Introduction

Dealing with the disfigurement of breast cancer surgery can be scary for any woman faced with the need for a mastectomy.  Fortunately, reconstructive options exist to reconstruct the breast.  Dr. Khalifeh and Dr. Singh offer the most advanced breast reconstruction techniques.

The Washington, DC based Ivy Plastic Surgery team also offers a unique 2 attending surgeon technique to shorten the operative time required in demanding surgeries such as the deep inferior epigastric artery flaps (DIEP) and other free flaps.  By working together, Dr. Khalifeh and Dr. Singh can shorten operative times by half, and can do unilateral DIEP flaps in around 3 hours, and bilateral DIEP flaps in around 5 hours, making these procedures safer for patients.

If you are thinking about having reconstructive surgery, it is a good idea to talk about it with your surgeon and a plastic surgeon experienced in breast reconstruction before your mastectomy. This lets the surgical teams plan the treatment that is best for you, even if you decide to wait and have reconstructive surgery later.

What is breast reconstruction?

Breast reconstruction is a type of surgery for women who have had a breast removed where techniques are used to recreate the breast mound and then the nipple.  The surgery rebuilds the breast to match the unaffected side or recreate both sides. The nipple and areola (the darker area around the nipple) can also be added, usually at a later shorter surgery . Most women who have had a mastectomy can have reconstruction.

Patients with a lumpectomy can also be candidates if the lumpectomy was deforming.

Why have breast reconstruction?

Women choose breast reconstruction for many reasons:

• to make their breasts look balanced when they are wearing a bra
• to permanently regain their breast contour
• to avoid using an external prosthesis (form that fits into the bra)

You will be able to see the difference between the reconstructed breast and the remaining breast when you are nude. But when the breasts are in a bra, they should be alike enough in size and shape that you will feel comfortable about how you look in most types of clothes.

Things to think about...

Timing of Breast Reconstruction:  Immediate or delayed breast reconstruction

Immediate reconstruction is done at the same time as the mastectomy. An advantage to having immediate reconstruction, is that the chest tissues are undamaged by radiation therapy or scarring. This often means that the final result looks better. Also, immediate reconstruction means one less surgery.

Immediate reconstruction techniques may still require a number of steps after the first surgery to complete the process. Even if you are planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take.

Delayed reconstruction means that the rebuilding is started later. For some women, this may be advised if they need radiation to the chest area after the mastectomy. Radiation therapy given after breast reconstruction surgery can cause complications.

Types of breast reconstruction

Several types of operations can be done to reconstruct your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. A tissue flap is a section of your own skin, fat, and muscle which is moved from your tummy, back, or other area of your body to the chest area.

Implant procedures

One-stage immediate breast reconstruction may be done at the same time as your mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant where the breast tissue was removed to form the breast contour.

This Northern Virginia patient underwent a Bilateral Mastectomy with immediate breast implant reconstruction.  The patient's nipple was spared during the procedure.

Two-stage reconstruction or two-stage delayed reconstruction is done if your skin and chest wall tissues are tight and flat. An implanted tissue expander, like a balloon, is placed beneath the skin and chest muscle. Through a tiny valve beneath the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over time. After the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant. Some expanders are left in place as the final implant.

This Washington, DC patient underwent a Bilateral Mastectomy followed by Breast Implants and Nipple Reconstruction with tattooing.

 There are some important factors for you to think about if you are thinking about having implants:

• Implants may not last a lifetime, and you may need more surgery to replace them later.

• You can have local complications with breast implants such as rupture, pain, capsular contracture (scar tissue forms around the implant), infection, or an unpleasing cosmetic result. This means that implants may become less attractive over time.

Tissue flap procedures

DIEP Flap Procedure

Dr. Khalifeh and Dr. Singh have extensive expertise in this minimally invasive tissue flap procedure. 

By taking the tissues normally removed during a tummy tuck, the doctors reconstruct your breast.  Working together, the time for this advanced procedure is shortened to 3 hours for one side and 5 hours for both sides.  This unique 2 attending approach makes this procedure shorter and therefore safer.

In general, flap procedures behave more like the rest of your body tissue, replacing your breast tissue with your body fat For instance, they may enlarge or shrink as you lose or gain weight. There is also no worry about replacement or rupture.

This Bethesda, MD patient had a nipple sparing mastectomy with immediate bilateral DIEP Flaps.  Her breast tissue was replaced with her abdominal tissue tightening the belly and restoring the breasts.

TRAM (transverse rectus abdominis muscle) flap:

The TRAM flap procedure uses tissue and muscle from the lower abdominal wall (tummy tissue). The tissue from this area alone is often enough to shape the breast, and an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle is moved from the abdomen to the chest area. The TRAM flap can decrease the strength in your abdomen, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower abdomen, or a "tummy tuck."

There are 2 types of TRAM flaps:

• A pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area.

• In a free flap, the surgeon cuts the flap of skin, fat, blood vessels, and muscle for the implant free from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer than a pedicle flap. The free flap is not done as often as the pedicle flap, but some doctors think that it can result in a more natural shape.

Latissimus dorsi flap

The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.

 

This Rockville, MD patient had a Latissimus Dorsi Flap procedure and reduction on the unaffected right breast to match.

Gluteal free flap

The gluteal free flap is another newer type of surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It is an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons. This procedure is much like the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest area. A microscope (microsurgery) is needed to connect the tiny vessels.

Nipple and areola reconstruction

You can decide if you want to have your nipple and areola (the dark area around the nipple) reconstructed. Nipple and areola reconstructions are optional and usually the final phase of breast reconstruction. This is a separate surgery that is done to make the reconstructed breast look more like the original breast. It can be done as an outpatient under local anesthesia (drugs are used to make the area numb). It is usually done after the new breast has had time to heal (about 3 to 4 months after surgery).