Author: Breast Reconstruction Associates

How Do They Reconstruct a Breast after a Mastectomy?

Written by Breast Reconstruction Associates on May 16, 2023. Posted in Breast Reconstruction.

If you and your Breast Surgeon make the decision to have a total mastectomy, you will be referred to a Plastics and Reconstructive Surgeon to learn about the reconstructive process. Reconstruction can be done at the same time of the mastectomy, as an immediate reconstruction, or delayed after oncologic treatment is complete. Breast reconstructive surgery involves two primary methods: implant-based or autologous reconstruction.

Types of Breast Reconstruction Procedures

Implant-Based Reconstruction

Implant reconstruction uses an implant to rebuild the breast mound. The implants are primarily made of either saline or silicone gel and come in a variety of sizes.

The reconstruction can be done in one surgery, known as direct-to-implant reconstruction; however, the majority of cases are done in stages. At the time of the first surgery, a tissue expander is placed. The expander is filled to the desired size in the office and then later exchanged for the final implant at another surgery.

Implants can be a good option for some patients, but they do require “maintenance,” as they are not lifetime devices. This usually requires a future surgery to replace the implant (approximately every 10 to 15 years).

Autologous Reconstruction

Autologous or flap surgery means using one’s own skin and fat tissue to reconstruct the breast mound. This tissue is removed from the donor site and transplanted to the breast. Several donor sites are available for tissue transfer, including the abdomen (DIEP flap), thighs (PAP flap), or buttocks (SGAP or IGAP flap).

Historically, patients underwent a TRAM flap, which involved harvesting the abdominal muscles in addition to the skin and fat. As surgical techniques have evolved, we have transitioned to muscle sparing techniques like the DIEP flap, which avoids the abdominal morbidity common to the prior TRAM flap procedure.

The abdominal fat has a consistency similar to that of the breast tissue, allowing for a more natural appearing and feeling breast reconstruction, and it does not require any long-term maintenance procedures.

Breast reconstruction can significantly improve a woman’s morale and self-esteem throughout their survivorship journey. Some women view breast reconstruction surgery as a symbolic step to close the cancer chapter and feel whole again.

Radiation and Tissue Expander; What Should I Know?

Written by Breast Reconstruction Associates on April 14, 2023. Posted in Mastectomy Radiation, Radiation Therapy.

The indications for radiation therapy after mastectomy may include larger tumor size, nodal metastasis, or involved or close surgical margins. In some scenarios, the need for radiation is known prior to the mastectomy, and in other cases, it’s not determined until after the mastectomy, when the final pathologic stage is determined.

Occasionally, a tissue expander, which is a temporary implant, may be used as a placeholder at the time of the mastectomy to allow for further cancer treatment, i.e. chemotherapy and/or radiation therapy. The tissue expander helps preserve more skin on the chest wall and creates a temporary breast mound during cancer treatments so that you feel and look normal in clothing.

After all the treatments are concluded, the tissue expander is then exchanged for either an implant or tissue-based reconstruction. Patients who elect to have a permanent implant placed are at higher risks for both short-term and long-term complications. Short term complications include infection and extrusion of the implant while long term risks include an accelerated progression to capsular contracture. Tissue-based reconstruction offers a safer alternative for patients requiring radiation therapy after a mastectomy as the overall complications do not differ from non-radiated patients.

The decision to use a tissue expander is unique to each patient as it is influenced by the overall cancer treatment plan. Please contact us at Breast Reconstruction Associates so we can work with you, your breast surgeon, and your radiation oncologist to determine the best reconstruction strategy.

Breast Surgery for Older Women

Written by Breast Reconstruction Associates on March 15, 2023. Posted in Breast Cancer, Breast Reconstruction, Womens Health.

Breast cancer is the most common malignancy affecting American women with 1 in 8 women diagnosed during their lifetime. There are several risk factors involved in the development of breast cancer, some of which are modifiable (weight/BMI, hormone use, smoking and alcohol use) while others cannot be changed or controlled (age, genetics). Increasing age is considered the most significant risk factor for this diagnosis, and it may contribute to the treatment decisions as chronologically advanced women may have other co-morbidities that must be considered.

As we age, our organs experience various changes that can affect surgical healing. For example, the skin becomes thinner and has less connective tissue like collagen and elastin, all of which can lead to delayed healing. While we cannot reverse this physiologic process, we can control other components like smoking. All nicotine products cause vasoconstriction, which makes it more difficult for the arteries to deliver necessary oxygen and nutrients to all organs and tissue. Smoking and the use of nicotine products exponentially increases the risks of surgery and can sometimes disqualify a patient from reconstructive surgery. We prefer that any patient undergoing reconstructive surgery be off all nicotine products for at least 6 weeks.

General anesthesia is required during breast reconstructive surgery whether using implants or autologous aka tissue-based reconstruction. At Breast Reconstruction Associates, we use a two-surgeon team on all autologous cases to minimize the length of surgery and therefore the amount of anesthesia, which directly correlates to quicker recovery times. Age is a consideration for these surgeries as there are increased risks of post-operative delirium and post-operative cognitive dysfunction in patients aged 65 and older. These patients are at higher risk if they have an established diagnosis of any form of cognitive impairment.

At Breast Reconstruction Associates, we offer various reconstructive options for our patients and always involve the patients in this discussion and decision process. Each patient is unique due to their age, medical and family history, and tumor profile among many other considerations. We want to work with you and your breast cancer team to determine the best possible outcome, so please contact us today to set up a consultation.

Sources:
“Preparing for Surgery – Age Risks,” American Society of Anesthesiologists, https://www.asahq.org/whensecondscount/preparing-for-surgery/risks/age/.

I’ve Had (or Need) Post-Mastectomy Radiation, What Are My Reconstructive Options?

Written by Breast Reconstruction Associates on March 3, 2023. Posted in Breast Reconstruction, DIEP Flap Reconstruction, Mastectomy Radiation.

Radiation is a mainstay of treatment for breast cancer and is sometimes required after a total mastectomy. Even though the breast is gone, the chest wall including the skin and underlying pectoralis muscle as well as regional lymph nodes may benefit from radiation. The need for post-mastectomy radiation will be determined by your final surgical stage.

Radiation therapy can pose challenges for implant-based reconstruction as it leads to higher rates of implant failure requiring subsequent surgeries to remove or exchange the implant. Complications after radiation also include pain, delayed healing and infection, and accelerated progression to capsular contracture. In patients who have previously been treated with radiation or know post-mastectomy radiation is planned for a current cancer diagnosis, autologous reconstruction (meaning using tissue from one’s own body) is the preferred approach over implant-based reconstruction.

At Breast Reconstruction Associates, our preferred donor site for autologous reconstruction is the lower abdominal skin and fat (DIEP flap) as enough skin and fat can usually be harvested to reconstruct a breast without the need for an implant. However, there are other donor site options available if you’re not a candidate for the DIEP flap, e.g. previous abdominoplasty. Rarely, an augmentation implant may be combined with your own tissue to complete the reconstruction process.

If you previously underwent a mastectomy without reconstruction followed by chest wall radiation, you can proceed with autologous reconstruction even years later. Autologous reconstruction brings soft, non-radiated skin and fat to the chest wall to help create a new and more natural-appearing breast mound.

For patients with a current breast cancer diagnosis requiring radiation therapy, autologous reconstruction can be done immediately at the time of the mastectomy or in a delayed fashion once all cancer treatments have been completed. This decision is made on a case by case basis between you, your plastic surgeon and breast surgeon. If a delayed approach is considered, then the final reconstruction usually occurs 3 to 6 months after completing radiation therapy.

3 Things You Can Expect After Breast Reconstruction Surgery

Written by Breast Reconstruction Associates on August 14, 2022. Posted in Breast Reconstruction, DIEP Flap Reconstruction.

Breast reconstruction surgery is a major event in a patient’s life and can be a source of fear or anxiety. At Breast Reconstruction Associates, we want you and your loved ones to feel prepared and supported throughout the entire peri-operative process. Time will be spent with you prior to surgery to review the risks of surgery, the expected hospital course and the details of your post-operative recovery. Here are some basic changes you can expect after DIEP flap breast reconstruction:

1. Swelling

Because of the overall healing response of multiple surgical sites, swelling is normal and expected of the breasts and the abdomen after surgery.
Swelling can take 4-8 weeks to completely resolve.
Compression garments such as a compression bra, shape wear or an abdominal binder can help reduce swelling.
Swelling on one side of the body more than the other (such as one breast vs. the other or one leg vs. the other) warrants a call to your surgeon right away.

2. Scar Tissue

Scars will continue to remodel and mature which changes their appearance for 1 -2 years after surgery.
Topical therapies to improve the appearance of scars can be helpful. Please discuss with your surgeon the best options for you after surgery.
Scar tissue can also cause some tightness and discomfort. This can be improved with stretching, physical therapy or massage therapy of the surgical sites. Your surgeon can discuss this with you after surgery if needed.
We do our best to position scars in locations generally covered by most clothing/swimwear.

3. Sensory Changes

Its normal to experience numbness of the breast mound and around the central part of the abdominal incision.
Sensation can return to surgical site areas, but generally only partial return of sensation is achieved. If sensation has not returned after 6-12 months, the numbness is likely permanent.
Sensory changes can make it difficult to detect if something is too hot or too cold which is why we discourage the use of ice packs or heating pads.
We prefer you wait until you are 12 weeks post op to wear an underwire bra. Until that time, you may wear a post-surgical compression bra or a well-fitted sports bra.

The differences between a Lumpectomy with Radiation Therapy and a Mastectomy with Reconstruction

Written by Breast Reconstruction Associates on July 14, 2022. Posted in Mastectomy Radiation, Radiation Therapy.

Lumpectomy vs Mastectomy – What’s the difference?

A lumpectomy, or ‘partial’ mastectomy, is the removal of only a portion of the breast – specifically the tumor and a normal rim of breast tissue immediately surrounding the tumor. This is an option for cancer treatment and is followed by breast radiation to lower rates of recurrence. The combination of ‘lumpectomy + radiation’ is frequently referred to as ‘breast conservation therapy’ or ‘BCT’.

A mastectomy is the removal of the entire breast. In many cases, this eliminates a patient’s need for radiation therapy.

Cancer considerations

The size and location of a breast tumor determine if a patient is a candidate for breast conservation therapy. When considering BCT, breast surgeons are weighing complete clearance of cancer with the maintenance of an aesthetically satisfactory breast. Though a mastectomy is always an option to treat breast cancers, most breast surgeons treat more than 50% of patients with breast conservation therapy.

When deciding between these two approaches, patients are counselled that BCT and mastectomy have equivalent outcomes with regards to survival, but that BCT is associated with a higher rate of local recurrence.

Cosmetic Considerations

In general, when deciding between these two approaches, reconstructive surgeons are focused on optimizing the aesthetics of the breast, including consideration of volume, shape, and symmetry.

If you are a candidate for either surgical option, the tumor size and breast size are the main variables we consider when determining the most optimal cosmetic approach for you.

If the tumor is small and the breast is large, then only a small percentage of the breast would need to be removed. In such a case, BCT is often a good choice. If needed, the other breast can be reduced or lifted for purposes of symmetry. It is important to note, that the final appearance of the cancer breast may be impacted by radiation therapy. In the long-term radiation can cause volume loss and skin tightening of the breast, these changes can impact symmetry over time.

For women with small or moderate sized breasts, even a small tumor could require removal of a significant amount of the total breast volume, leading to a breast deformity or significant asymmetry. In such cases, a mastectomy with reconstruction may provide a better cosmetic result. A balancing breast lift of the other breast can also be performed simultaneously for symmetry purposes. In some circumstances, radiation can be avoided after mastectomy, which eliminates the possibility of future asymmetry caused by radiation.

How Long Does Mastectomy and Immediate Breast Reconstruction Surgery Take?

Written by Breast Reconstruction Associates on June 15, 2022. Posted in Breast Reconstruction.

Historically, DIEP flap surgery has been associated with extended operative times of 12 to 14 hours compared to those of implant reconstruction. However, at Breast Reconstructive Associates, we aim to change the narrative of DIEP flap surgery by performing these surgeries with a team of two experienced microsurgeons.

Our operative times have been reduced to an average of four hours for a one-sided mastectomy with reconstruction, and six hours for a double mastectomy with reconstruction. These are numbers for a total operative time from the start of the mastectomy to the completion of DIEP flap reconstruction.

The importance of reducing operative times correlates directly to patient safety. This means that there is less anesthesia time, reduced need for blood transfusions, no required ICU stays, and faster total recovery time.

How Radiation Therapy Affects Breast Reconstruction

Written by Breast Reconstruction Associates on May 13, 2022. Posted in DIEP Flap Reconstruction.

Radiation therapy is a common tool available in the treatment of some breast cancers. Most commonly, radiation therapy is part of the treatment for patients who undergo a lumpectomy, or “partial” mastectomy. In these cases, radiation is done to the remaining breast tissue to lower the chance of recurrence. Radiation can also serve a role in some patients undergoing a mastectomy, usually when the following criteria are met:

Larger tumor sizes
Axillary lymph node involvement with the cancer
Close surgical resection margins

Radiation can impact the size, shape, volume and/or projection of the breast, and it can also impact the quality and character of the breast and chest wall skin in the treatment field. All of these factors are considered when planning for breast reconstruction.

Timing of reconstruction is very important, as reconstruction can have an impact on breast cancer treatment. Due to the sensitivity of the treatment schedule, your reconstructive surgeon will often work in coordination with your medical and radiation oncologists to determine optimal timing for reconstruction.

Depending on the circumstance, radiation can be done either before or after reconstruction. Each patient scenario is unique, so you should ask your reconstructive surgeon about the optimal timing of reconstruction, specific to your case. Importantly, the method of reconstruction will have a significant impact on when the reconstruction is done relative to radiation treatment. An experienced reconstructive surgeon will choose a plan that is safe, but that also optimizes the aesthetics of your outcome.

In our practice, when radiation therapy is required, we try to avoid the use of implants for reconstruction. In mastectomy patients who require (or who have had) radiation, DIEP flap reconstruction is the safest approach. The surgery involves using the patient’s own tissue to reconstruct the breast. The result is a soft, natural, long-lasting result, despite the need for radiation.

Breast Reconstruction Associates specializes in DIEP flap surgery. Please do not hesitate to contact us for more information. Scheduling a consultation is simple and allows us to better discuss your situation.

Who’s a Good Candidate for Implant vs. Own Tissue Breast Reconstruction?

Written by Breast Reconstruction Associates on April 13, 2022. Posted in Breast Reconstruction.

There are two main approaches when it comes to breast reconstruction after mastectomies—namely implant based reconstruction and autologous tissue based reconstruction. There are many differences in each approach and some patients are better suited for one approach vs another.

Implant based reconstruction is a good option for many patients who are considering mastectomies, but optimal results are often achieved in patients who are non-obese, have smaller breast size with little sag, and are considering reconstructing both breasts.

Studies have also shown that there are specific groups of patients who may have better results with tissue based breast reconstruction. Patients who are obese (BMI > 30), who have many health comorbidities such as diabetes and hypertension, or who have had or will need radiation therapy all do well with tissue reconstruction. These same groups however are at increased risk for complications or failure with implant reconstruction. Autologous tissue based reconstruction offers a safer alternative for these patients.

The tissue based reconstruction approach to breast reconstruction can be considered by all patients interested in pursuing mastectomy including most patients with normal and lower BMIs. In a 2019 study from the Journal of ASPS, it was found that the obese population reported greater satisfaction after tissue based reconstruction than with implant based reconstruction [sup](1)[/sup]. This finding is consistent with the conclusion of the 2017 study from the Journal of Clinical Oncology that found all patients, regardless of past medical history or body habitus, reported greater satisfaction with tissue based reconstruction over implants [sup](2)[/sup]. While it is a good option for higher risk patients, autologous tissue based reconstruction can provide safe, successful and satisfying results for many women.

As a patient considering breast reconstruction, it’s important to discuss all available options with your surgeon to determine the best fit for you. At Breast Reconstruction Associates, our goal is to help you be a fully informed participant in your care and to feel comfortable moving forward with your reconstruction plan. Please reach out to us for your Fort Worth breast reconstruction needs. We also have locations in Oklahoma City, OK and Austin, TX.

DIEP Flap vs. Implant Breast Reconstruction

Written by Breast Reconstruction Associates on March 15, 2022. Posted in Breast Reconstruction, DIEP Flap Reconstruction.

Breast cancer patients now have a lot of options when it comes to reconstructive surgery. The Deep Inferior Epigastric Perforator flap, also known as DIEP flap, replaces the soft tissue and skin removed during mastectomy with abdominal tissues[sup](1)[/sup]. This is an advanced method of breast reconstruction; unlike the TRAM flap procedure, the DIEP flap preserves all the muscles of the abdomen.

The procedure is available at Breast Reconstruction Associates, your DIEP flap providers in Dallas Fort Worth, Texas. Our goal is simple: we offer a state-of-the-art breast reconstruction option to women through a team approach of individualized and compassionate care.

The benefits of the DIEP flap vs. implant breast reconstruction are as follows:

1. The patient’s skin and fat are utilized to replace the breast volume that is removed during the mastectomy. This avoids the need to use an implant to recreate the breast volume.

2. Implant reconstruction patients may experience implant ruptures or capsular contracture, also known as breast hardening, that may need one or more maintenance surgeries years after their initial reconstruction. With DIEP flap reconstruction, the reconstructed breast tends to get softer and even more natural-feeling over time. After completing the DIEP flap reconstructive process, there is no anticipated maintenance necessary for the longevity of the reconstruction.

3. One advance in DIEP flap reconstruction is sensory nerve reconstruction of the flap. The hope with this additional step in a DIEP flap reconstruction is to provide sensation to the transplanted tissue. At this time, we are not doing this routinely in all cases, but rather it is offered in select patient scenarios. Your surgeon can discuss this option, review the pros and cons, and determine if sensory nerve reconstruction should be included as part of your reconstruction.

4. Post-operative pain is a common concern for patients considering DIEP flap reconstruction. It is often falsely assumed that implant reconstruction is less painful since it has a shorter operative time compared to the DIEP flap and does not involve surgery to the abdomen. At Breast Reconstruction Associates, we utilize a post-operative pain protocol that effectively manages most patient’s pain without requiring the use of narcotic pain medication.

In our practice’s experience, patient’s recovery and healing after DIEP flap reconstruction are actually significantly easier than what most people anticipate. Many of our patients choose to go home after a two-night stay in the hospital.

Truly, the DIEP flap is an excellent breast reconstruction option for women which results in a natural-looking and feeling breast after mastectomy, especially in women who prefer to avoid the use of implants. If you want more information about today’s “gold standard” in breast reconstruction, feel free to contact us at Breast Reconstruction Associates, your DIEP flap experts in Dallas Fort Worth, Texas.

Sources:

https://www.breastcancer.org/treatment/surgery/reconstruction/types/autologous/diep