Home ▸Breast Reconstruction
- What Is Breast Reconstruction?
- Revisions in Implant Reconstruction
- Direct to Implant Single Stage
- Autologous Tissue Breast Reconstruction
- Autologous and Prosthetic
- DIEP Flap Breast Reconstruction
- Symmetry Matching Procedures
- Pedicled TRAM Flap Breast Reconstruction
- Nipple-Areola Reconstruction
- Free TRAM Flaps
- Nipple-Areola Tattooing
- “Pedicled” TRAM Flap Breast Reconstruction
- Breast Reconstruction Cost
- Prosthetic Breast Reconstruction
- Breast Reconstruction Insurance Coverage
- Expander Implant Exchange and Revisions
What Is Breast Reconstruction?Breast reconstruction is designed to rebuild the breast, typically following cancer treatment, to restore the shape of the natural breast. Depending of the size, location, and severity of the breast defect, women have several options for reconstruction. For women who undergo a lumpectomy, a local skin or muscle flap may be all that is needed to repair smaller defects. For those who require a total mastectomy, reconstruction of the entire breast can be accomplished with prosthetic implants or autologous tissue transfer. Depending of the size, location, and severity of the breast defect, women have several options for reconstruction. For women who undergo a lumpectomy, a local skin or muscle flap may be all that is needed to repair smaller defects. For those who require a total mastectomy, reconstruction of the entire breast can be accomplished with prosthetic implants or autologous tissue transfer. As recently as 30 years ago, the options for breast reconstruction were limited. The procedures from that area typically yielded results that were unnatural and gave a less than cosmetically pleasing result. Research and innovation over the last several decades have enabled Plastic Surgeons to provide their patients with a much more sophisticated range of options. Whether a woman undergoes a unilateral or bilateral procedure, a cosmetically pleasing, natural breast reconstruction may be possible with modern techniques.
I required bilateral mastectomies because of breast cancer. Dr. Z’s caring, guidance, and advice gave me results I never dreamed of! I am happier now with my body (at 55) than I was in my 30’s! I am SO glad I listened and took his advice. His concern and expertise are unmatched!
June 11, 2012
- Autologous Tissue Reconstruction: This refers to using one’s own tissue to recreate the breast.
- Prosthetic Breast Reconstruction: This refers to using tissue expanders and permanent implants to recreate the breast
- Autologous Tissue with Prosthetic Reconstruction: This refers to a combination of the above two techniques to accomplish breast reconstruction
Direct To Implant Single Stage Breast ReconstructionTraditionally, breast reconstruction has been performed in two stages. The first operation is when the mastectomy is carried out, which leaves the breast with shapeless skin, allowing for gradual expansion over several months. The second operation is typically when a permanent breast implant is placed, finalizing the reconstruction process. However, with the many advancements in the field of breast reconstruction, Dr. Zemmel is pleased to offer a newer technique that requires only one operation. With direct to implant single stage reconstruction, the patient receives the permanent implant at the same time as their mastectomy. This eliminates the need for a tissue expander, though patients have the option to alter their results at a later time. Should they choose to do so, saline solution can be added or removed from the implant via an injection to achieve their ideal size. They can also opt to replace their saline implant with a silicone gel implant. A benefit of direct to implant single stage reconstruction is that the nipple and areola can often be spared, as long as cancerous tissue is not directly beneath. The technique has proven to work beautifully for those who have small tumors, as well as for women who are considering a preventive mastectomy (those who carry the BRCA gene). Patients typically experience a shorter surgery and recovery period overall, since only one surgery is needed. During your initial consultation, Dr. Zemmel will determine if single stage breast reconstruction is right for you, upon assessing your medical history and discussing with you what you hope to achieve.
Autologous Tissue Breast ReconstructionThis family of procedures refers to using the patient’s own tissues to reconstruct the breast. Tissues are typically taken from the abdomen, back, or buttocks. The primary advantage of using one’s own tissue is that this tissue will heal and grow with the patient. Unlike with implant reconstruction, there is no future maintenance required. Implant reconstruction sometimes requires replacement of the implants in the event of a rupture or deflation. Tissue reconstructions look and feel more natural. For a one-sided reconstruction, it is easier to obtain better symmetry with a tissue reconstruction. The main disadvantage of an autologous tissue reconstruction is that tissue must be harvested and transplanted from an otherwise healthy part of the body. This creates a donor site, which can be rarely subject to complications. For pedicle TRAM flaps, that can result in weakness of the abdominal wall, hernias, and scarring.
In recent years, there have been dramatic technical advances in autologous breast reconstruction, which is considered by many to be the “gold standard” of breast reconstruction. Advances in microvascular surgery, including “muscle-sparing” techniques and “DIEP perforator flaps”, have made it possible to transfer the necessary tissue with minimal trauma to the donor site. This has resulted in dramatically reduced donor site problems without compromising the outcome of the breast reconstruction. Furthermore, these technological advances have made the option of autologous breast reconstruction a reality for patients who previously were not considered good candidates.
If someone told me after surgery I would be feeling this well, I would not have believed them. Dr. Zemmel has exceeded my expectations.
DIEP Flap ReconstructionThe Deep Inferior Epigastric Artery Perforator (DIEP) Flap is one of the most common breast reconstruction techniques performed by Dr. Zemmel. During the operation, he harvests skin and fat tissue from the lower abdomen (similar to a tummy tuck) while sparing the abdominal muscle. This flap is carefully disconnected from its blood supply and then reattached to the blood supply in the chest to form the reconstructed breast. Since the rectus muscle is not removed, patients tend to experience a faster recovery with less pain. This also eliminates the potential of developing specific complications like a hernia or resulting muscle weakness. A major advantage to undergoing breast reconstruction with the DIEP Flap technique is results tend to look and feel like the natural breast. Additionally, patients can achieve a slimmer tummy area in the same procedure.
Pedicled TRAM FlapsThe first successful method of breast reconstruction was the pedicled transverse rectus abdominis myocutaneous (TRAM) flap. This procedure is the most commonly performed tissue reconstruction in the US. In this operation, a wide ellipse of skin and fatty tissue is transplanted from the lower abdomen to recreate the breast. Blood flow must be brought into the tissue so the tissue is left attached to the rectus muscle. The rectus abdominis muscle is taken from the abdominal wall and tunneled underneath the skin of the chest and into the breast. The muscle serves as a conduit for blood flow in and out of the new tissue. Without it the tissue will not survive. The flap gets its blood supply from the superior epigastric artery and vein, which remain attached. Dr. Zemmel closes the donor site with sutures primarily, but also reinforces the abdominal wall with a synthetic mesh typically used in hernia repairs. The flap is then shaped to form a facsimile of a breast. The pedicled TRAM flap is capable of achieving very good results and was a tremendous advance in the art of breast reconstruction. For certain patients, it still remains the technique of choice. For some patients, however, (especially those who are obese or who smoke) the blood supply of the pedicled TRAM flap can be insufficient, leading to partial flap loss and poor aesthetic results.
Free TRAM FlapsBlood flow to a TRAM flap is improved if it is based on the deep inferior epigastric vessels. In this procedure, called the free TRAM flap, these blood vessels are divided and then reattached using microsurgical techniques to recipient vessels in the chest wall or in the armpit. The free TRAM flap has two main advantages over the conventional, pedicled TRAM flap. First, the blood supply is more direct so blood flow is stronger and less likely to cause partial flap loss or fat necrosis. Secondly, only a small part of the rectus abdominis muscle needs be harvested with flap so there is less postoperative pain and abdominal wall weakness. Patients recover from breast reconstruction surgery more quickly and the aesthetic results tend to be better. The main disadvantage of the free TRAM flap is its total reliance on the successful connection or anastomosis of the blood vessels to maintain survival of the flap. If the connection becomes obstructed and blood does not reach the flap, the tissue will die and the breast reconstruction will fail. In experienced hands, the failure rate is less than 2 percent. Failure is even less common in patients who are not obese. Free TRAM flaps require a much longer operative time due to the microvascular reconnection of the blood vessels. Free TRAM flaps yield excellent cosmetic results because of the improved blood flow and ease of shaping the breast flap. Free TRAM flaps also do not require harvesting of the rectus muscle of the abdomen. This significantly reduces the trauma and morbidity to the abdomen wall, reducing the risk of abdominal wall weakness and hernia formation.
“Pedicled” TRAM Flap Breast ReconstructionIn recent years, there have been dramatic technical advances in autologous breast reconstruction, which is considered by many to be the “gold standard” of breast reconstruction. Advances in microvascular surgery, including “muscle-sparing” techniques and “DIEP perforator flaps”, have made it possible to transfer the necessary tissue with minimal trauma to the donor site. This has resulted in dramatically reduced donor site problems without compromising the outcome of the breast reconstruction. Furthermore, these technological advances have made the option of autologous breast reconstruction a reality for patients who previously were not considered good candidates.
Prosthetic Breast ReconstructionThe second option for breast reconstruction, called prosthetic breast reconstruction, uses implants to reconstruct the breast, similar to those used in cosmetic breast augmentation. Unlike a breast augmentation, there is little remaining tissue to cover the implant and a new pocket for the implant must be created. A tissue expander must be inserted into the mastectomy site prior to the insertion of the implant to make a pocket where the implant will ultimately lie. Prosthetic breast reconstruction techniques spare the patient the loss of donor site tissue as well as donor site scarring. Once the tissue expander has healed 2 weeks after surgery, expansion begins. Patients return to the office each week and receive and injection of saline into the expander. This sequentially inflates the expander and stretches the overlying skin. After expansion is completed the patient rests for approximately 3 months to let the tissues come to equilibrium. Patients then return to the operating room and the second stage is completed. This consists of exchange of the tissue expander for a permanent saline or silicone implant. Modifications to the overall breast shape also occur at this stage. Nipple areola reconstruction is performed 3 months after the second stage. The prosthetic breast reconstruction procedures take less time to perform and the hospital stay is generally shorter. However, prosthetic breast reconstructions is a multi-stage procedure performed over 6 to 12 months. A minimum of 2 stages are required. The permanent implant will likely require maintenance in the future.
Dr Zemmel took something very bad and made it a very good experience for me.