the final implant placed at the time of the mastectomy. The best candidates for this are women who have slightly large but not very droopy breasts who would not mind being a little smaller after the mastectomy than before. Women who have extremely large or extremely droopy breasts may not be good candidates.
Oncoplastic reduction/mastopexy – This technique often provides terrific results for a woman who has large breasts and chooses to have just the tissue containing the cancer removed instead of the entire breast. She may have already had a lifetime of pain in her back and neck and shoulders due to the weight of her breasts. She might have grooves in her shoulders from her bra straps. Women who choose this procedure undergo removal of only the tissue containing the cancer and the tissue immediately around that. Sometimes the defect that remains may be filled with nearby breast tissue as the breast tissue is rearranged and often made smaller. Typically the woman’s nipple is elevated to a more pleasing position and the breast is re-shaped. This procedure may be completed as an outpatient. Most women who choose this type of cancer care also require radiation.
Latissimus flap – This procedure may be a good option for a woman who has breasts that are somewhat droopy (“ptotic”) and who is only going to have one breast removed. Skin, fat, and muscle are transferred from the woman’s back to the mastectomy site. This tissue is draped over a tissue expander or an implant that has been placed in the mastectomy site. Latissimus flap technique allows for more shaping and sculpting of the breast than just using a tissue expander or an implant alone. The skin, muscle, and fat create a more natural look and feel to the breast. In most cases the tissue expander is later replaced with a long-term implant.
TRAM flap – TRAM flap breast reconstruction is a less common technique today, but remains a good option for the right candidate. This operation uses abdominal skin, fat, and muscle to create a breast; usually there are no breast implants or tissue expanders involved. In most cases there is enough skin, fat, and muscle to be transferred from the abdomen to the mastectomy site to create a breast that looks very similar to the other breast. However, women who have had several abdominal operations, are overweight, have other medical conditions, or smoke are not good candidates for TRAM flap breast reconstruction.
Free tissue transfer – This type of breast reconstruction completely detaches skin, fat, and usually muscle from one area and reconnect the blood vessels of these tissues with blood vessels around the mastectomy site. The most common of these techniques is called a DIEP flap, which is a modification of the TRAM flap. In DIEP flap reconstruction abdominal skin and fat are used to reconstruct the breast, with only a small cuff of muscle being taken.
Women undergoing tissue expander or latissimus flap breast reconstruction typically spend one night in the hospital. TRAM flap patients may spend two or three nights, and DIEP flap patients may spend 4 or 5 nights in the hospital. Women who undergo breast reconstruction are usually tired and sore for a week or two. Surgical drains may be left in place to prevent a build-up of fluid and are usually removed within a few weeks. The majority of women will want two or three weeks off from work, and they need to arrange for some help around the home for at least one week.
Some women decide that they want to have a nipple/areola reconstruction. This is usually accomplished after the breast shape has been created and the woman is happy with her overall size, shape, and symmetry. Nipple reconstruction is a short operation and often is performed under local anesthesia. The areola is made by using color placed by a tattoo technique.