Information on when to begin reconstruction, what options are available and what to expect for results.
Information on when to begin reconstruction, what options are available and what to expect for results.
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 whenever possible we try our best to provide reconstruction at the same time as the mastectomy to help you feel more whole as early as possible.
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.
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 an 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 that can be done prior to the nipple sparing surgery. 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.
Acellular dermal matrix (ADM) is a soft mesh made from donor skin treated to remove any cell material. After implantation, this mesh serves as a scaffold for the patient’s own cells to grow into.
ADM offers a number of advantages for implant-based breast reconstruction. Generally, ADM serves to provide support, coverage and positioning for the implant as part of the reconstructed breast. Depending on where your implant sits within the breast pocket (e.g. in front or behind the pectoralis major muscle) in addition to other factors, ADM may or may not be used in your implant-based breast reconstruction. Please discuss with your plastic surgeon whether your reconstruction is appropriate for use of ADM.
Naturally, your breast tissue is situated in front of the pectoralis major muscle. Once the breast tissue is removed, your plastic surgeon may place the reconstructed breast behind the pectoralis major muscle (sub-muscular) or in front of it (pre-pectoral) depending on a number of different factors.
With pre-pectoral implant-based breast reconstruction, acellular dermal matrix (ADM), whose properties are outlined in detail under the Acelluar Dermal Matrix section, is utilized to mimic muscle coverage which is seen in sub-muscular implant reconstruction. ADM may also be utilized in a sub-muscular implant-based reconstruction to provide more support to the implant as well. Discuss with your surgeon what is recommended for you.
Pre-pectoral implant-based and sub-muscular reconstruction each offer their own advantages. Not every implant position is possible for each patient. There are many factors which determine where your reconstructed breast may be situated. Please discuss with your plastic surgeon to determine if which type of breast reconstruction is most suited for you.
Saline vs. Silicone
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 (saline). Reconstructions using permanent saline implants tend to result in an unnatural appearance and feel. In addition, the average life-span of saline implants is well 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”.
Anaplastic large cell lymphoma (ALCL)
Anaplastic large cell lymphoma (ALCL) is an extremely rare form of lymphoma that is believed to be caused from the body being in constant contact with the textured coating around a breast implant. It typically presents as a sudden swelling (containing fluid) in the breast, or may be detected as a new hard lump over the breast implant. It generally occurs after the implant has been in the patient’s body for years, average is 8 years. It has been associated with textured surface silicone and saline implants, and not found to be associated with smooth surfaced implants. This condition is extremely rare. The life time risk of having this cancer is 1 out of 3,817 to 30,000 in women who have textured surface implants. Due to the rarity of this new cancer, Health Canada and FDA have not recommended removal of these implants from the market, or issued any product warning.
Read More Here ALCL Presentation to patients
The DIEP or Deep Inferior Epigastric Perforator flap (abdominal flap) utilizes abdominal skin and fat from the lower part of the abdomen. The blood vessels that supply the skin and the fat are found within the “abs muscle”: the rectus abdominis muscle. The blood vessels are very small and the surgeon uses loupes to identify the vessels. The skin and fat, with blood vessels are then transferred to the mastectomy site, where a microscope is used to reconnect them to blood vessels located in the chest. The surgeon will then sculpt the tissue to form a breast mound on the remaining chest area after mastectomy. The sculpting and scars will be slightly different depending on whether it is an immediate or delayed reconstruction.
Previous methods for breast reconstruction using your own tissue (autologous), such as the pedicled TRAM (Transverse Rectus Abdominus Myocutaneous) flap, require less technically advanced procedures than what is needed for the DIEP flap.
A TRAM flap involves taking part or the whole rectus abdominis muscle. Therefore, with a DIEP flap, patients are able to resume their pre-operative activities more normalafter surgery.
The DIEP flap procedure is a “free flap” using own tissue. This is a very meticulous method that must be performed using microscopic techniques, and therefore, this procedure take longer. The patient will have a scar from hip to hip on the lower abdomen and around the belly button. The advantages to the DIEP flap procedure include a very pleasing cosmetic result, which mimics the look and feel of a natural breast. Additionally, by using the patient’s own abdominal tissue, there will be improved abdominal contour (like having a tummy tuck). Compared to the pedicled or free TRAM flap, the DIEP flap procedure carries less risk of abdominal weakness, bulge and hernia formation.
Single DIEP flap procedure
Before and after left delayed mastectomy reconstructed using a DIEP flap with nipple areolar reconstruction
Double DIEP flap procedure
The SGAP or the Superior Gluteal Artery Perforator flap (buttock flap), is an option for patients who do not have enough abdominal tissue. The breast can be reconstructed with the skin, fat, and the blood vessels taken from the buttock area in order to achieve a breast mound. The SGAP flap procedure uses tissue from the top part of the buttock without injury to the underlying muscles. The tissue is then transferred as a free flap to the chest and a microscope is used to connect the blood vessels supplying this tissue to blood vessels in the chest at the mastectomy site. The tissue is then sculpted into a new breast mound. This procedure may require a tissue expander if there is not enough skin on the chest wall after previous mastectomy. This procedure is not appropriate for all patients and requires suitable body shape. It is a second line option with specific surgical indications.
A: Reconstructed breast using bilateral SGAP flaps B: Donor site scars from SGAP flaps
The TMG/TUG or the Transverse Myocutaneous Gracilis/Transverse Upper Gracilis flap is taken from the inner thigh region. The scar can be similar to that of a cosmetic medial thigh lift. The gracilis muscle is taken along with this flap in order to provide the blood supply. There are other muscles within the thigh that have the same function as the gracilis and therefore, removing it does not lead to weakness. The tissue is then transferred to the chest as a free flap and a microscope is used to connect the blood vessels supplying this tissue to vessels in the chest at the mastectomy site. The tissue is then sculpted into the new breast mound. Depending on the breast size one or two flaps may be needed to recreate a breast mound. This procedure is not appropriate for all patients and requires suitable body shape. It is a second line option with specific surgical indications
Before and After bilateral skin sparing mastopexy and immediate breast reconstruction in bilateral DIEP flap
Another option for breast reconstruction is to use an ellipse of skin with muscle (Latissimus Dorsi) from the patient’s back. This large but thin muscle runs along the back and inserts into the shoulder allowing for shoulder movement. Using this muscle for breast reconstruction can cause slight weakness with some activities, such as climbing or pushing off with the arm. For most patients, normal daily activities will not be limited.
The Latissimus Dorsi flap can create a breast alone or can be used 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 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 the chest wall, and is too thin or not a candidate for a DIEP flap.
Image Below: Scar location on back may be concealed by MOST types of clothing.
Image Below: Scar location on back for Latissimus Sorsi may be hidden in bra strap.
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 these can include: 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.
|Implant/Expander||Autologous tissue||Latissmus Dorsi/
|SURGERY||2 separate shorter
|1 longer procedure
(3hrs and 2hrs)
|HOSPITALIZATION||Day surgery or
|Average 4 days||2 nights stay for 1st
surgery for 2nd
|RECOVERY||2-4 weeks following
|8-12 weeks||3-4 weeks following
1st procedure, 2
|Mastectomy scar &
scar at donor site
|Scar on back, flap
|SHAPE & FEEL||No natural sag,
firm over time
|More natural than
|OPPOSITE BREAST||More changes
needed to match
needed to match
needed to match
|COMPLICATIONS||Breast feels more
firm & less natural
appearing with time
|1% risk of
with complete falp
loss, 5% risk of
hematoma in back
at donor site
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.
Right mastopexy and left mastectomy and immediate breast reconstruction with TE/Implant and nipple areolar 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.
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.
Oncoplastic surgery is a combined cancer surgery where a lumpectomy to completely remove the cancer is performed with immediate breast reconstruction. This unique surgery combines plastic and reconstructive surgery techniques with breast cancer surgery so that the appearance of the breast can be preserved to the greatest extent possible, without compromising local control of disease. Not all patients who require lumpectomies will benefit from oncoplastic surgery. However, in certain patients where the tumor is in a cosmetically sensitive part of the breast, oncoplastic surgery may be recommended by your breast surgeon and plastic surgeon. Depending on the patient, oncoplastic surgery can be used to accomplish one or more of the following goals:
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.