One of the most important days during Breast Cancer Awareness Month is Breast Reconstruction Awareness Day (BRA Day). Taking place on October 16 this year, surgeons and advocates all over the world will share information on groundbreaking and established surgical technologies in order to educate their patients, other medical professionals and caregivers about different types of reconstruction procedures. Of course, reconstruction is not always an option following mastectomy, but for those who are candidates, taking time to understand and select the best surgery type is essential. Following is an overview of current reconstruction procedures available today as well as highlights of two of our favorite Bay Area plastic surgeons.
There are two major types of reconstruction – implant reconstruction (using implants to create a breast mound) and flap reconstruction (using one’s own tissue to create the breast mound). While they may not sound so different on the surface, implant vs. flat procedures are actually quite disparate in terms of preparation, surgery length and recovery time.
Implant-based reconstruction was first introduced in the ’70s and is still the most common technique used today. Traditional practice until just recently was to detach the pectoral muscle, place a tissue expander underneath and then suture the muscle back together to hold the implant in place.1
Using a saline or silicone implant to rebuild a breast often requires less surgery, but it still typically requires more than one procedure. Implant reconstruction can also create the need for additional procedures down the line, due to the implant wearing out or the development of capsular contraction, the build-up of scar tissue around the implant.
Implant reconstruction is often best suited for people who:
- Do not need radiation therapy. For those who go through radiation prior to surgery, often times the skin is left weakened or scarred, making it difficult or impossible to support an implant. Having radiation after surgery can result in increased capsular contraction as well as potentially harden the implant itself, making it look less natural.
- Want to avoid having additional incisions on the body (flap reconstructions take tissue from other areas, but more on that in a bit)
- Prefer to have a shorter surgery (flap reconstructions require more time in the OR)
- Want to “even out” their breasts if surgery is performed only on one side2
Implants are now placed either above or below the pectoral chest muscle, and there’s lots of debate currently as to which is best. Some claim that sub-muscular placement leads to more natural results because the implant is secured beneath the muscle and tissue and thus can be better positioned and stabilized. Also, because muscles receive high blood flow, placing implants under the muscle helps reduce the build-up of scar tissue and the risk of infection. But for many, sub-muscular placement results in pain, weakness in the chest and arms, as well as animation deformity, where the breast moves and changes shape when the pectoral muscle is flexed.
Due to these ongoing issues, many physicians are now using what’s called “prepectoral” reconstruction techniques, placing implants on top of the muscle and under the skin (either real skin, in the case of skin or nipple-sparing mastectomies, or skin substitutes). Thanks to the use of biologic mesh, or a thin layer of collagen, skin is built up to cover the implant - designing a more natural silhouette, protecting the implant and holding it in place in a way that is similar to the sub-muscle procedure.3
Plastic and Reconstructive Surgeon Dr. Karen Horton MD, private practice in San Francisco, offers prepectoral reconstructions to all her patients, using permanent, post-operative adjustable implants rather than tissue expanders. In her opinion, this technique combined with nipple-sparing mastectomies (99% of the time) results in the most beautiful and natural results with the least amount of downtime. By leaving the pectoralis major muscle alone, discomfort after breast reconstruction is minimal, and reconstruction is completed within an average of 2-3 weeks following mastectomy.
Dr. Anne Peled MD, co-director of the Breast Cancer Center of Excellence at Sutter Health California Pacific Medical Center, is both a breast surgeon and a Plastic and Reconstructive Surgeon. She too prefers the prepectoral implant method for its ability to create a natural look with minimal pain and discomfort. Together with her husband, Dr. Ziv Peled, a plastic surgeon specializing in nerve surgery, she has also developed a procedure to preserve sensation following mastectomy – something that has historically been considered one of the greatest drawbacks of undergoing such a procedure.
“One of the surgical options I’m most excited about is the sensation preserving mastectomy and implant reconstruction approach that I do as a team with my husband. We’ve been thrilled to see that most of our patients regain sensation throughout the breasts after surgery, allowing them to move past their cancer or cancer prevention surgery without the daily reminder of what they’ve been through.” – Dr. Anne Peled MD
Flap reconstruction is when different combinations of skin, muscle fat and blood vessels are transferred from another part of a patient’s body to the chest to create a breast mound. Amazingly, tissue can be taken from the abdomen (TRAM, DIEP or SIEA flap), back (latissimus dorsi flap), buttocks (gluteal flap) or inner thigh (TUG). These types of microsurgeries are much more complex, because they involve more than one incision site, larger incisions as well as longer recovery times. However, these techniques can also render much more natural results due to the fact that the breast itself is made of real vs. artificial tissue. Women with implants often complain that their breasts are solid, cold or oddly shaped; whereas women who have flap procedures get to enjoy a more authentic silhouette, with tissue that over time, even has the ability to age like natural breasts. Not all women are candidates for flap reconstruction, frequently due to insufficient excess tissue, but those who are can discuss the options at length with their surgeons.4
More and more cancer centers throughout the world offer various flap reconstruction choices, depending upon one’s body type. Dr. Anne Peled practices lumpectomy reconstruction, oncoplastic reconstruction (lifts or reductions combined with lumpectomy), abdominal and back flaps. Dr. Karen Horton performs microsurgical breast reconstruction that uses excess fat from the lower abdomen or upper inner thigh. These procedures transplant tissue on tiny blood vessels from the “donor site” to a recipient site on the chest without sacrificing major muscles of the body.
Dr. Horton also specializes in complex breast revision procedures, in cases where the initial reconstruction left a patient with undesired, asymmetrical or painful results.
As mentioned previously, though, not all women can or want to be reconstructed, and this option is an important consideration as well. For many who have endured radiation therapy, the remaining skin is simply too fragile or damaged to support additional surgeries or the weight of an implant. Others just want an end to the seemingly never-ending stream of hospital visits. Nothing is simple, and oftentimes, the complications that arise following surgery can dramatically extend treatment time, resulting in an even greater emotional and psychological burden. These days, many women are opting to go flat or use prosthetic breasts in lieu of additional operations, accepting their new natural shape whole-heartedly.
Most important is to remember that we have time to make the right decision – with careful consideration of our bodies, sensitivities, lifestyles and personalities. It’s impossible to quantify the value of research, conversations with multiple surgeons or women with different experiences as well as deep contemplation. They are all essential aspects of making the best individual decision, and that’s why we appreciate BRA Day so much, for encouraging us to come together and learn.