There are many options for patients seeking breast reconstructive surgery.
Immediate vs. Delayed Reconstruction
The first decisions patients and their surgeons have to make whether to undergo immediate reconstruction or delayed reconstruction. Immediate reconstruction is performed at the same time as the mastectomy, whereas delayed reconstruction is performed in a separate operation at a later date.
Implants vs. Autologous Tissue
The next decision patients and their surgeons have to make is whether to do an “implant based” reconstruction, “autologous tissue based” reconstruction, or even possibly blending implants with autologous tissue.
“Autologous tissue” means fashioning a new breast with your own tissues. This might be tissue from your back (latissimus flap), or your abdomen (TRAM or perforator flap), or with fat injections. Autologous tissue reconstruction and fat injections are lengthy discussions alone so for the purpose of this blog we will focus on implant bases options.
Implant breast reconstruction most often has been performed as a two or three staged operation. The first stage is to place an expander. The expander is placed under the pectoralis muscle and breast skin. The expander functions as an adjustable balloon that can be filled intermittently with salt water to slowly stretch the muscle and skin on top of it till there is enough room to place a regular implant in the space. The placement of the permanent implant is the second stage of the procedure. The third stage is a minor operation to make a nipple if the patient desires that option. In some patients that nipple can be made at the second stage so no third stage is needed. Also some patients just choose to have tattooing done to create the image of a nipple and areola. The classic two stage operation can be initiated at the time of the mastectomy (s) which as previously mentioned is called “immediate” reconstruction. If the patient waits some days, weeks, months later to start the reconstructive surgeries that is delayed reconstruction.
Some institutions or surgeons like to wait till they have all the final pathology results back before starting any reconstructive efforts so they might have some patients wait just 5 or 6 days after mastectomy and than do the plastic surgical part. I’ve rarely found this to be indicated and if a patient is an acceptable candidate for immediate reconstruction we start at the OR visit as the mastectomy is performed. The decision to do immediate or delayed breast reconstruction can have several puzzle pieces to the decision, and occasionally relates to your surgeons preferences. Is the patient going to likely need chemotherapy or radiation? Does the patient have other health issues such as heart and vascular disease, or is the patient a smoker or a diabetic. Like most things in medicine each health issue comes into play with these decisions. There is clear psychologic benefit for patients to start breast reconstruction early if they know they want it. In the typical patient with no major risk factors in our practice they most often choose to proceed with immediate reconstruction. In the last five to six years several trends have evolved in implant reconstructions.
The biggest new trends in implant reconstruction relate to the more frequent use of nipple sparing mastectomies, and the use of Acellular Dermal Matrices (ADM’s). Let’s start with ADMs first. Acellular dermal matrices are segments or human or pig skin that has had the cells and immunologically active materials removed. Your dermis is the tough hearty part of your skin and that dermis can be treated so that it can be used in other patients and grow into them like a strong piece of tissue. We use ADM’s to help fix the bottom of the breast, allow for more rapid expansion, and there is evidence that the breast may stay softer longer (less capusalar contracture) when ADM’s are used. When patients have thin or weakened pectoral muscles , or what would be a tight pocket for their expander the ADM’s can help those problems. Of course like all good things there are down sides. The incidence of seroma and infection, or skin break down following expander placement may be higher in some studies. The final word is not in for it takes many years to collect enough reliable data to be sure if all the advantages outweigh the down sides. Personally I use ADM’s about 40% to 50% of the time.
Often my intraoperative assessment tells me the patient really doesn’t need them so I don’t use them if not indicated; some doctors like to use ADM’s all the times and some never use them so obviously we all have our surgical styles. The other trend I mentioned is that more and more patients are undergoing nipple sparing and other types of skin sparing mastectomies so they have shorter scars and maintain more of their own skin. Not everyone is a candidate for skin sparing or nipple sparing mastectomy. The type or position of the cancer may prevent it, or patients with larger and more hanging (ptotic) breasts are not good candidates for that approach. Acellular dermal matrices have helped us get better results with this skin sparing mastectomies, and also made it possible to get very nice results with single stage reconstructions with the use of ADM and a permanent implant placed at the time of mastectomy. This avoids the expansion phase, but has the down side of only being able to place small to moderate sized implants so it doesn’t work for every body type or every cancer situation. Of course patients love the idea of saving the nipple areola and having a one staged operation and be done with the whole hassle of expansion, but again I caution that “this glove only fits certain hands”. Hopefully this gives a great starting point to understand options in implant reconstruction. If you need a formal consult to learn more and see many typical patient results of these types of procedures you can reach Dr. Nelson at (520) 575-8400 and schedule a consult.
There is a great deal of interest in breast reconstruction by fat grafting currently. This has exciting promise for the patients and the physicians, but patients need to be aware that full reconstruction with fat is still viewed as experimental. For years Dr. Nelson has used fat grafting to fill partial defects in the breast as part of a standard reconstruction. Fat grafting can be used to hide contour defects around implants, hide rippling or add a little volume where the mastectomy hollowed an area that a reconstruction couldn’t fill by standard techniques. Sometimes some graft with fat or other fillers might be placed under a nipple areola reconstruction to give more definition. Patients need to be aware that most insurances don’t cover fat grafting or fillers as a standard option yet so the patient may have fees associated with fat grafting. Where fat grafting has the most current promise is in correcting lumpectomy contour defects or correcting small volume changes after multiple biopsy procedures. The science of fat grafting and stem cells for reconstruction is a rapidly evolving area of breast reconstruction science.