Breast Reconstruction

BREAST RECONSTRUCTION

Dr. Koumanis is an expert at breast reconstruction with over 14 years of experience performing advanced techniques to restore the female breast after mastectomy. In the following section, frequently asked questions will be answered involving breast reconstruction using implants and also your own tissue.

IMPLANT BREAST RECONSTRUCTION

What is Breast Reconstruction?

Breast reconstruction is the use of autologous tissue (i.e. your own tissue), breast implants, or a combination of the two in order to restore the shape of ones’ breasts.

How many surgeries does it take to achieve final results?

It takes approximately 2-3 surgeries to achieve the final results. It depends if your mastectomy surgeon will be performing a nipple sparing approach or whether the tumor is close to the nipple ducts and therefore must be taken. The third and final step in reconstruction is to make nipple flaps. If a nipple sparing approach is used nipple flaps are not needed.

What happens in each step?

The first step involves the mastectomy. After the mastectomy and at the same anesthesia setting Dr. Koumanis will take a tissue expander first and wrap it with Alloderm (cadaveric acellular dermal skin) and place it either behind the pectoralis muscle of the chest or above it, wrapping the front/anterior surface of the tissue expander. Then 2 drains are put in each breast pocket to help drain fluid in the postoperative period. The drains stay in between 1-2 weeks usually.

1. Inferior Skin flap of Breast
2. Alloderm™ sling cradling the implant

Then 3 weeks later expansion starts in the office. The skin is prepped with betadine and alcohol and sterile normal saline is injected into the expander once weekly until the desired size has been attained.

Once the expansion is completed, the second stage involves removing the tissue expander and replacing it with a permanent silicone cohesive gel implant and some flap revisions by excision of the skin envelope is sometimes needed.

The third stage involves creation of nipple flaps if the nipples and areolas were excised during the mastectomy.

What is the advantage of putting the implant above the pectoralis muscle?

Diagrams of Alloderm™ courtesy of Allergan® brochure

ADM=Acellular Dermal Matrix

When does one perform a unilateral (one side) versus a bilateral (two-sided) breast reconstruction?

A unilateral breast reconstruction is performed when a one-sided mastectomy due to cancer is performed. A bilateral procedure is performed when there is cancer on both sides. A bilateral procedure is sometimes performed due to patient desire to reduce her risk of cancer on the opposite breast although. Bilateral procedures whereby by the opposite breast is removed prophylactically are common due to strong family history of breast cancer, genetic risk (BRCA1 and BRCA2 genes), in ability to properly monitor the opposite breast, or patient anxiety of having to undergo a possible future cancer procedure or mastectomy.

If one side is performed, then the other breast sometimes needs a reduction or a mastopexy (i.e. lift) in a future procedure. Bilateral reconstruction procedures have one advantage that they offer better symmetry as both breasts will consist of implants. If there is no strong family history, or genetic predisposition, or bilateral disease, then a prophylactic mastectomy provides little advantage in relation to oncological risks and survival. With that being said, we perform bilateral procedures with one side being prophylactic quite frequently.

How long does the whole process take?

As discussed above, implant breast reconstruction requires a minimum of 2 operations (tissue expander first, then exchange of tissue expander to silicone gel implant once fully expanded), and a third small operation is only needed if nipple flap reconstruction is required. If no radiation or chemotherapy is required in your breast cancer treatment plan, then things go fairly quickly. In this case most breast reconstructions are completed within 4 months. If radiation and/or chemotherapy is required, then the process takes longer. Please see below.

Where are the incisions made?

Incisions are made in accordance to where the tumor is located. If the mastectomy is being performed prophylactically due to BRCA1 or BRACA2 genetic predisposition, then a nipple sparing approach can be used if the nipples are in a decent position. Then the incision is made laterally along the inferior breast fold, to hide the scar as much as possible. If the nipple needs to be raised than a peri-areolar incision is used to enter the breast. In most cases a skin sparing approach is used whereby as much of the breast skin is retained during the mastectomy.

Figure: Various incisions used in mastectomy and breast reconstruction surgery

1. Inframammary incision (hidden scar ^*NS approach)
2. Inferior peri-areolar incision (^*NS with lateral extension if needed)
3. Superior peri-areolar incision (^*NS with lateral extension if needed)
4. Classical elliptical incision (horizontal across breast when closed)

^*NS=nipple-sparing

BEFORE

BEFORE

AFTER

Completed Bilateral Breast Reconstruction with Nipple Sparing, Hidden Scar Technique

A nipple sparing approach can be used even in the case of a breast tumor if the following criteria are met:

1. Tumor is less than 2 cm in diameter
2. No lymph node involvement
3. Tumor is greater than 2 cm distance from the nipple

These criteria have been evolving but may affect the ability to provide a nipple-sparing approach:

1. Grade 1-2 tumor
2. HER-2 receptor negative
3. Estrogen/Progesterone (ER/PR) positive

The following are criteria against a nipple-sparing approach:

1. Tumor closer to nipple (<2 cm)
2. Patient’s with Paget’s disease of the nipple
3. Patient’s with Inflammatory carcinoma of the breast
4. Severely ptotic (i.e. sagging) breasts
5. History of previous radiation to the breast

What if I need radiation or chemotherapy?

In the chance that you require chemotherapy and/or radiation then this is usually done after the first surgery (i.e. mastectomy and tissue expander). By the time you begin your therapy, which is within 6 weeks of surgery usually, we will usually have you fully expanded. Needing chemotherapy and radiation will obviously delay completion of your breast reconstruction. With chemotherapy only, the second stage surgery can commence within 4-6 weeks after your last treatment to allow for your immune system to return to its normal state.

If you require radiotherapy, then the exchange of the tissue expander to the silicone gel implant will take place 6 months after your final radiotherapy session. The tissues require time to heal from the radiation damage and fibrosis. Sometimes Dr. Koumanis will perform a fat grafting procedure at 3 months after radiation to help heal the radiated tissue around the implant and soften the tissues and decrease the effects of radiation fibrosis.

Radiotherapy can cause loss of the implant through infection or extrusion. If this occurs, then an autologous reconstruction (i.e your own tissue from elsewhere) may be needed. A latissimus muscle flap with a new implant or a DIEP flap (i.e. skin and fat tissue from the abdomen) the may be required for a successful outcome.

Are silicone implants safe?

Silicone gel implants are safe.  They have been FDA approved in the setting of a breast augmentation or breast reconstruction. They do not cause cancer and there is no evidence that they cause any autoimmune disorders. Almost all of our patients tolerate them very well. There is the recent issue of BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma) associated with breast implants. BIA-ALCL is a rare but treatable type of lymphoma that has been linked to certain breast implants. It is more frequently associated with older textured implants. Dr. Koumanis generally uses smooth gel implants except in certain circumstances.  Dr. Koumanis to this date has not experienced BIA-ALCL in any of his patients. He will discuss the symptoms in detail during your consultation. Symptoms usually include an enlarged breast with seroma fluid contained within the breast pocket. No all enlarged breasts with fluid after implant reconstruction is due to BIA-ALCL so a fluid sample is usually taken to rule out the diagnosis.

How long do the silicone implants last?

In general, silicone cohesive gel implants last approximately 10 years, although we have seen many last even longer.

Do I need frequent follow up and monitoring?

It is best to be followed up yearly for the first few years then bi-yearly after that. If a rupture does occur, this is not life threatening. If a rupture of an implant is suspected, an ultrasound is the first line to detect the rupture. If this is inconclusive, an MRI will be ordered which is more sensitive at detecting a rupture.