Breast Cancer

Procedures Offered:

Post-Mastectomy Radiation Therapy affects the procedural options available to you.

View pre and post-operative photos involving expanders and implants.

May contain graphic images.

 

View pre and post-operative photos involving bilateral mastectomies and bilateral expander/implant reconstruction.

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Expanders and Implants

This procedure typically involves at least two surgeries, but has the fewest scars and is the least invasive of all of the options.

A tissue expander is a balloon placed at the time of the mastectomy and adds about 1 hour of extra surgery time. This procedure usually entails one and sometimes two days in the hospital. Recovery times vary, but typically is in the 2-3 week range.

During weekly office visits over 2-3 months and starting about 2 weeks after placement, the expander is slowly filled with salt water until the desired size is reached. When chemotherapy (if necessary) is completed, the expander is removed and the permanent implant placed. This takes about 1 hour and is done on an outpatient basis.

After healing from the second surgery, a nipple can be created in the operating room in a pain free manner with skin taken locally from the reconstructed breast. A tattoo is added later in the office for the areola color.

Expander and implant surgery is best suited to women who are small breasted and slender. It will appeal to woman who are looking for symmetry in clothing. Over the years the appearance will change little, while the unaffected breast will have normal aging changes.

Expander and implant surgery is not as well suited for larger breasted women, recipients of radiation therapy, women who want symmetry out of clothing, or for those who would have difficulty with repeated office visits. Yet it may stay still be the best choice for beginning the reconstruction process.

Your surgeon may discuss the use of processed human skin as part of your implant reconstruction. One stage reconstructions are sometimes possible.

Risk of infection is always a possibility and this typically leads to failure of the procedure with need for removal of the expander. The risk is approximately 1 in 25.

 

 

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Abdominal Flap Breast Reconstruction / Free TRAM / DIEP Flap

View intra and post-operative photos of an abdominal flap breast reconstruction.

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This option is sometimes called a 'tummy tuck' breast reconstruction. Skin and fat between the navel and pelvic bone are used to create a mound of tissue to replace the removed breast. The result is a flatter stomach and a breast mound reconstruction made of your own tissue. The goal of this procedure is to create a breast mound symmetric with your opposite breast that is as natural and lasting as possible.

Microsurgery is often used to help in the movement of tissue from the abdomen to the chest. These are called "free flaps", because the tissue is free and disconnected from the body for a brief time. Depending on the anatomy of the blood vessels to the tissue, sometimes all of the lower rectus abdominis muscle is harvested with the skin and fat. This is called a "free TRAM flap". If only a portion of the muscle is needed, it is a "muscle sparing free TRAM flap", and if no muscle is taken from the abdomen, it is called a "DIEP" flap or "SIEA" flap. There may be a tradeoff between the reliability of the flap and the recovery of the abdomen from surgery. About 1 in 25 times the vessels clot off resulting in partial or total loss of the flap. The disrupted circulation can also result in small areas where the transferred fat dies and becomes firm. These can be removed or improved with surgery at a later time.

Because the flap is taken from the abdomen there is a resulting long hip to hip scar near the underwear line, which will partially fade over time. The surgery can cause some weakness in the abdominal muscles because part of one muscle is often taken with the flap; the exact amount needed cannot be determined until the time of surgery and depends on the woman's individual blood vessel anatomy.

Women in good health who have had children, have generous lower abdominal tissue and fat, and wish for breast symmetry out of clothing are good candidates for this procedure. Smokers and obese women may have a more complicated postoperative healing process.

This procedure takes at least 4-5 hours and requires 3-5 days in the hospital, with the first night in intensive care to monitor the transferred flap. A blood transfusion is occasionally necessary. Drains will be placed during the surgery and left for 5-7 days (these prevent fluid from collecting in the breast and abdominal area which complicates the healing process).

You should plan on at least 6-8 weeks of postoperative recovery time.

Additional Resources

Read more information on TRAM flaps.

 

 

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Latissimus Flap Breast Reconstruction

View pre and post-operative photos involving latissimus flaps.

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This option utilizes skin and muscle from the back which is tunneled just under the axilla to create a breast mound. Because the back has less fatty tissue than the abdomen, an implant is usually necessary to achieve the desired breast size. The blood supply to this tissue is left intact so failure of the flap is rare. This is a useful procedure for women who have large breasts but do not have sufficient abdominal tissue, have wound healing problems, previous infections of the chest, or have had prior radiation therapy of the chest.

This procedure takes about 3 hours and requires 2-3 days in the hospital. Drains stay in the back for 1 to 3 weeks to prevent fluid collections there. Besides the scar on the breast, there is also a long scar on the mid-back region of the affected side. This scar is placed in a natural fold line that many women have to improve the quality of the scar. Recovery for this procedure is in the 3-4 week range.

For a larger breast size, an expander (rather than a permanent implant) is placed at the time of surgery under the latissimus flap and necessitates extra office visits to fill the expander. A second surgery to replace the expander with a permanent implant is then performed.

 

 

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Bilateral Breast Reconstruction

View pre and post-operative photos involving bilateral breast reconstruction.

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Bilateral refers to breast reconstructions on both sides. For various reasons, patients decide to undergo bilateral mastectomies. Some of these patients request bilateral breast reconstructions.

Important Concepts For These Patients
Bilateral breast reconstruction with expanders and implants is still a multi-step procedure with numerous office visits. Operating on both sides is not much more involved than operating on just one side. It is still a 60-90 minute procedure that occurs after the mastectomies. A second operation in the OR is needed to remove the expander, make adjustments, and to place the permanent expander. The second surgery is done as an outpatient, typically 3 months after the placement of the expanders, or after chemotherapy and/or radiation therapy have been completed.

The implants, because they are both round, achieve some added symmetry for the patient. A patient will continue to have weekly office expansions until she feels that the size of the expanders is appropriate for her build, her clothes, and her expectations. The final size depends upon the patient's expectations for how she will look in clothes.

If the patient has already had radiation to her chest or if there is some wound healing issue, the patient may elect to have an expander on one side, and a latissimus flap for the other side. Rarely, both side latissimus flaps are performed, especially for women who have had bilateral chest radiation for Hodgkin's disease in the distant past.

For the patient with abundant abdominal tissue, a bilateral breast reconstruction with free flaps is an option. In comparison to the use of expanders and implants, this is a much more involved procedure, lasting 8-10 hours in length for the mastectomies and the reconstructions. As for any free flap, there is a risk of the small blood vessels clotting off, and the loss of the flap. The recovery from this procedure is fairly long, because parts of both stomach (rectus) muscles must be used to help dissect out the blood vessels to the flaps. Mesh is often needed to reconstruct the abdominal wall and to help prevent a bulge or a hernia. Half of the lower abdominal tissue is used to make one breast, and half is used for the other. The size of the breast reconstruction then depends on the amount of abdominal skin and fat available. In general, the reconstructed breast mounds are a bit smaller than the patient's cup size before surgery.

 

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How Radiation Therapy Affects Breast Reconstruction Surgical Options

View pre and post-operative photos involving radiation therapy.

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Radiation is delivered to women with breast cancer to help prevent the return of the cancer on the chest. There are studies that imply a small improvement in overall cancer cure rates when radiation is added to surgery for breast cancer.

Radiation is specialized energy delivered to the breast or chest, and it causes a very precise and selective "burn" to the tissues. The tissues become red often during treatment, and rarely wounds develop. The tissues then go on to heal from the radiation treatment. Some people show absolutely no ill effects from the treatment, while in others the tissue and skin is contracted, firm, and discolored.

One important concept is that a history of radiation therapy causes unpredictable healing when surgery is needed on the radiated tissues, even multiple years after the radiation.

Another important concept is that radiation makes breast reconstruction more difficult, and probably with overall poorer cosmetic outcomes.

A final important issue is the effects of radiation are unpredictable, and so plastic surgeons tend to not want to do complex flaps for breast reconstruction before radiation therapy. Plastic surgeons tend to perform flaps after radiation therapy has been delivered to the tissues.

Three Scenarios In Which Patients and Plastic Surgeons
Must Discuss Radiation Therapy

  1. Patients with newly diagnosed breast cancer, who will receive
    radiation therapy after the mastectomy.
    Women with large breast tumors and women with more than three positive lymph nodes often are treated with radiation after the mastectomy. When there is a high suspicion on the part of the breast cancer surgeon that radiation will be needed after the mastectomy, this should be communicated with the plastic surgeon.

    In general, there are two main ways to achieve a breast reconstruction for Scenario A. The reconstruction can be performed after the mastectomy and radiation has been completed. This is the same as Scenario C, below. Alternatively, a tissue expander is placed at the time of the mastectomy, and the tissues expanded before the radiation. The radiation therapists at Northwestern believe it is totally acceptable to radiate the tissues with the expander in place. After radiation therapy is completed and the tissues have all healed (several months later), the patient can undergo the definitive breast reconstruction. That can be a simple implant exchange, the latissimus flap, or the TRAM flap. Immediate breast reconstruction with a tissue expander preserves all of the options available for women who will undergo post-mastectomy radiation therapy. While implant reconstructions under radiated skin often are firmer and with more capsular contraction than for non-radiated patients, this option is simple and suffices for many patients.

  2. Patients with a previous lumpectomy and radiation therapy.
    Women with a recurrence after breast cancer treatment are not candidates typically for expander/implant reconstructions, because the radiated skin does not expand well and the expanders often become infected. Scenario A with implants is possible, because the tissue is expanded before the radiation is delivered. Patients in Scenario B are recommended to have either the latissimus or the tram flap breast reconstructions. Both of these flaps are non-radiated, and the non-radiated flap tissue helps with healing. The choice to use the back or the abdomen depends on patient choice and the surgeon's evaluation of the amount of abdominal tissue for a TRAM flap.

  3. Patients who already have had mastectomies and radiation,
    and now want a breast reconstruction.
    For the same reasons outlined in Scenario B, patients in Scenario C are counseled to undergo one of the flap reconstructions for breast reconstruction.

 

 

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Breast Reconstruction: Tissue Expanders

A tissue expander is a flat balloon placed underneath the skin and underneath the throwing muscle (the pectoralis muscle) of the chest. Patients wake up fairly flat on the surgery side after the mastectomy. About two weeks after surgery, the tissue expander will be "blown up" by injecting salt water into the implant, and this process takes 2-3 months of weekly visits. Then, after the expander has reached a symmetric size with the opposite breast and after any additional cancer treatments are over, the expander is removed in the operating room and a permanent implant is placed. The nipple is created in the operating room as a third step. The tattoo for the brown of the nipple occurs in the office about 1 month later to complete the four step process.

Ideal Candidates for Tissue Expander Breast Reconstructions

Tissue expanders and implants are round in appearance. They work best for slender patients with A or B cup breasts. The opposite breast is round, and with the nipple in the center of the breast mound. If the opposite side is not round but rather more of a triangle shape, patients request a surgical manipulation of the opposite non-affected breast to help achieve symmetry. Patients who select tissue expander breast reconstruction would say they want more symmetry in clothes, rather than out of clothes. They want to avoid extra risks, and to avoid any additional scars on the abdomen or the back. They have the time and ability to come to the office for multiple easy office visits. They don't mind the idea of a second outpatient surgery to take out the expander and to put in a permanent implant. This second surgery takes about 1 hour and is done as an outpatient. Most patients only miss 4-7 days of work for this second surgery if they work out of the home.

Patients who are not "ideal" candidates for tissue expander breast reconstruction are heavier with C and D cup breasts, or with the opposite breast with the nipple pointing downward. Patients who want symmetry out of clothes are not ideal candidates for this procedure. Patients with difficulty coming to the office also find this means of reconstruction difficult. Smokers and obese patients have more complications than non-smokers and ideal body weight patients for all of the 3 types of breast reconstruction. Patients who have had radiation therapy already prior to the mastectomy are typically advised not to undergo this procedure.

Advantages to Breast Reconstruction with a Tissue Expander

Disadvantages to Breast Reconstruction with a Tissue Expander

Risks of Tissue Expansion

 

 

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Breast Reconstruction: TRAM Flaps

A "tummy-tuck" breast reconstruction uses the skin and fat between the umbilicus (belly button) and the pubic bone to create a mound of tissue for a breast reconstruction. The goal of these reconstructions is to create symmetry with the opposite breast out of clothes, and without the help of a bra. These procedures are known as TRAM flaps, which is an abbreviation for "transverse rectus abdominis myocutaneous flaps". Transverse refers to the orientation of the skin, rectus abdominis is the muscle on which this tissue is based, and a flap refers to a moved piece of tissue.

Variations of TRAM Flaps

For the past 5 years, Dr. Dumanian has only performed muscle sparing free TRAM flaps or DIEP flaps when patients elect to have a tummy tuck breast reconstruction. The decision of how little muscle to take with the flap depends on the anatomy of the patient, and this is not known until the time of surgery. Rarely, the blood vessels dictate the performance of the SIEA flap. There is a tradeoff between the quality of the flap and the injury to the abdominal wall for free flaps. The more muscle taken from the abdomen, the more blood vessels exist to supply the flap, and the better the flap. The better the flap, the potentially worse to the abdomen, and vice versa. The better the abdomen and the less muscle used, the greater the chance of a partial or total flap loss. Partial losses can be shown as poor healing of the skin, or else "fat necrosis", which is a hard area of the tissue of the flap. Total losses are devastating to the patient and fortunately are rare. A total flap loss does not put the patient’s life in danger, however. Problems with the abdomen include problematic "bulges" in the lower abdomen, weakness, back pain, and numbness in the overlying skin. Fortunately, none of these issues tend to be too problematic.

Who are the "best" candidates for a TRAM flap? First, a woman who selects a TRAM flap breast reconstruction has the goal for symmetry out of clothes after surgery. Women who have had children and who have a generous amount of tissue between the umbilicus and the pubic bone are the best candidates. There is a balance or ratio between the breast size and the belly size. Patients with relatively generous abdomens can be excellent TRAM flap candidates. Sedentary patients who do not have high requirements for their abdomen are good flap candidates. Patients who have already undergone radiation to the breast or chest should have a flap reconstruction, taken either from the abdomen or from the back.

Patients who are not "ideal" candidates for TRAM flaps are very slender, or else have a lower up and down scar between the umbilicus and the pubic bone. These scars allow the surgeon to only use ½ of the abdominal tissue to make one breast. Patients who do much heavy lifting must consider the possibility of abdominal wall weakness after surgery, and what that could do to their occupation. Smokers and obese patients have more complications than non-smokers and ideal body weight patients for all of the 3 types of breast reconstruction.

Advantages to Breast Reconstruction with a TRAM Flap

Disadvantages to Breast Reconstruction with a TRAM Flap

Risks of TRAM Faps

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Updated August 10, 2012
© 2012 Gregory Dumanian, M.D.