Learning you have breast cancer is an emotional and overwhelming experience. In today’s world, there are many effective ways to treat breast cancer to include surgery, chemotherapy, and radiation. Discussing an individualized reconstructive plan with your plastic surgeon prior to committing to a treatment strategy is invaluable in achieving the best possible post-treatment appearance.
At Restore SD Plastic Surgery, we are here to support your treatment choices and to create a reconstructive plan that restores your breast physically and helps your emotional journey to recovery. Reconstructing the breast to create a balanced, natural result is what Dr. Douglas and Dr. Gallus do best and have been doing for over a decade.
The Best Candidates
Breast reconstruction is not for everyone but at Restore SD Plastic surgery we feel strongly that all women facing breast cancer treatment should have the opportunity to learn about their options. A federal mandate, The Women’s Health and Cancer Rights Act, was passed in 1998 to protect women’s rights regarding breast reconstruction. This law ensures women are offered reconstruction following mastectomy and symmetry surgery for the opposite breast in group insurance plans that cover mastectomy.There are a few reasons why patients are not candidates or may need to change the timing of the reconstruction.
Typically, breast reconstruction is done at the time of mastectomy. This is referred to as Immediate Breast Reconstruction. The most common reason to do reconstruction later (known as Delayed Breast Reconstruction) is a treatment plan that includes postoperative radiation. In that situation, it is often best to wait on the final reconstruction until the radiation is completed and you have healed from the radiation treatment. Even in these cases you may be a candidate for an implant based reconstruction that is replaced after radiation treatment. This is known as Delayed Immediate Reconstruction. Other reasons to delay reconstruction are a smoking history, obesity, and diabetes that is not well controlled.
These risk factors delay wound healing and increase the complication rate associated with surgery. Your surgeon can discuss your options in the setting of these risk factors and other health conditions that may affect your surgical result. Delivering a safe, consistent, natural, and attractive reconstruction is our goal.
The most important thing to understand about breast reconstruction is that it should be individualized for every patient. A diagnosis of breast cancer brings with it many doctor visits, each with a flood of new information. The treatment options can be overwhelming and at Restore SD Plastic Surgery we want to help you to make an educated and informed decision regarding your breast reconstruction. Your consultation will be in a calm and unhurried environment that allows you and your family members to openly communicate your reconstructive desires, concerns, and yes, even fears.
If you decide to proceed with mastectomy and reconstruction there are many options that can involve implants or use of your body’s own tissues or both. The process of reconstruction can take up to a year and we want to ensure that the right plan is in place when we begin the journey.
Breast reconstruction can be performed at the time of mastectomy (Immediate) or several months or years later (Delayed). The most common reasons for Delayed reconstruction are outlined above. No matter the timing of the reconstruction, the major techniques of breast reconstruction use implants/tissue-expanders, use your own tissue (autologous), or some combination of the two. Your options will vary depending on the shape, size, natural drooping (ptosis) of your breast as well as your skin quality and personal preferences.
In implant-based reconstruction, a tissue expander is placed in the breast pocket, typically below the pectoralis muscle. It is a deflated balloon that is partially filled with saline at the time of surgery. After a couple weeks of healing, the expander is inflated weekly in the office until the desired volume is reached. This can take a few weeks but is typically completed by six to eight weeks after surgery. Your Restore SD Plastic Surgeon will then plan the next stage of surgery in which the expander is removed and replaced with a permanent implant. At this surgery, fat is often taken from another area of your body and grafted around the implant to create a smoother contour and refine the result.
In certain patients, direct to implant reconstruction (DTI) is an option. At the time of mastectomy, a permanent implant is placed and following healing, you are ready to move on to nipple reconstruction and areolar tattooing. Fat grafting may help refine the result at the time of nipple reconstruction.
In autologous reconstruction, your own tissue is used to create a natural appearing breast. The most common way of performing this reconstruction is to use your tummy tissue. This is known as a TRAM flap or DIEP flap depending on the surgical technique used.
Another common way of reconstructing the breast is to use a Latissimus Dorsi flap. Using part of your back muscle is a reliable way of providing the necessary soft tissue coverage for a long-lasting breast reconstruction in patients who have been radiated. It is most often used in conjunction with a tissue expander to provide the volume needed to recreate a natural looking reconstruction.
Breast reconstruction surgery is performed under general anesthesia. Depending on the type of reconstruction performed the procedure may take from 1-2 hours to several. Your hospital stay is also dependent on the type of reconstruction performed.
Most tissue expander and implant based surgery patients can go home the day following the procedure. Autologous reconstruction patients usually spend two days to one week in the hospital depending on the specific reconstructive surgery performed. Recovery also varies on the type of surgery. All surgical procedures come with varying amounts of discomfort. At Restore SD Plastic Surgery, your postoperative comfort and pain control are important and we use the long-acting pain medication Exparel to ease your recovery. You will be seeing your Restore SD surgeon frequently after surgery. It is best to avoid travel in the first several weeks after surgery. Please discuss surgical timing with the Restore SD team to allow adequate healing and follow up prior to any planned travel. Many complications occur from getting too active too early. Your Restore SD team will guide you back to your work, recreational and more vigorous daily activities.
- What happens at my breast reconstruction consultation?
We realize that the diagnosis of breast cancer is difficult and comes with great uncertainty and perhaps even a fear of the unknown. At Restore SD Plastic Surgery, we prefer to see you after you have met with your surgical oncologist, your medical oncologist, and the radiation oncologist. Treating the breast cancer is the primary priority and when you visit with us you will have a good idea of what your oncology team is recommending. We will talk with you about the various reconstructive options and which one offers you the best and safest opportunity to achieve the reconstructive results you desire.
When you come to Restore SD Plastic Surgery to discuss Breast Reconstruction, your Restore SD surgeon will perform a detailed breast examination as well as review your medical history and any medications you are taking. At your consultation, you will have photos taken with our Vectra 3D imaging system and discuss treatment areas and options while viewing your photos series. With our state of the art Canfield software, potential surgical results can be viewed and adjustments can be made, helping you to visualize possible outcomes.
- Why should I have breast reconstruction?
For many women, having breast reconstruction after cancer restores a sense of wholeness. At Restore SD Plastic Surgery, we enjoy performing breast reconstruction and are dedicated to ensuring that you have the information you need to make an educated and informed choice.
- How do I choose a surgeon for my breast reconstruction?
It is important to ask if your surgeon is Board Certified by the American Board of Plastic Surgery. As Board Certified plastic surgeons at Restore SD, we have years of training and expertise in breast reconstruction surgery that cannot be imitated by short courses and alternative certifications. Ensure that your surgeon is proficient in breast reconstruction surgery and immediate reconstructive surgery in particular. The American Board of Plastic Surgery is one of 23 members of the American Board of Medical Specialties. These specialties represent the traditional core of fully trained specialists. Alternative boards have cropped up over the last several years to lend legitimacy to incompletely trained or poorly trained practitioners. Accept nothing less than a surgeon certified by the American Board of Plastic Surgery who preferably is a member of the American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS).
- Why should I choose Restore SD Plastic Surgery for my breast reconstruction?
We have passionately pursued excellence in breast reconstruction for over a decade and are in the prime of our careers. Our most meaningful patient encounters come from our breast reconstruction patients and we stay on the cutting edge of new techniques and technologies. We have vast experience operating together on the most complex of cases and function seamlessly as a team for double mastectomy patients. Let us Restore you to a sense of completeness and wellness!
- What if I have large breasts and would like to be smaller after reconstruction?
Your Restore SD surgeon will partner with you to create an individualized plan that addresses your goals. There are a variety of safe, consistent, and reproducible techniques that will allow you to downsize to smaller breasts after reconstruction. Postoperatively, you may look forward to some relief from neck and upper back concerns.
- What if I have smaller breasts and want to be bigger?
Enlarging the size of your breasts is possible in many but not all women. Your Restore SD surgeon will work with you to decide on realistic goals that can be safely achieved and yield optimal results.
- I have the BRCA gene. Should I have a double mastectomy?
For peace of mind, many women are opting for double mastectomies and immediate reconstruction. Performing reconstruction on both sides at the same time gives your Restore SD surgeon the best opportunity to give you an optimal result with excellent symmetry and shape. Most often these reconstructions are performed with implants but your individualized plan with your Restore SD surgeon may lead to exploring techniques that use your body’s own tissues.
- The oncology team told me I need radiation therapy. How does that affect my reconstruction?
Radiation is a game-changer in the field of breast reconstruction. An area that is radiated is forever affected and will impact decisions in your reconstructive planning. If radiation is planned, we recommend delaying reconstruction for 9-12 months after completing the radiation treatments. Reconstruction after radiation often involves a technique that uses your body’s own tissues to bring in healthy, fresh, and non-radiated skin and/or muscle to the area. Fat grafting has also been shown to ameliorate some of the adverse effects of radiation. Some patients may still be candidates for implant based reconstruction after radiation treatment. Treating the breast cancer effectively is the primary goal and as experienced surgeons, we are comfortable and confident in delivering excellent results to those patients who require radiation as part of their cancer treatment.
- DIEP Flap, TRAM Flap, Latissimus Dorsi Flap – What’s the difference?
Each of these are reconstructive options that use your body’s own tissues and are called autologous reconstructions. The DIEP flap and TRAM flap use tissue from the lower abdomen to reconstruct the breast. In the TRAM flap the rectus muscle (six-pack muscle) is left attached and used as the blood supply to the flap. The DIEP flap involves disconnecting the lower blood vessels and reconnecting them in the chest to provide blood supply to the tissue. The TRAM flap sacrifices muscle function and the DIEP flap can maintain some or all the muscle function. The latissimus dorsi muscle is the large back muscle and can be used with some skin from the back to reconstruct the breast and often requires a tissue expander and subsequent implant to achieve enough volume for an attractive reconstruction. Your Restore SD surgeon will discussion your options in detail with you to arrive at the best choice.
- I’ve heard you can get a tummy tuck as part of your breast reconstruction – I want that!
The TRAM flap and DIEP flaps both use lower abdominal tissue to reconstruct the breast. The advantages of these techniques are that the abdominal fat and skin closely approximate the feel of breast tissue and will give a very natural appearance. Not everyone is a candidate for this procedure and your Restore SD surgeon will discuss your options with you. This is not a cosmetic procedure and although the results are similar the goal is breast reconstruction and requires some differences from a tummy tuck to include incision location. We often caution patients about insisting on these techniques just to get the tummy tuck – remember that achieving your reconstructive goals is about selecting the right procedure for you that is safe and takes your body shape and overall health into account.
- I want breast reconstruction but still want to get pregnant and have children – what should I do?
In this situation, an implant based reconstruction is usually the answer. There are reports of women who have had DIEP or TRAM flap reconstructions and gone on to have full-term deliveries and healthy babies but the donor site results will change with pregnancy. Some women will initially have an implant based reconstruction and then return for a DIEP or TRAM flap after they are done having children.
- I am a smoker – What do I need to know about my breast reconstruction options?
Smoking adversely affects wound healing and may increase your chances of having a postoperative complication. Stopping smoking prior to surgery is essential to giving yourself the best chance to heal after surgery. Quitting 8 weeks prior and 8 weeks after is recommended. It may be your chance to quit for good! Smoking may necessitate performing a delayed reconstruction to optimize your chances for healing and allow you enough time to quit prior to surgery.
- I have diabetes – What do I need to know about my breast reconstruction options?
Diabetes is a condition that can affect wound healing and increase chances for infection. Having good control of the condition and maintaining a stable HbA1c before and after surgery is vital. Working closely with the provider who manages your diabetes will help ensure you have the best and safest outcomes. Poorly controlled diabetes or associated medical conditions may necessitate performing a delayed reconstruction to allow you enough time to achieve better glucose control.
- Will I need a transfusion? Do I need to donate blood ahead of time?
While transfusion after surgery is unlikely, it is not zero. Mild anemia can be seen in women who menstruate. Part of your preoperative evaluation will include a blood panel that will evaluate your starting blood levels. If you have mild anemia, we may recommend iron pills prior to and after surgery. We do not recommend transfusion lightly and will not suggest it unless it is the safest and best course of action. The blood supply in the United States is very safe and it is not necessary or desirable to donate your own blood before surgery.