Women’s Plastic Surgery | Breast Reconstruction

INTRODUCTION
We at Women's Plastic Surgery are able to offer all types of breast reconstruction. Breast reconstruction is a very personal procedure. We take into account our patients' desires, anatomy, and personal circumstances; and we provide all the available options. We are the only group in San Francisco and the Bay Area that offers specialty expertise in ALL TYPES OF BREAST RECONSTRUCTION. We believe that this is essential for the best results, and we custom tailor the best operation for you.

The thought of a mastectomy can be very frightening for a woman. Firstly, the prospect of breast cancer is very scary in itself. Then, in addition to being diagnosed with a potentially life-threatening disease, she also must face the loss of her breast, which for many women conjures up thoughts such as disfigurement and loss of sexuality.

We strongly believe that in many cases, a reconstructed breast can be attractive and beautiful, even without clothing. Our goal is to create a beautiful and well-proportioned breast for each woman undergoing mastectomy, although this is not possible in all cases. It is important for women to know that there are certain techniques in breast reconstruction that will give a woman the best chance of having a good aesthetic result. We would like to share our opinions on this topic with you.

GETTING THE BEST BREAST RECONSTRUCTION POSSIBLE
There are four basic tenets to getting the best breast reconstruction possible.

Evaluate the aesthetic quality of your plastic surgeon’s results: Be sure your surgeon is experienced in breast reconstruction and has a good artistic sense. Look at photos of your doctor’s results to get a sense of his or her aesthetic skill. Often it is not the type of reconstruction that is done, but the way that it is done, which will determine your overall aesthetic result. Our office prides itself on being one of the region’s largest centers for breast reconstruction.

Immediate breast reconstruction: This means that your new breast is reconstructed at the same time as your mastectomy, so you do not wake up without a “breast.” Immediate breast reconstruction offers many advantages:

Most women are candidates for immediate reconstruction. The only patients who should consider delaying their reconstruction are those with advanced tumors when surgical margins may be involved, those with multiple serious medical problems, and those who are psychologically unprepared for reconstruction. Smokers are at increased risk of complications, so they should quit smoking as far as possible in advance of surgery.

Your surgeon will assist you in deciding whether an implant reconstruction is the best option for you. We at Women's Plastic Surgery are the only group in San Francisco and the Bay Area that offers specialty expertise in ALL TYPES OF BREAST RECONSTRUCTION. We believe that this is essential for the best results, and we custom tailor the best operation for you.

In this method, a saline, silicone or mixed implant is used to replace the missing breast tissue. The main principle in implant reconstruction is to stretch the remaining breast skin to create the appropriate fullness to match the other breast. Traditionally, implant reconstruction is a multi-stage process (the reconstruction involves several operations), although in our office, most patients can get a single-stage reconstruction (one general anesthetic surgery).

In one stage reconstruction, either a saline-filled or a saline and silicone gel filled is used. These implants double as an expander and a permanent implant. Once the implant is filled to the proper capacity, only the filling port needs to be removed, which can be done under local anesthesia.

In multiple stage reconstruction, the first step is placement of the expander implant. This implant has a valve which is underneath the skin which allows the surgeon to add more saline to the implant. Once initial healing has occurred, the implant is filled weekly in the doctor’s office to slowly stretch the skin. Once the skin is stretched sufficiently, the 2nd stage surgery is planned. At that time, the expander implant is replaced with a new saline or silicone implant.

Single Stage Adjustable Nipple Sparing Reconstruction: Over the last 5 years this has been the primary implant technique in our practice. It is our preferred technique because the scar is hidden under the breast, and there is less pain and recovery than traditional expander reconstruction because the implant is placed OVER the muscle. The operation is 2-3 hours and one overnight hospital stay. Most women are off pain medicine in a week or less. It is ideal for women with BRCA 1&2 and other women with strong family history of breast cancer. It is also ideal for women with DCIS and invasive cancer 2cm away from the nipple. This technique is oncologically safe since the nipple is cored out and sent to the pathologist and no women who fit the above criteria have had recurrences. To our knowledge, there is no one else in the country performing this procedure above the muscle without the necessity of cadaver skin graft (Alloderm). In addition, we perform mastopexy/reduction of the breast AT THE SAME TIME as the mastectomy if the skin circulation allows. We also use adjustable implant (not expander) which is has less than the full volume for the first few days thus allowing the skin to recover and decreasing our nipple and flap loss significantly over other techniques. The final volume adjustment is made 1 wk after the operation and can be refined later as the patient's wishes.

This technique has taken years to refine, but it is the simplest and most aesthetic implant reconstruction on the market. It is also being used in our practice with DIEP and other microsurgical flaps.

For those women who have tumors which are very large, very aggressive, or involving the nipple, single stage reconstuction removing the nipple is still available (this is the operation used in Reconstructing Aphrodite).

Traditional skin sparing mastectomy : This is when the general surgeon who is performing the mastectomy only removes old biopsy scar with or without the nipple. The remaining breast tissue is shelled out from underneath the breast skin, leaving most of the breast skin intact. This remaining skin gives the plastic surgeon more tissue to work with and allows for the most natural looking result. If you are planning a delayed reconstruction, you can still request that your general surgeon leave the extra skin. This will give the plastic surgeon more tissue to work with at a later date, or can be removed easily if you decide not to have reconstruction. Skin sparing mastectomy has been shown to be very safe and has the same cure rates as the old radical mastectomies when all of the skin was removed.

Consider surgery on your opposite breast: Having symmetrical breasts is very important in obtaining the ideal aesthetic result. Although we do everything we can to make your new breast match your other one, sometimes it is just not possible without altering the other breast. For instance, some patients have a very large and droopy opposite breast, and others may have one that is too small to easily match. These women are good candidates to have surgery on the other breast, such as a breast reduction, breast lift, or breast augmentation. Fortunately, surgery on the opposite breast is covered by insurance. (A new federal law guarantees this!)

Patients with prior radiation to the breast who need a delayed reconstruction with skin expansion. In our practice, we perform single stage reconstruction who have had prior lumpectomy and radiation with excellent results. This is because our technique allows alot of skin for implant reconstruction and no expansion is needed.

Radiation makes it difficult or impossible to EXPAND skin if there is not enough skin available to perform and implant reconstruction.

Summary of Implant vs. Flap

Advantages of Implant Reconstruction

Shorter initial surgery
Quicker initial recovery
No surgery on abdomen or other body parts necessary
Works well in bilateral mastectomies

Disadvantages of Implant Reconstruction

Does not feel like exactly like a real breast
Will not usually perfectly match other breast if it is unaltered
May require more surgeries over a lifetime
Implant may leak or develop scar tissue

Advantages of Flap

Feels and looks similar to real breast
Once healed never needs replacing
Get “tummy tuck” at same time
Probably fewer operations over lifetime

Disadvantages of Flap

Longer surgery initially with more time in hospital
Longer and more painful recovery
Scar on abdomen, or thigh
May need blood transfusion (unusual)

DIEP FLAP BREAST RECONSTRUCTION
Your surgeon will assist you in deciding whether a DIEP flap reconstruction is the best option for you. We at Women's Plastic Surgery are the only group in San Francisco and the Bay Area that offers specialty expertise in ALL TYPES OF BREAST RECONSTRUCTION. We believe that this is essential for the best results, and we custom tailor the best operation for you.

The DIEP flap stands for D eep I nferior E pigastric artery P erforator flap. “DIEP” refers to the blood vessel that supplies the skin and subcutaneous tissue of the lower abdomen in the same distribution as the TRAM flap. However, the DIEP flap does not include any muscle in the flap. The DIEP flap is a “perforator flap”: it is supplied by blood vessels that travel within and perforate through the rectus abdominis muscle.

The DIEP vessels are isolated during surgery by teasing apart the rectus muscle fibers to access the blood vessels. The muscle is left in place on the abdominal wall, together with all the motor nerves that provide power to the muscle. In a small percentage of cases, your surgeon may choose intraoperatively to base the tissue on a different blood vessel called the superficial inferior epigastric artery (SIEA). This does not change the tissue used in the flap or your final result, but may significantly shorten your operation time.

The DIEP flap is only performed by Reconstructive Microsurgeons, who have special training and experience with microvascular anastomoses and free flaps. Our office provides this expertise.
The DIEP flap can take longer than the conventional TRAM flap: standard operating times are 4-5 hours for a single (“unilateral”) reconstruction, and up to 8-10 hours for a “bilateral” reconstruction (both sides). The time of surgery can be increased by 1-2 hours if the reconstruction is immediate (done at the same time as the mastectomy). However, being under general anesthesia for this length of time is still safe and is common for many reconstructive procedures.
The DIEP flap is a “free flap” and involves “microsurgery”. Microsurgery is surgery that is performed under the operating microscope. The flap tissue from the abdomen is isolated on its microvascular pedicle (one artery and one or two veins that bring blood supply to and from the tissue). The pedicle is isolated and then divided, effectively cutting off the blood supply to the flap. The flap is then transferred to the chest area and the blood vessels are reconnected (the “microvascular anastomosis”) blood vessels in the chest region. With microsurgery, there is a small (3-5%) risk of failure of the microvascular anastomosis. If the blood vessels were to fail or clot off, a return to the operating room would be necessary to redo the anastomosis and to reestablish blood supply to the flap. In contrast, the TRAM flap has virtually no failure rate.
The hospital stay ranges from 3 to 5 days on average, depending on the speed of recovery and postoperative pain. This is in comparison to 1 to 2 days in hospital for an implant reconstruction.
The recovery time following a DIEP flap is longer than after an implant reconstruction. Generally, physically strenuous activities (running, aerobic activity, lifting more than 5 pounds) are to be avoided for 4-6 weeks after surgery. However, walking and light activities begin in hospital, and should continue at home following discharge from hospital.
Blood loss is usually minimal, but in a bilateral reconstruction, and together with a mastectomy, a blood transfusion may be required. Autogenous blood donation (donating 1-2 units of your own blood up before surgery) may be arranged up to 3 weeks before a bilateral reconstruction.
No muscle is taken with the flap. It is less likely to get abdominal muscle weakness, hernia or bulge postoperatively with the DIEP flap, although it is still possible.

Healthy, physically active, non-smoking patients with enough abdominal tissue to create a breast mound are good candidates for the DIEP flap. Often, women have excess abdominal skin and fat following pregnancy and also benefit from the tummy tuck closure. In addition, radiation of the breast prior to reconstruction or anticipated radiation following surgery is another indication for the DIEP flap.

Smokers, patients with diabetes or blood clotting problems are not good candidates for microsurgery. Patients who have had a previous abdominoplasty, previous TRAM or DIEP flap do not have the tissue available for reconstruction using the abdominal skin and fat. Previous abdominal liposuction increases risks of complications with a DIEP flap, but it is not an absolute contraindication. Patients with very low body fat or an inadequate amount of abdominal tissue may not be candidates for the DIEP or SIEA flap to reconstruct a breast mound similar to their other breast. Rarely, the location and number of scars on the abdomen from previous surgery can interfere with the blood supply to a DIEP flap.

In these cases, other types of reconstruction may be more appropriate options. Your surgeon will help you to determine which is the best reconstruction for your unique situation.

The SIEA flap stands for the Superficial Inferior Epigastric Artery flap, the artery which directly supplies the tissue. The SIEA flap contains the exact same tissue as the DIEP flap, but is based on a different blood vessel system. The SIEA flap makes use of the superficial blood supply to the skin and fat of the abdomen, while the DIEP flap uses the deep blood supply.

Approximately only 30% of people have an SIEA vessel that is visible during surgery and that can be used for microvascular anastomosis. This is not known until the time of surgery and cannot be tested preoperatively. As opposed to the SIEA vessels, the DIEP vessels are always present and can always be used.

Advantages of the SIEA flap include a shorter operating time, less surgical dissection, no disturbance of any muscle or fascia, and little to no abdominal discomfort after surgery. Recovery time is often less than for the DIEP flap. Disadvantages include the fact that less than 30% of individuals have this blood vessel, and it may or may not be large enough for microvascular anastomosis.

There are several other types of microvascular free flaps in addition to the DIEP flap that are available for breast reconstruction. These include the TUG flap, S-GAP and I-GAP flaps.

Patients who have had a previous abdominoplasty, previous TRAM or DIEP flap do not have the tissue available for reconstruction using the abdominal skin and fat. Previous abdominal liposuction increases risks of complications with a DIEP flap, but it is not an absolute contraindication. Patients with very low body fat or an inadequate amount of abdominal tissue may not be candidates for the DIEP or SIEA flap to reconstruct a breast mound similar to their other breast. Rarely, the location and number of scars on the abdomen from previous surgery can interfere with the blood supply to a DIEP flap.

In these cases, other types of reconstruction may be more appropriate options. Your surgeon will help you to determine which option is the best reconstruction for your unique situation.

TUG FLAP
The TUG flap is the Transverse Upper Gracilis flap. The TUG flap is the second-line technique of choice for microsurgical breast reconstruction technique when abdominal tissue is unavailable. It is taken from the upper inner thigh area, in the same distribution as a cosmetic inner thigh lift. It provides a soft and shapely breast reconstruction using tissue from the inner thigh and can enable immediate nipple reconstruction. Your surgeon will determine which area is most appropriate for flap reconstruction.

S-GAP FLAP
This flap uses skin and adipose tissue from the buttock based on the Superior Gluteal Artery Perforator. This is lower down on our choice of reconstructive options. The amount of tissue available is less than that for the DIEP, SIEA and TUG flaps and is of firmer and more fibrous consistency. A change in position during surgery is required, the dissection of the flap is more technically challenging and the length of blood vessels available for microvascular anastomosis is shorter. It can result in a more conspicuous donor site contour abnormality.

I-GAP FLAP
Like the S-GAP flap, the I-GAP flap uses tissue from the buttock but is based on the Inferior Gluteal Artery Perforator. It similarly requires a longer operating time, intraoperative change in position, and has a more significant donor site contour deformity when compared to free flaps from the abdomen or inner thigh. This is also a second-line reconstructive choice.