Sunday, January 4, 2009

Breast Reconstruction Surgery - Part I - Tissue Expanders, Breast Implants and Alloderm

This posting is the first of a 3-part series on breast reconstructive surgery discussing the reconstructive options available to women facing mastectomy for breast cancer.

Every woman has a right to breast reconstruction. This has now actually become a federal mandate and insurance companies are required to pay for all types of breast reconstruction by law. Having said that it is also important to remember that it’s not up to the health insuranc carrier to decide which reconstruction a patient receives. That’s determined by the patient and her surgeons.

Breast reconstruction is not a form of cosmetic surgery – it restores something that nature has provided but cancer has taken away. There is also no age limit – as long as there are no medical conditions that render the surgery unsafe and the breast cancer is diagnosed at an early enough stage, most women are candidates.

Breast reconstruction can be performed as an “immediate” or “delayed” procedure. As the term implies, immediate reconstruction is performed immediately after the mastectomy while the patient is still under anesthesia. Once the general surgeon has completed the mastectomy the plastic surgeon begins creating the new breast. Advantages of this approach include the option of preserving most of the breast skin (“skin-sparing mastectomy”) and a shorter scar. The patient also wakes up “complete” and avoids the experience of a flat chest. Immediate reconstruction generally provides far superior cosmetic results.

Delayed reconstruction generally takes place several months following mastectomy. Patients required to undergo radiation after mastectomy may be advised to delay reconstruction in order to achieve the best results. This delay may last several months in order to allow the tissues to recover as much as possible from the radiotherapy.

There are several reconstructive options for women to choose from, ranging from breast implants to “autologous” techniques using the patient's own tissue to recreate a more “natural”, warm, soft breast. The nipple and areola can also be recreated.

Tissue Expanders and Breast Implant Reconstruction

This is the most common method of reconstructive breast surgery currently being used in the United States. Most surgeons perform this is a two-stage procedure. The tissue expander is essentially a temporary breast implant which can be placed either at the same time as the mastectomy or after the mastectomy has healed. The expander is used to stretch the skin envelope and recreate the size of breast the patient wants. The expander is ultimately replaced by a permanent implant (saline or silicone) at a separate procedure several months later.

Some patients undergoing immediate breast reconstruction are candidates for one-step breast implant reconstruction whereby a permanent implant is inserted at the time of the mastectomy and the patient avoids going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and Alloderm (a cadaveric acellular dermal graft). This is specially treated skin from a cadaver that is used to provide a sling and coverage of the lower part of the implant.

Two types of implants are available to patients: saline and silicone. There are many opinions regarding both types of implants and it is advised that you speak with your surgeon as to which implant would be best for you. Patients who undergo implant reconstruction should be aware that their breast implants may need to be replaced at a future date.

Implant reconstruction can be the best option for some patients. However, tissue expanders and implants can be fraught with complications long-term, particularly if the patient has had or is going to have radiation therapy as part of her cancer treatments. For these reasons, many surgeons and patients prefer autologous reconstruction, i.e. reconstruction using the patient's own tissue taken from another part of the body. These will be discussed in upcoming posts.


Dr Chrysopoulo is a board certified plastic surgeon specializing in reconstructive breast surgery after mastectomy. Techniques offered include Alloderm one-step reconstruction and DIEP flap reconstruction. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.



Anonymous said...

I'm so ticked off right now! I had a double mastectomy a year ago and at the same time the plastic surgeon put in the expanders. When I met with him pre-surgery he said you can be as big as you want.
After healing, I started getting the expanders filled. I now have basically the size of man-boobs and he says that's as big as he wants to go, that my skin is too tight to do more. I went thru radiation and went back to him and THEN he said well with the scar tissue you got from radiation we really can't do any more.
I am pissed. Now looking for a new plastic surgeon. If I knew it was going to be such a hassle, I wouldn't have even bothered.

Dr C said...

I'm sorry you've had such a bad experience. Unfortunately tissue expander and implant reconstructions generally do not do as well as reconstructions using your own tissue in the face of radiation. Have you considered using your own tissue for reconstruction?

Dr C

Anonymous said...

I had radical mastectomy 4 yrs ago tried to get reconstruction done right away before chemo. My breast surgeon took so much out that my expanders had to be removed so that I could do chemo. 4 yrs later, I have no other choice but use my own tissue. Not sure about which type. What do you recommend DIEP or SIEA or the buttock option. Not sure which way to go. But it is a good idea to get reconstructed any way I am tired of covering the top part of my body and not be able to wear anything sexy.

Dr C said...

No one procedure is best for everyone. The best tissue reconstruction depends on several factors including your body habitus. It's impossible to say which is the best option without a consultation I'm afraid.

Dr C