Breast Cancer Reconstruction

Gregory Dumanian, M.D., offers surgical breast reconstruction in Chicago for patients who have undergone lumpectomy or mastectomy surgery to treat cancer. With many breast reconstruction options to choose from, breast cancer patients can look and feel like themselves again – they can even enhance breasts for a more voluptuous figure. Here is an outline of the plastic surgery options available for breast reconstruction.

Breast Reconstruction with Tissue Expanders

When using a tissue expander to reconstruct the breast on the side of the body that has undergone mastectomy, Dr. Dumanian places a deflated balloon beneath the skin, as well as beneath the pectoralis chest muscle. When patients wake up following mastectomy surgery, the side with the tissue expander looks relatively flat.

About two weeks after surgery, Dr. Dumanian will start to inflate the tissue expander by injecting saline (sterile saltwater) into it, taking two to three months of weekly visits to do so. Once cancer treatments are finished and the tissue expander has reached a size that is symmetrical to the contralateral (opposite side) breast, Dr. Dumanian will replace the temporary expander with a permanent breast implant in an outpatient surgical procedure. During this procedure, Dr. Dumanian will also take skin from the reconstructed breast area to create a nipple on the reconstructed area. The caring staff will later tattoo the nipple to match the color of the patient’s areola.

Suitable Candidates for Tissue-Expanders Breast Reconstruction

Suitable candidates for breast reconstruction with tissue expanders are typically slender and have small breasts (i.e., A or B cup size). They have a contralateral breast that is round with the nipple in the center of the breast. They wish to avoid any extra risks or scars that are associated with other types of surgical breast reconstruction. Suitable candidates for this type of breast reconstruction do not mind coming in for multiple office visits to achieve final aesthetic results. Suitable candidates should not smoke and should not be obese, as these factors increase the risk of complications in any type of surgery.

On the other hand, heavier patients with larger breasts (i.e., C or D cup size) are not ideal candidates for this type of breast reconstruction surgery. Also, those with downward-pointing nipples may not be suitable candidates. Lastly, patients who have undergone radiation treatment prior to undergoing mastectomy surgery may not be suitable candidates for this procedure.

Advantages of Breast Reconstruction With Tissue Expander

By opting for a tissue expander, breast reconstruction patients avoid new scars because Dr. Dumanian creates the implant incision on the mastectomy scar. Also, this procedure only calls for one hour of additional surgical time following mastectomy. Often, patients are able to return home the day following the mastectomy and reconstruction procedure. This breast reconstruction method also lessens any additional surgical risks.

Disadvantages of Breast Reconstruction With Tissue Expander

The main drawback of breast reconstruction with a tissue expander is that an expander is not an actual breast. Women who opt for tissue expanders are more concerned with appearing symmetrical in clothes than they are with looking symmetrical while unclothed.

Also, there is a one-in-20 risk of infection with this method. If this happens, Dr. Dumanian must remove the expander until the infection is treated. However, patients who experience infection with this method of breast reconstruction may still be able to undergo breast reconstruction after the infection is cleared.

Multiple steps and office visits are required with this type of breast reconstruction. Some patients may see this is as a hassle; although most patients are fine with this protocol.

One final drawback to this method is that the untreated breast will continue to age and be affected by gravity while the reconstructed breast implant will not necessarily change over the years. Thus, patients with this type of breast reconstruction may opt for revision surgery down the line to adjust the implant size or lift or reduce the unreconstructed breast.

Tissue Expander Risks

As with any surgery, there are certain inherent risks. For instance, there is a one-in-20 chance of complete expander loss and reconstruction failure. Also, patients run a small risk of having the expander placed in an unfavorable position. Dr. Dumanian will adjust the final position of the implant as he removes the expander and replaces it with a breast implant (during the second procedure).

Patients with unrealistic expectations regarding the results of tissue expansion surgery, and those who experienced difficulty during surgery, may be unhappy with the final look of their breasts. By educating patients and establishing a clear understanding of patients’ aesthetic goals, Dr. Dumanian is able to reduce this risk.

There is a rare risk that the expander could be punctured or have other problems. This may stop the expander from stretching tissue as needed. If this happens, Dr. Dumanian will replace the expander with a new one during a surgical procedure.

There is also a risk of scabbing at the incision sites. Smoking increases this risk. This risk is also increased in large-breasted women.

General surgical risks include bleeding, fluid accumulation, nerve sensation, loss of shoulder motion, blood clots in the leg and, very rarely, death.

Breast Reconstruction With TRAM Flaps

Dr. Dumanian also offers breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flaps. This procedure (or any variation of it) is also called “tummy tuck” or abdominal flap breast reconstruction. In this method, Dr. Dumanian utilizes the abdominal muscle, fat and/or tissue from the area between the umbilicus (navel) and pubic bone to craft a mound of tissue that resembles a breast. With this type of breast reconstruction, patients’ main concern is achieving breast symmetry that is evident when unclothed.

Different Types of TRAM Flaps Free TRAM Flap. With a free TRAM flap, Dr. Dumanian may use the same tissue as in the procedure above. However, in this procedure, Dr. Dumanian temporarily separates (or “frees”) the blood vessels and then reattaches them to other blood vessels in the chest. This procedure does require microsurgery, but the benefits are that the transferred tissues receive a heartier blood supply and less muscle is harvested, which can lessen the risk of bulging in the upper abdomen or hernia.

Note that there is a one in 30 chance of complete flap loss with this procedure. This occurs when blood vessels develop clots in them, and the plastic surgeon is unable to reopen the blocked vessels.

Muscle-Sparing Free TRAM Flap. With a muscle-sparing free TRAM flap, Dr. Dumanian uses only a postage-stamp-sized amount of the rectus muscle to create the flap. Again, Dr. Dumanian temporarily separates (or “frees”) blood vessels in this process. Because most of the abdominal muscle is left intact, there is less chance of abdominal complications such as hernia or bulging.

Note that there is a one in 25 chance of complete flap loss with this procedure. This occurs when blood vessels develop clots in them, and the plastic surgeon is unable to reopen blocked blood vessels.

DIEP Flap. With a deep inferior epigastric artery perforator (DIEP) flap, Dr. Dumanian uses only lower abdominal skin and tissue – no muscle – to reconstruct the breast. The blood vessels used in this method run underneath and within the abdominal muscle. While this procedure does require microsurgery, it is beneficial because it nearly eliminates the risk of certain abdominal complications such as bulging or hernia. It also offers patients tummy-tuck-like results, smoothing the lower abdominal area where excess skin and fat were taken.

Note that there is a one in 25 chance of complete flap loss. This occurs when blood vessels develop clots in them, and the plastic surgeon is unable to reopen blocked blood vessels.

SIEA Flap. With a superficial inferior epigastric artery (SIEA) flap, the plastic surgeon uses only lower abdominal skin and tissue – no muscle – to reconstruct the breast, similar to DIEP flap breast reconstruction. In this case, however, the blood vessels used to supply blood to the new breast tissue run within the subcutaneous (i.e., under the skin) fatty tissue, not within the abdominal muscle.

Because these subcutaneous blood vessels are too small to sustain a flap in the majority of patients, SIEA flap breast reconstruction is not as common as DIEP flap reconstruction.

Things to Keep in Mind With TRAM Flaps

For the past five years, Dr. Dumanian has only performed muscle-sparing free TRAM flaps and DIEP flaps for patients electing tummy tuck breast reconstruction surgery. Each patient has a unique anatomy that dictates how much or how little abdominal muscle to take with the flap. Dr. Dumanian and other surgeons cannot make this determination until the time of surgery.  

Patients should keep in mind that with free flaps, there is a tradeoff between flap quality and abdominal wall injury. Put another way, the more abdominal muscle that Dr. Dumanian uses, the better the flap will perform because it has more blood vessels (which are present in the muscle used) supplying it blood. On the other hand, using more abdominal muscle may worsen the risk of abdominal injury and complications. However, there is a greater chance of partial or complete flap loss as less abdominal muscle is used. Again, there is a tradeoff between flap quality and abdominal wall injury that patients must be aware of.

Suitable Candidates for TRAM Flaps

Suitable candidates for TRAM flap breast reconstruction want to achieve visible breast symmetry while unclothed. They have had children and have a liberal amount of tissue in the lower abdominal region that can be used for the procedure. Additionally, patients who have undergone radiation therapy on the breast or chest region are suitable candidates for TRAM flap breast reconstruction. They can use tissue from the abdomen or back area. Finally, suitable candidates do not smoke and are of normal body weight.

Very slim patients may not be suitable candidates for TRAM flap reconstruction. Also, patients who have a vertical scar on the lower abdomen may also not be suitable candidates because Dr. Dumanian can only use half of the patient’s abdominal tissue in the procedure. Also, patients may experience abdominal wall weakness following TRAM flap reconstruction, so patients who frequently lift heavy objects may not be suitable candidates.

Advantages of TRAM Flap Breast Reconstruction

Patients may choose to use a TRAM flap for breast reconstruction in order to attain visible breast symmetry while unclothed. They may also choose this method to avoid having breast implants or to improve their abdominal profile. Another advantage of this method is that it does not require multiple procedural visits like the tissue expansion method does.

Also, a patient’s reconstructed breast will age in a similar fashion to the intact breast. If a patient gains or loses weight, or if she simply gets older, her reconstructed breast should continue to look similar to her contralateral breast.

Things to Keep in Mind with TRAM Flap Breast Reconstruction

Patients should be aware that this method usually produces a significant abdominal scar. Also, there is a chance of bulging in the upper abdomen or abdominal weakness with this procedure.

This surgical procedure can take four to five hours, and the patient will be transferred to the hospital’s ICU immediately following surgery in order to monitor the flap. The patient must spend three to five days in the hospital. Patients may potentially need a blood transfusion with this method, as well.

Additionally, patients will undergo significant recovery time. They may experience abdominal pain for four to eight weeks following the procedure. Dr. Dumanian will explain what to expect during recovery and how to care for the treated area.

TRAM Flap Risks

As with any surgery, there are certain inherent risks. For example, there is a one-in-25 chance of complete flap loss and reconstruction failure.

There is also a small risk of breast asymmetry, but Dr. Dumanian can perform surgical manipulations on either the flap or contralateral breast when he reconstructs the nipple.

Patients with unrealistic expectations regarding the results of TRAM flap breast reconstruction surgery, and those who experienced difficulty during surgery, may be unhappy with the final look of their breasts. By educating patients and establishing a clear understanding of patients’ aesthetic goals, Dr. Dumanian is able to reduce this risk.

Fat necrosis, a destruction of fat cells, causes a subcutaneous area of the flap to feel firm and is a small risk associated with this procedure. Fat necrosis can be painful and may need to be excised during a separate procedure.

There is also a risk of scabbing at the incision sites. Smoking increases this risk. This risk is also increased in large-breasted women.

General surgical risks include bleeding (Some TRAM flap patients may need a blood transfusion), fluid accumulation, nerve sensation, loss of shoulder motion, blood clots in the leg and, very rarely, death.

Latissimus Flap Breast Reconstruction

Dr. Dumanian may suggest latissimus flap breast reconstruction for patients who have large breasts but do not have enough abdominal tissue for other methods of breast reconstruction. Dr. Dumanian may also advocate latissiums flap breast reconstruction for patients who have complications with wound healing, who have had prior chest infections or who have already had radiation therapy on the chest.

With this method, Dr. Dumanian uses skin tissue and muscle from a patient’s back to create a breast mound. In general, the back has less fat than the abdomen, so latissimus flap breast reconstruction patients usually need a breast implant to achieve the desired aesthetic results.

Things to Keep in Mind with Latissimus Flap Breast Reconstruction

Latissimus flap breast reconstruction surgery typically takes three hours. Following surgery, the patient must spend two to three days in the hospital. Patients should expect three to four weeks of recovery.

Dr. Dumanian will insert drainage tubes in the patient’s back to prevent fluid accumulation. The tubes will be removed one to three weeks after surgery.

Patients will have a scar on their breast, as well as a significant scar in the middle of the back on the affected side. When possible, Dr. Dumanian will make any incisions in hidden areas on the body to minimize scar visibility.

Women with larger breasts may opt for a tissue expander at the time of the latissimus flap procedure, and this expander will be inserted in the office to increase the final size of the reconstruction.   Later, Dr. Dumanian will perform a second surgery to replace the expander with a permanent implant.

Because the blood supply to the tissue is left intact with this method, flap failure with this technique is rare.

Bilateral Breast Reconstruction

For a variety of possible reasons, patients may choose to undergo bilateral mastectomies. Bilateral refers to “two sides.” These patients may then require bilateral breast reconstruction – reconstruction on both breasts.

What Bilateral Breast Reconstruction Entails

Bilateral breast reconstruction is not necessarily a more-involved process than single breast reconstruction. However, bilateral breast reconstruction with expanders and implants is still a multiple-step process, during which the patient must make several office visits.

As with single breast reconstruction surgery, Dr. Dumanian will spend 60 to 90 minutes operating during the first surgery following a bilateral mastectomy. He will position expanders during this surgery. Following the procedure, the patient will visit the office on a weekly basis to inflate expanders until the desired breast size is achieved. The final size of the breasts should be appropriate for the patient’s build and aesthetic goals.

Dr. Dumanian will then remove expanders during a second operation, make any needed adjustments and insert permanent breast implants. Because patients attain two round breast implants, they will notice added breast symmetry with this method.

Dr. Dumanian typically performs the second surgery on an outpatient basis, about three months following the initial surgery in which he placed expanders, or once chemotherapy and/or radiation therapy are finished.

Things to Keep in Mind With Bilateral Breast Reconstruction

Bilateral free flap breast reconstruction may be a good option for patients with plentiful abdominal tissue. However, this procedure is more involved than breast reconstruction using expanders and implants. The mastectomies and reconstruction procedures with this method take eight to 10 hours. Also, as with any free flap, there is a small risk of blood clots, which can lead to flap loss.

Additionally, the recovery period is longer with bilateral free flaps. Both rectus (stomach) muscles are used in this procedure, and mesh is often used to repair the abdominal wall, as well as to prevent bulging or a hernia.

With bilateral free flap breast reconstruction, Dr. Dumanian uses each half of the tissue in the lower abdomen to reconstruct each breast. The final size of a patient’s reconstructed breasts depends on the amount of skin and fat available in the abdominal region. Typically, a patient’s reconstructed breasts are a touch smaller than her original breasts.

When patients do not have adequate abdominal tissue to reconstruct both breasts, a decision to perform bilateral latissimus flaps is sometimes made.  For these patients, an attempt is made to hide the scar in the bra strap line.  Another option is to perform bilateral DIEP flap reconstruction, realizing that the final breast mound size and shape may be small.  These DIEP flaps can be increased in size with later fat grafts.  These fat grafts are harvested from the back, thighs, and buttocks with liposuction, and then injected in the breast mounds.

How Radiation Therapy Affects Breast Reconstruction

Patients with breast cancer undergo radiation therapy to help prevent the return of cancer in the affected area. During the course of treatment, radiation energy is applied to the affected area and burns certain tissues, including cancer cells. Although areas that are exposed to radiation become red during treatment, wounds rarely develop, and the tissue eventually heals. Cancer cells are damaged in the course of radiation treatment.

While people show absolutely no adverse effects from radiation treatment, others experience symptoms such as firm, contracted and discolored tissue and skin. Just as patients react differently to radiation therapy, they also heal differently following the treatment. How each patient heals is unpredictable, even many years following radiation therapy.

Thus, radiation therapy makes breast reconstruction difficult and may leave patients with poor aesthetic results. This is why Dr. Dumanian prefers to perform certain breast reconstruction procedures following radiation therapy – and not before.

To learn more about breast reconstruction options, or to schedule a personal consultation, please contact Dr. Dumanian at Northwestern Plastic Surgery at 312-695-1999.

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