BREAST RECONSTRUCTION FORUM

Patient Evaluation Cancer Operation: -How has the patient been treated? -What is the treatment plan? -Radiation history -Lumpectomy with radiation vs mastectomy -vs bilateral mastectomy

Patient evaluation Patient variables: -Body habitus (enough tissue vs too much) -Past surgical history (? Previous abdominoplasty) -Social history (smoking ?) -Patients wishes and education Internet Opinion on implants “Save my muscle”

Breast Reconstruction Tissue Expander/ Implant Recon. Autologous Recon. (patient’s own tissue) -Latissimus Dorsi Flap -TRAM -DIEP -GAP

Pros Implants Autologous -Shorter operations -Body Habitus not a factor -Greater variability in adjusting size Autologous -Less long term complications -Breast will adjust with weight changes -Natural appearance -Long term studies show patients feel reconstruction is “own breast”

Cons Implants Autologous -Does not work with radiation -Longer surgery -Short term implant complications -Long term implant complications -Capsular contracture Autologous -Longer surgery -Body Habitus -BMI<35 -Non smokers -Longer recovery

Radiation Therapy Radiation affects the skin and subcutaneous tissue. The skin color or turgor may be affected. Most important is radiation affects the blood vessels in the skin and subcutaneous tissues. These changes affect the type of reconstruction and the results. Due to these changes it is important to include this variable when discussing your reconstruction options.

Tissue Expander/ Implant Tissue Expander is inserted into the Breast “Pocket” under the muscle. The estimated recovery time for this procedure is 2-3 weeks. Weekly office visits will be required in order to fill the expander, with Saline, until ideal size is attained. Once expansion is completed the patient will wait 3 months.

Tissue Expander/ Implant The permanent implant will be placed during the second surgical procedure. Follow up at the office will be scheduled for 1-2 weeks after the second surgery. The patient will wait for 3 months before scheduling further surgery i.e.) symmetry/ nipple reconstruction. Following that procedure the patient will be seen in 2 weeks. Again there will be a 3 month waiting period before the final step, Areola tattoo, is completed.

Latissimus Dorsi Flap with Tissue Expander Incision is made in the upper back. The latissimus muscle is tunneled through the axilla and placed into the mastectomy defect. The flap itself is only about one inch thick usually requiring an expander/ implant to be placed in order to match the opposite breast. The muscle/ tissue with an expander are shaped into a breast mound. The estimated recovery time for this procedure is 4-6 weeks. This surgical procedure last approximately 4-6 hours. The patient does have a hospital stay anywhere from 2-3 days. Follow up will be scheduled for 1 week following discharge from the hospital. Post op visits will occur weekly in order to fill the expander, with Saline, until ideal size is attained.

Latissimus Dorsi Flap with Tissue Expander Incision is made in the upper back. The latissimus muscle is tunneled through the axilla and placed into the Breast “Pocket.” The flap itself is only about one inch thick usually requiring an expander/ implant to be placed in order to match the opposite breast. The muscle/ tissue with an expander are shaped into a breast mound. The estimated recovery time for this procedure is 4-6 weeks. This surgical procedure last approximately 4-6 hours. The patient does have a hospital stay anywhere from 2-3 days. Follow up will be scheduled for 1 week following discharge from the hospital. Post op visits will occur weekly in order to fill the expander, with Saline, until ideal size is attained.

Latissimus Dorsi Flap with Tissue Expander Once expansion is completed the patient will wait 3 months. The permanent implant will be placed during the second procedure. Follow up will be scheduled for 1-2 weeks. The patient will wait for 3 months before scheduling further surgery i.e.) symmetry/ nipple reconstruction. Following that procedure patient will be seen in 2 weeks. Again there will be a 3 month waiting period before the final step, Areola tattoo, is completed.

DIEP Deep Inferior Epigastric Perforator Flap This surgical procedure has evolved from the traditional TRAM Flap, a non-muscle sparing flap. The DIEP procedure allows the abdominal muscles to stay (six pack abs) in place which aids in preventing hernias from occurring

DIEP This surgical procedure has evolved from the traditional TRAM Flap, a non-muscle sparing This procedure is more complex than the latissimus dorsi muscle flap or a TRAM flap. It requires two well trained mircovascular surgeons. It is a longer surgical procedure and is not an option for everyone. A CT Angiogram of the patient’s abdomen/ pelvis will be required in order to determine the patient’s eligibility for this specific surgical procedure. An elliptical incision is made in the abdominal tissue/ fat. That tissue with the blood supply is removed from the abdomen as a “Free Flap” and reattached to the vessels in the Breast “Pocket.” The flap is shaped into a breast mound. The estimated recovery time for this procedure is 4-8 weeks. The surgical procedure last approximately 6-12 hours. The patient does have a hospital stay anywhere from 3-5 days. flap. The DIEP procedure allows the abdominal muscles to stay (six pack abs) in place which aids in preventing hernias from occurring

DIEP Cont. Follow up at the office will be scheduled for 1 week following the patient’s discharge from the hospital. The patient will follow up weekly for approximately 3 weeks. Subsequent surgical procedures may be necessary to give the breast its ideal shape. Once the breast is shaped, the patient will wait for 3 months before proceeding with the nipple reconstruction. Following that procedure the patient will be seen in 2 weeks. Again there will be a 3 month waiting period before the final step, Areola tattoo, is completed.

NO SMOKING Causes constriction of blood vessels which slows down the wound healing process. Nicotine decreases the speed in which oxygen and nutrients reach the skin edges, affecting wound healing and causing a higher incidence of complications. Because of the seriousness of these potential problems, we require all patients to discontinue the use of tobacco products at least 2 months prior to the surgery date. A urine nicotine test will be administered prior to scheduling surgery as well as on the day of surgery!

Complications -Bleeding -Fluid accumulation (seroma) -Infection -Tissue necrosis -Capsular contracture However, risk for complications during Breast Reconstruction are no greater than any other surgical procedure! Any incision in the skin will leave a scar, how well the scar heals is patient dependent (the surgeon does not determine the scars appearance)!

Drains Each one of these procedures does require the placement of drain(s). This allows for the excess fluid to be removed. It is important NOT to shower while the drains are in place! Drains will be removed when the fluid accumulation is below 30cc for more than 24 consecutive hours.

In Conclusion Breast Reconstruction is a commitment from both you and your physician. The entire process from beginning (mastectomy) to end (areola tattoo) takes approximately a year! We, at CMC Cosmetic and Plastic Surgery, want you to make an educated choice about breast reconstruction. We are here not only to answer questions but be a supportive part of your breast reconstruction journey. YOU ARE NOT ALONE!