Breast Reconstruction

T

he science of breast reconstruction has dramatically improved over the last twenty years. The reasons? Better insurance, and better patient education. If you're considering a breast reconstruction - whether following a mastectomy or for other reasons -- it's important to understand the different options, and what they involve.

What option is best for you? How do you prepare for surgery, and what will the recovery be like?

Implants

The most basic reconstructive option involves the use of an implant. Following removal of the breast, a tissue expander is placed beneath the chest wall muscle and skin. The expander is gradually filled with salt-water over a period of weeks to months, allowing overlying skin to grow and replace the original breast skin. This expander is then replaced at a later date with a permanent implant to achieve symmetry with the opposite breast.

TRAM Flap

Reconstruction can also be performed using tissue from a different area of your body. Flap reconstruction requires additional incisions, so a woman will have more scarring than she would have with an implant. However, results are more natural and the use of an implant may be avoided.

The most popular of the flap reconstruction procedures is the TRAM (Transverse Rectus Abdominis Myocutaneous) flap, which uses muscle, skin, and fat from your abdominal wall to reconstruct the breast mound. Tissue remains attached to its blood supply and is tunneled beneath the chest wall skin where it is arranged to replicate the appearance of your other breast. By removing tissue from your abdominal wall, you essentially undergo a tummy-tuck procedure and awake from surgery with a reconstructed breast and a tighter, flatter abdomen. While this is an excellent option, it is generally reserved for patients with a little extra weight around the middle, and is not a good option if you are excessively thin.

Other procedures incorporate tissue from your back, and in less common cases, "free tissue" is brought from a more remote site--such as your buttocks--removed from its blood supply, and ultimately rejoined to a new blood supply using an operating microscope. While this technique is appropriate for a select group of patients, it is technically demanding and associated with a higher risk of complications.

The Choice is Yours

Both the flap reconstruction and implant procedures achieve excellent results. The real question is, which route do you feel most comfortable with? A decision can be reached after careful consultation with a plastic surgeon. Many women request simultaneous surgery on their other breast-such as a reduction, breast-lift, or augmentation-to improve symmetry with the reconstructed breast.

Preparing For Surgery

In preparation for surgery, your doctor will give you detailed instructions regarding various vitamins and herbal supplements to avoid, and will ask you to limit your intake of alcohol as this may cause excessive bleeding. If you smoke, you will need to stop two to three weeks prior to surgery. Any blood-thinning medications should be discontinued at least seven to ten days before surgery. Although blood loss is generally minimal, you may want to discuss the option of donating your own blood before surgery, so that it will be available to your surgeon should she need it during the procedure.

You should arrange for extra help for the early recovery period and ask someone to drive you for at least two to three weeks after surgery.

Complications
Though complications are rare, they can include infection, bleeding, fluid collections beneath your skin, excessive bruising, wound-healing problems, and difficulties related to anesthesia.

Follow-up surgery
While the major portion of breast reconstruction involves the breast itself, reconstruction of a nipple and areola will complete the process and is generally performed three to six months after your initial surgery. At this time, tissue from the breast mound will be used to construct a nipple followed by tattooing several weeks later to fashion an areola. Additional procedures can then be done to further refine the reconstructed breast. These are generally minor and performed on an outpatient basis.

Recovery

Recovery after surgery is highly individual, and depends on the type of surgery you choose.

Flap procedure recovery
Patients undergoing flap procedures generally require longer recovery periods, with the first twenty-four hours being the most difficult in terms of stiffness and general discomfort. After this initial period, you should do quite well. Expect to stay in the hospital four to five days. You may have surgical drains and will be taught to measure their output at home. These are then removed as the output decreases.

Implant recovery
With tissue expander reconstruction, you can expect a much shorter hospital stay-generally less than twenty-four hours-and a much shorter recovery period, overall. In about two weeks, expect to return to your doctor's office to begin expansion.

Healing and feeling
Breast reconstruction will usually leave you with numbness over areas where the surgery was performed. This may improve with time and varies from patient to patient. Scars generally soften and fade and will be less noticeable as the healing process continues. The shape of your reconstructed breast will also improve over time to better resemble your other breast.

Check-ups
Although you will have little to no remaining breast tissue on the reconstructed side, your surgeon will recommend continuing yearly mammograms. If your reconstruction involves placement of an implant, you will want to go to a radiology center that is comfortable with this type of procedure.

Most important, reconstruction has no known long-term effects on breast cancer recurrence. If your doctor has recommended chemotherapy or radiation therapy, reconstruction should not delay or interfere with these treatments.

Insurance
Coverage for your breast reconstruction has been mandated by the Women's Health and Cancer Rights Act and should be supported by your insurance provider.

Surgery: To Wait or Not to Wait

In 1999, 45 percent of patients underwent reconstruction at the time of their mastectomy while 39 percent chose to do so at a later date. While delaying reconstruction allows you to adapt to the removal of your breast, immediate reconstruction reduces the total number of surgeries. There is no right answer-this is a personal decision and one that should be discussed at length with your physician.

Conclusion

As a result of improvements in surgical technique and patient education, the outcome of breast reconstruction continues to improve. With better access to information regarding your options, you will be more prepared to discuss these choices with your healthcare providers and decide which one is best for you.

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