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Your Guide to Breast Reconstruction: Helping you make the decision between the different types of reconstruction (7862)

Your Guide to Breast Reconstruction: Helping you make the decision between the different types of reconstruction (7862) - Clinical Hub, Patient Education, Health and Nutrition Facts For You, Cancer, BMT, Hematology

7862



Your Guide to Breast Reconstruction: Choosing Between Different
Types of Reconstruction

UW Health offers many types of breast reconstruction. The two most common either use
implants or your own body fat/skin from your belly. A third type uses one of your back muscles
with or without an implant. There are other ways to rebuild a breast, but the above three are most
commonly chosen by patients.

Reconstruction using an implant Reconstruction using your own body
fat/skin
This procedure uses synthetic implants, which
are often silicone-filled. In the United States,
more than 70% of women who want breast
reconstruction choose this method.

In most cases, this is done in 2 separate
surgeries:
Surgery 1: An expander (balloon) is placed
under the chest muscles. The expander is then
gradually filled in clinic over 2 to 4 months to
the desired size.
Surgery 2: The expander is removed and
replaced with a silicone implant.

For some patients the reconstruction can be
done in one surgery by placing the implant
directly into the breast without the need for an
expander,

This method uses the skin and fat from the
lower belly to reconstruct the breast. This is
like a cosmetic tummy tuck, but instead of
throwing away the excess skin and fat, we use
them to reconstruct the breast.

There are many variations of the procedure.
include the TRAM flap (transverse rectus
abdominis muscle flap), in which part of the
abdominal wall muscles are used with the
flap, and the more popular DIEP flap (deep
inferior epigastric artery flap), where only the
fat and skin of the belly are used without
including the abdominal muscles.
Am I a candidate for using an implant?

Candidates are those who:
ξ Want a cup size between B to D
ξ Have not had radiation treatment to the
breast or chest
ξ Are within a certain body weight to height
ratio (e.g.less than 190 pounds for a 5’5”
height)
Am I a candidate for using my own body
fat/skin?

Candidates are those who:
ξ Have not had a tummy tuck in the past
ξ Do not have large scars in the belly area
ξ Are within a certain body weight to height
ratio (e.g. 145-215 pounds for a 5’5”
height)




Reconstruction using an implant Reconstruction using your own body
fat/skin
Advantages:
ξ Faster recovery, shorter healing time, and
shorter hospital stay compared to using
your own body fat/skin
ξ A young look and feel to the breast
ξ Smaller scars which are often limited to
the breast. Even when a breast implant
needs to have further surgeries, it can be
done through the same scar.

Advantages:
ξ Uses your own tissues and removes the
need for silicone or other foreign
materials
ξ A more natural look and feel to the breast
ξ You will get a “tummy tuck”
ξ No long term upkeep is needed
ξ Late complications are uncommon

Risks:
ξ Infection: The implant may need to be
taken out.
ξ High Touch-Up Rate: Many patients need
a third surgery to improve the cosmetic
outcome of the implant. (Often done
outpatient and can be scheduled at your
convenience)
ξ Capsular Contracture: Scar tissue can
form around the implant and change the
shape or position.
ξ Silicone Leak/Implant Rupture: Most of
these do not cause any symptoms and are
seen on mammograms or MRIs. The FDA
recommends having an MRI 3-5 years
after getting an implant. Most implants
are changed every 10-15 years.
ξ Animation Deformity: Because the
implant is placed under your chest
muscles, it moves with your shoulder
movements.
ξ Ripples: Folds often seen in the upper part
of the breast. Easier to notice when you
lean forward.
ξ Association with the very rare ALCL
lymphoma (cancer of the immune system)
ξ Breast implants give a young look to the
breast, which some women find attractive.
Others may feel it is an unnatural look.
Breast implants do not gain or lose
weight, move, or age like a natural breast.

Risks:
ξ Time to Heal: This is a long procedure.
You spend 4 or 5 nights in the hospital
and are off work for 6-8 weeks. You may
feel some tightness in the belly for up to 6
months.
ξ Belly Complications: While we often do
not include the abdominal muscles in this
method, there is still a chance for a hernia,
weakness of the abdominal muscles, or
rarely, long term pain/tightness in the
abdomen.
ξ Loss of Fat: Fat can fail to survive when
moved to the breast.
ξ Changes in Size: Because the breast is
made of belly fat, it will change in size if
your body weight changes.
ξ Touch Ups: Most patients need a touch up
procedure to make the breast look better.
(Often done outpatient and can be
scheduled at your convenience)
ξ Use of Important Vessels: We use one of
the chest vessels (internal mammary
artery) to provide blood supply to the
breast. This vessel is also sometimes used
when a patient needs cardiac surgery.


Implant Reconstruction
The most common method of breast
reconstruction using implants is the two-
stage approach. At the time of the
mastectomy, a short-term “expander” (like a
balloon) is placed. Over the next 2 to 4
months you come back to the clinic to have
the expander “filled.” Filling is when salt
water (saline) is put in the expander. You
can see and feel the breast get bigger with
each fill. When you get to a size that you
like, outpatient surgery is scheduled. The
two-stage approach requires two surgeries -
one to place the expander, and the second to
take out the expander and put in the implant.

In a few cases, we can do a one-stage
approach, where the implant is placed
directly at the time of the mastectomy. This
removes the need for an expander, clinic
visits for fills, and a second surgery to take
out the expander. Not all patients qualify
for this procedure. This direct (one-stage)
implant also uses Alloderm or a Vicryl mesh
(see below).

*Please note – whether you have the one-
stage or two-stage approach, there is a
high chance you will need a touch up.

The implant can be placed above or below
the muscle. Placing it below the muscle is
more common and has the best chance to
heal. Placing it above the muscles can be
appropriate for some patients. It tends to be
more comfortable for the long term with less
movement with muscle contraction.

DIEP Reconstruction
DIEP uses excess skin and fat from the
lower belly to form a breast. This is like a
tummy tuck, but the tissues are placed in the
breast instead of being thrown away. This
approach has shown long-term success. As
you heal, the new fat becomes part of you
and should last forever. Long-term problems
are rare with DIEP and you do not need
special care once you heal. The breast will
change in size with weight changes, just like
the fat did when it was in your belly. The
tummy tuck effect also makes your belly
look flatter and slimmer. The new breast
moves and ages naturally and you do not
have to worry about the same problems as
implants. DIEP involves a hospital stay of 3-
5 days and longer healing time.

Normal Healing:
ξ 6-8 weeks off of work.
ξ Up to 3 months to return to full
activity.
ξ Up to 6 months for the feeling of
tightness in the belly to go away.

There are two main risks of this surgery.
The first is failure of the fat to survive, or
“take” at the new site. The second is
weakness or loss of part of the abdominal
muscles, which might lead to abdominal
wall weakness, hernias, a lower abdominal
bulge, or low back pain.

TRAM vs. DIEP Flaps
ξ A TRAM flap uses one of your “six
pack” muscles plus the skin/fat flap.
ξ A DIEP flap uses belly fat with or
without very little muscle.

Most reconstructions that we do using a
patient’s own skin/fat are DIEP flaps. This
lowers the chance for problems in the
abdominal wall, but muscles can still be
damaged. DIEP surgery is long and
complex, but our doctors and nurses are well
trained to manage these patients. Two
surgeons often work together in the
operating room (OR).

Using the Back Muscles for Flaps
(Latissimus Dorsi)
This option takes one of your back muscles
and moves it to the breast, where it is placed
over an expander. The normal expansion
process takes place until you get to a size
that you like. Surgery is then set up to take
out the expander and place an implant.


The back muscle acts as an extra layer of
tissue over the implant. This adds volume to
the breast, makes it look nicer and more
natural, and lowers the chance for problems.
You will have a scar on your back, and the
side where the muscle was taken from will
be slimmer than the other side. There is
small chance the muscle will not survive
after it is moved to the breast, and you may
have weakness with some shoulder
movements.

Touch Ups
While we aim for the best cosmetic outcome
in the first surgery, many patients need a
touch up. This is true for both types of
reconstruction – implants and skin/fat use.
Most touch ups are done outpatient and
scheduled at your convenience. One of the
most common touch ups is called fat
grafting. This method collects fat through
liposuction from somewhere on the body
and injects it into the breast. This adds more
volume to the breast and can correct any
areas of concern. Other touch ups may
include replacing the implants with a
different size or shape, changing the position
of the implant, making the breast
smaller/larger, and revising scars.

Breast Reconstruction on One or Both
Sides
For patients with both breasts done, the
same type of reconstruction is often used on
both sides. Once reconstruction is done, both
breasts are close in size and shape. When
only one breast is done, the other breast
often needs surgery to make it match the
reconstructed breast. This can be an
augmentation (make it larger), a reduction
(make it smaller), or a breast lift. Perfect
symmetry is hard to achieve, but we aim to
make your breasts as close in size and shape
as possible.
Alloderm and Mesh
Alloderm is a mesh made of human skin. It
does not have any living cells and does not
cause rejection or an immune reaction. It is
sometimes used with the two-stage method
and almost always with one-stage. It has
many benefits, which include making
expansions easier, helping you reach the
second stage of surgery faster, and perhaps
enhancing your cosmetic outcome. It can,
however, increase your infection risk (by
around 2%), and require you to keep your
drains in longer after a surgery.

If you have a DIEP, we often use a synthetic
mesh in the abdomen. This lowers the
chances of a hernia forming. The mesh is
foreign to your body and can cause
problems as well.

How will the Breast feel After Surgery?
After a mastectomy, most patients have little
to no feeling in the skin of the breast. This is
from the mastectomy and will not change
with reconstruction. While the size and
shape of the breast can be changed, the
breast will not feel, look, or move like a
natural breast. Implants move less, are more
firm, and may feel cold in the winter. Most
patients do not have long-term pain after the
surgery, but pain after mastectomy is
possible (even in patients who do not have
reconstruction). Some patients have pulling,
cramps, or decreased feeling at the site of
the reconstruction. This should improve with
time.


Your health care team may have given you this information as part of your care. If so, please use it and call if you
have any questions. If this information was not given to you as part of your care, please check with your doctor. This
is not medical advice. This is not to be used for diagnosis or treatment of any medical condition. Because each
person’s health needs are different, you should talk with your doctor or others on your health care team when using
this information. If you have an emergency, please call 911. Copyright ©12/2016 University of Wisconsin Hospitals
and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#7862