1. When to begin reconstruction

Reconstruction can be either immediate (at the same time as the mastectomy) or delayed (at a later time).This decision may be made based on the characteristic and stage of your breast cancer, and will be made together with your breast surgeon. In many cases, immediate reconstruction is a reasonable and safe option. With our superb team of 6 breast surgeons at the Princess Margaret and Mount Sinai Hospitals, we routinely work together to provide reconstruction at the same time as the mastectomy. Our philosophy is that as long as our breast surgeons feel that you will not require radiation after surgery, then we try our best to provide reconstruction at the same time as the mastectomy to help you feel more whole as early as possible.

 



2. Procedures


Types of mastectomies for immediate reconstruction

Skin-Sparing mastectomy, Nipple-Sparing Mastectomy and

Skin-Sparing and Nipple-Sparing Mastectomies and

For women who require mastectomy for treatment or prevention of breast cancer, there are two common approaches that surgeons use during a mastectomy when it is combined with an immediate breast reconstruction called skin-sparing mastectomy and nipple sparing mastectomy.

 

Skin-Sparing Mastectomy (SSM)

A skin-sparing mastectomy is a way to remove breast tissue, and save the breast skin. The surgeon leaves most of the breast skin, creating a natural skin envelope, or pocket, that is filled with a breast implant or with the patient’s own tissue from another part of her body. The skin-sparing mastectomy method significantly improves the cosmetic outcome and gives the best option for reconstruction. If the nipple can be saved and has not been invaded by any cancer cells the surgeon would then perform a nipple-sparing mastectomy.

 

Nipple-Sparing Mastectomy (NSM)

A nipple-sparing mastectomy is a way to remove breast tissue, and save the breast skin and nipple. The nipple-sparing procedure removes cancerous breast tissue through a small incision usually around the areola area of the nipple. The surgeon leaves most of the breast skin, creating a natural skin envelope, or pocket, that is filled with a breast implant or with the patient’s own tissue from another part of her body. More women are now choosing the nipple-sparing mastectomy method because the patient’s own nipples will always look more natural than and artificially made nipple and patients may feel more feminine and more like themselves with their own nipples.

 

Nipple SAVE (Surgery to Allow Vascular Enhancement” is a surgical procedure done in preparation for a nipple-sparing mastectomy. Nipple SAVE is a procedure used to decrease likelihood of nipple necrosis, which can occur because of loss of blood supply and can lead to nipple loss, following nipple-sparing mastectomy.
The added step, Nipple SAVE would occur as an outpatient procedure, a few weeks before the nipple sparing mastectomy. The patient is awake because simple skin freezing is used. Your surgeon will make an incision at the bottom border of the nipple and then separate the nipple from the underlying breast tissue. This will disconnect the blood vessels that normally provide circulation to your nipple, and encourages new vessels to connect from the breast skin to your nipple- areola complex. Your surgeon will also take a biopsy of tissue and send it to the pathology lab.

 

DIEP

The DIEP flap utilizes extra abdominal skin and fat from the lower part of the abdomen.The blood vessels that supply the skin and the fat are found in your ‘abs’, the abdominal rectus muscle. The surgeon will carefully remove the artery and vein from the muscle, using expert microsurgical skills, while keeping the muscle intact. Unlike the TRAM flap, only the essential structures are utilized which include the skin and fatty tissue; the muscle is not necessary for reconstruction. As a result of a less invasive procedure, patients are able to resume their pre-operative activities much sooner after surgery.

In this procedure, the surgeon will remove the excess abdominal skin and fat from the lower part of the abdomen, and hook up this tissue to the blood vessels in the chest area. The blood vessels are so small that the surgeon must use a microscope to reconnect them. This will allow blood to be directed to the new tissue on the breast area. The surgeon will then sculpt the tissue to fit the remaining chest area left from the mastectomy. To reconstruct the nipple in the future, a skin patch from the abdomen will be preserved on the chest to build the future nipple. If you have undergone a complete mastectomy, the abdominal skin will be used to resurface your new breast.

Previous methods of breast reconstruction using your own tissue, such as the pedicled TRAM flap, required a less technically advanced procedure than what is needed for the DIEP flap. The DIEP flap procedure is a very meticulous method that must be perfored under the microscope, and therefore, this procedure can be quite long. Another disadvantage of the procedure is that a horizontal scar will be created from hip to hip on the lower abdomen. In contrast, the advantages to the DIEP flap procedure are a very pleasing cosmetic result, which mimics the look and feel of a natural breast. Additionally, by using the patient’s own abdominal tissue, the patient will have an improved abdominal contour (like having a tummy tuck). Compared to the pedicled TRAM flap, the DIEP flap procedure carries less risk of abdominal weakness, bulge and hernia formation.

 

Example: Single DIEP flap procedure


Before and after delayed mastectomy defect reconstructed using a DIEP flap.

 

Example: Double DIEP flap procedure

 

SGAP

The SGAP flap, or the Superior Gluteal Artery Perforator flap (buttock flap), is ideal for those who do not have an adequate amount of excess tummy tissue. The breast may be reconstructed with the skin, fat, and the tiny blood vessels taken from the buttock area to achieve a smaller cup breast size. The SGAP flap procedure uses tissue from the top part of the buttock without injury or sacrifice of the underlying gluteal muscles. The tissue is then transplanted to the breast and a microscope is used to connect the blood vessels supplying this tissue to those at the mastectomy site. The tissue is then sculpted into the new breast mound.

We have found in our experience that the best candidates for the SGAP procedure are women who are undergoing immediate breast reconstruction (at same time as the mastectomy). In addition, this procedure can only create small breast mounds, cups A or B, otherwise a visible indentation will be left on the upper aspect of the buttock. For bilateral breast reconstructions using the SGAP, we perform one side at a time staged 6 weeks apart since each side requires around 8-10 hours.

 

Example: SGAP procedure

 

Thigh Flap

TMG (Transverse Myocutaneous Gracilis) flap is taken from the inner thigh region, in a similar distribution as in a cosmetic inner thigh lift. The gracilis muscle is taken to provide the blood supply to this flap, this is usually not missed following its removal. This flap is used to create a smaller sized breast and almost no contour change in shape can be expected in the inner thigh following this flap. In both the gluteal and thigh flaps, the amount of skin that can be taken is limited, so these techniques are mostly used for immediate breast reconstruction. Since tissue must be completely removed from the body and transferred to the chest, microsurgery is required to restore circulation to the transplanted skin and fat. The disadvantage of this flap is that touch-up surgeries to the breast are almost always necessary.

 

Example: Thigh Flap

 

TAP

A method to repair small breast defects, such as those left from breast conservation or lumpectomy, is the thoracodorsal artery perforator flap (TAP flap). This flap is a small area of tissue taken from the side of the breast and the back. The major advanatage of this flap over the latissimus dorsi flap is that this flap completely preserves the back muscle. The resulting scar is well hidden in the bra strap line. We commonly use this flap for lumpectomy defects that leave an unsightly indentation on the side of the breast.

 

Implant

The most straightforward reconstruction method is to use implants only. This is an attractive method for women who do not wish to have a more extensive procedure using their own tissue. In our experience, this is a great option for smaller breasted women, without a lot of abdominal fat, who are looking for a speedy recovery from surgery.

Traditionally, this option is completed in two phases. In the first phase, your plastic surgeon will insert a tissue expander below your pectoralis (chest) muscle. The tissue expander is a pocket that will stretch out your chest skin and muscle. After your incisions have healed (two weeks) you will come to the clinic for tissue expander inflations. The clinic staff will use a magnet on the outside of your chest skin to locate the port that is inside the tissue expander. They will use a needle to inflate your expander with a saline (salt-water) solution. You will have inflations every one to two weeks for up to three months. After the inflation process, the skin will need to rest for at least 3 to 6 months. A second, shorter surgery will be performed to switch the tissue expander for a permanent implant (silicone or saline).
We do not perform and do not recommend reconstruction using implants alone following mastectomy. It has the highest complication rate of all the techniques.

It is important to understand that an implant-based breast reconstruction is a different procedure than a cosmetic breast augmentation procedure. A cosmetic breast augmentation allows for a natural shape and feel because the implant sits below the breast tissue and the breast tissue pads the implant. In an implant-based reconstruction, there is no more natural breast tissue, and the skin is thin, so the implant can be felt. Due to these issues after mastectomy, the implant is positioned underneath the pectoralis (chest) muscle. This helps to prevent scarring around the implant and infection, as well as improves the feel of the implant. Even so, implants can become infected, or your body can form a capsule of scarred and firm tissue around the implant. These risks need to be considered when decided on which type of reconstruction to have.


Nipple Sparing Mastectomy with Tissue Expander and Implant reconstruction, before and after example

We do not perform and do not recommend reconstruction using implants alone following mastectomy. It has the highest complication rate of all the techniques.

You need to be aware that an implant reconstruction is not the same as a cosmetic breast augmentation procedure. In cosmetic breast augmentation, the breast implant is placed underneath normal breast tissue, which cushions the implant and therefore allows the breast to have a natural shape and feel. After mastectomy, the breast skin is thin and due to the lack of breast tissue, the implant is readily felt. The implant is placed under the pectoralis muscle to improve the feel of the implant as well as to minimize infection and problems with scarring around the implant. The lower part of the implant will not be covered by muscle and Alloderm can be used to cover the lower part of the implant to improve the cushioning of tissue over this area. However, implants may become infected or the tissue around the implant may become scarred and firm in the future, and this needs to be taken into account when considering this option.

 

Alloderm

The one-stage dermal matrix/ implant technique involves the use of a material called acellular dermal matrix that is made from the skin from a human body (donated cadaveric skin) that has been specially prepared for your body to accept it. This material will provide a hammock-like support to the breast implant. The use of this material (acellular dermal matrix) has been approved in the US and Canada for many surgical procedures including breast reconstruction.

 

Example: Unilateral immediate one-stage Alloderm-assisted implant procedure

 

Breast implant safety

Both saline and silicone gel implants are safe and available for use in Canada. The chance that an implant would be "rejected" by the body is rare.

Saline implants are plastic shells made of silicone and filled with salt water. Reconstructions using permanent saline implants tend to result in an unnatural appearance and feel. In addition, the average life-span of saline implants is only around 10 years, which is shorter than silicone implants. Other than a few limited uses, we generally do not recommend the use of saline implants as the permanent breast prosthesis for reconstruction.

In the 1980s, there were thoughts that silicone gel may be associated with breast cancer and rare autoimmune disorders. Many studies published from reputable university centers worldwide have found no significant evidence to support this cause and effect relationship. After a temporary ban on the use of silicone implants for breast augmentation by the United States Federal Drug Administration (FDA) in the 90s, the use of silicone implants was approved in Canada in October 2006. The newer generation silicone implants contain thicker silicone gel that is more cohesive than the older versions and in turn are more "form-stable".


 

 

 

 

 

 

 

 

Latissimus Dorsi

Another option for breast reconstruction is to use a muscle from the patient’s back called the Latissimus Dorsi, and an ellipse of skin. This large but thin muscle starts at your shoulder and continues down your back, and it is used for shoulder movement (not your back). Using this muscle to restore your breast may cause slight impairment of overhead activities, such as climbing or pushing off with your arm. For most people, their normal daily activities will not be limited.

The Latissimus Dorsi flap can create a breast alone or can be utilized in combination with a tissue expander or implant. The tissue expander can be filled with saline (salt-water) solution to stretch the flap, and can be exchanged for a permanent silicone implant, which has a more natural feel. The Latissimius Dorsi flap will cover the implant, and help to prevent complications such as infection and scarring. The ellipse of skin replaces the area where the nipple has been removed.

The best candidate for the latissimus dorsi flap +/- tissue expander or implant is a patient who has already had a mastectomy as well as radiation to her chest wall, and is too thin or cannot tolerate a DIEP flap. This procedure can be unilateral or bilateral, and the cosmetic restoration.
SGAP
The SGAP flap, or the Superior Gluteal Artery Perforator flap come from the buttock region, and is the most suitable option for women who have more buttock tissue than lower abdominal tissue. The breast may be built using the skin, fat, and the tiny blood vessels taken from the buttock to create a breast mound. The SGAP flap procedure uses tissue from the top part of the buttock without injury or sacrifice of the underlying gluteal muscles. The tissue is then moved up to the breast and a microscope is used to reconnect the blood vessels between the buttock tissue and the blood vessels on the chest. The buttock skin and fat is then molded to form the new breast mound.

We have found in our experience that the best candidates for the SGAP procedure are women who are undergoing immediate breast reconstruction (at same time as the mastectomy). In addition, this procedure can only create small breast mounds, cups A or B, otherwise a visible indentation will be left on the upper aspect of the buttock. For bilateral breast reconstructions using the SGAP, we perform one side at a time staged 6 weeks apart since each side requires around 8-10 hours.


Scar location on back may be concealed by MOST types of clothing.


Scar location on back for Latissimus Sorsi may be hidden in bra strap.

 

Example: Latissimus Dorsi and Tissue Expander / Implant Procedures



3. Selecting the right technique for you

The best method of reconstruction for you depends on several factors.
These include:

• Size and shape of your breasts
• One or both breasts removed
• Amount of body tissue in the potential donor sites such as: abdomen, thigh, and buttock
• Whether or not you will or have received radiation therapy.

Your plastic surgeon will recommend one or more options to you based on these
factors. It is important that you understand the major advantages and disadvantages of each method.

Outlined below is a brief comparison of implant and tissue reconstruction techniques.





4. Other commonly performed procedures matching the opposite breast

A reconstructed breast will not precisely match your natural breast. If you have large breasts, you may need a reduction of your opposite breast in order to match the reconstructed breast. If you have smaller breasts that sag, you may need a lift of the natural breast or augmentation with an implant to improve the shape and symmetry. Both reductions and lifts leave permanent scars on your breasts. The precise location of the scars and technique used to balance the breasts will be explained in great detail by your plastic surgeon when planning for this stage.

If you desire either a lift or reduction or augmentation of your opposite breast, then your plastic surgeon will apply to the Ministry of Health to have this procedure covered by OHIP. This process can take upwards of 3 months.

 

Example: Before and After Balancing Procedures


 

Partial breast or lumpectomy reconstruction

It is very common to have asymmetry after lumpectomy especially if you have also received radiation to the breast. To make the breasts more balanced, you may need either tissue added to the smaller breast, or have the opposite breast lifted or reduced to match the size discrepancy. The most common flap that we use to add tissue to your breast is using the TAP flap.

If the nipple positions are very different, then it is possible to rearrange the breast tissue to make the nipple positions more similar. However, we recommend waiting until at least 6 months following the completion of radiation before carrying out any correction. In addition, you need to know that rearranging the tissue in a radiated breast is extremely challenging and has complication rates of up to 50% including delayed wound healing, infection, and skin breakdown. Your surgeon may not be able to perform corrections if he/she feels that your tissue is too damaged by the radiation.

 

Lipofilling or Fat injection

A supportive technique that we commonly use for fine-tuning breast contour abnormalities following either implant or autologous tissue reconstruction is with the use of fat injection. This is a fairly new procedure that was popularized in Europe and is being used only at the leading breast centers in North America. This is a new and extremely powerful technique may have the ability to fill in areas of indentation left by the mastectomy, or mask the rippling or palpable edge of implants, or even reconstruct small lumpectomy defects. Fat injection also may have the ability to improve the texture of skin following radiation and release scarred tissue. We use specialized patented equipment for liposuction and lipofilling to ensure efficacy and safety of these procedures.

 

Partial breast or lumpectomy reconstruction

It is very common to have asymmetry after lumpectomy especially if you have also received radiation to the breast. To make the breasts more balanced, you may need either tissue added to the smaller breast, or have the opposite breast lifted or reduced to match the size discrepancy. The most common flap that we use to add tissue to your breast is using the TAP flap.

If the nipple positions are very different, then it is possible to rearrange the breast tissue to make the nipple positions more similar. However, we recommend waiting until at least 6 months following the completion of radiation before carrying out any correction. In addition, you need to know that rearranging the tissue in a radiated breast is extremely challenging and has complication rates of up to 50% including delayed wound healing, infection, and skin breakdown. Your surgeon may not be able to perform corrections if he/she feels that your tissue is too damaged by the radiation.



 

5. Nipple areolar reconstruction

We prefer to allow your reconstructed breast to "settle" for at least 3 months so that the nipple and areola can be placed in the proper position. Nipple/areola reconstruction is done usually with local anesthesia as an outpatient surgery, meaning that you will not need to stay overnight at the hospital. This procedure usually involves very little discomfort.

 

Options for reconstruction of the nipple include:


• using tissue and fat of the reconstructed breast (local flap)

• using the opposite nipple if it is large or very pointy (nipple share)

• using tissue from other part of the body (labia is the most common)

• tattoo alone

 

Options for reconstruction of the areola include:

• tattoo alone

• skin graft from abdominal scar or groin crease

• Areolar share (if you have a large opposite areolar)