Case Studies

Breast Reconstruction

Breast reconstruction following mastectomy for cancer or other deformities has evolved considerably over the past 20 years.  The most common reconstructive procedures currently are TRAM flaps (moving skin, fat and muscle from the lower abdomen to the breast) or Latissimus flaps (moving skin, fat and muscle from the back to the breast).  Free flaps from the buttocks or thighs are another way to go.  I do not perform any of the above and if these flaps are required, I will refer patients to those in the Atlanta area that do a great job with these techniques.

Not everyone needs to have a major surgery for rebuilding the breast.  Tissue expanders followed by submuscular breast implants will do a fantastic job on many women in rebuilding the breast mound.  The nipple/areola complex will need to be constructed separately in any case.

Timing for breast reconstruction following cancer is another question.  While many reconstructive plastic surgeons like to rebuild the breast mound immediately after the cancer surgeon has removed the breast, I do not.  It is my personal philosophy that the area should heal and that adjunctive treatments such as radiation therapy and chemotherapy should be completed before reconstructive efforts are begun.  I see too many patients who have had immediate major reconstruction of the breast only to find later that there has been a local recurrence and time has been lost because the postoperative focus has been on the reconstruction and not on the treatment of cancer, and because radiation therapy was not done in preference to immediate reconstruction.

Before Surgery

Although the discovery of breast cancer is one of the most stressful conditions imaginable, consultations with both a cancer surgeon and a plastic surgeon are needed prior to any surgery on the breast.  This is one time when you really need to know exactly what to expect and what the success rate is likely to be.  Don’t let the emotional aspect of this disease outweigh your common sense and stampede you into doing something you are not sure is the best for you.  You will not loose anything if you decide to wait on reconstruction.  You cannot wait for cancer treatment.

Be sure to discuss the effects of radiation and chemotherapy on healing.  Ask to speak to other patients who have had the same surgery you are contemplating.

Delayed reconstruction after mastectomy will begin after radiation and chemotherapy are complete.  The time will vary with the length of time required for these therapies.  For those who choose reconstruction with tissue expansion and later insertion of breast implants, the time will be spent mostly with the cancer surgeon focusing on the treatment of the cancer and making sure there is no local recurrence or distant metastasis.  When the initial healing is complete and the adjunct therapies are finished, that is the time to revisit the plastic surgeon for definitive talks on the date for beginning reconstruction.  Usually, the breast mound is reconstructed either with a tissue expander (if the skin and chest tissue is tight or dense) or directly with a submuscular breast implant of sufficient size to match the opposite side.  It may be that the opposite breast is larger or smaller than optimum and either reduction or enlargement of the uninvolved side will be necessary.  If a tissue expander is necessary, this special implant will be enlarged gradually on a weekly basis with saline through an injection port until the agreed-upon size is reached.  At that time, the 2nd stage of the procedure is done, which is to remove the expander and exchange it for the final breast implant.

At this point, I prefer to allow the operated area to rest again until everything has settled into place.  Then the nipple/areola complex is reconstructed using a graft from some area of the body, depending on the color need to match the opposite nipple.  “Tidying up” (as my British patients say) can also be accomplished at this time to adjust for any asymmetries or shape issues.

With this type breast reconstruction, there are no other deforming scars of the abdomen or back where tissue has been removed to reconstruct the breast.  Yes, there is an implant that is used to form the breast but frequently with TRAM flaps or Latissimus flaps breast implants are needed in addition as the tissue transferred to the chest is inadequate for the size needed.

The Surgery

Most commonly, breast reconstruction as described above is done on an outpatient basis.  There are usually 2 procedures, sometimes 3 and each averages 1.5 to 2 hours.  A Board Certified Anesthesiologist will administer your anesthetic.  Tissue expander implants or saline-filled implants require only a 2.5 cm incision but gel-filled implants require a longer one.  Once the incision is made, the pocket to receive the implant is developed under the muscle.  Exactly where the pocket is made and how is dictated by the patients own body shape and physical attributes.  Implants placed in the submuscular plane will be slightly further apart than those in a subglandular position.  Once the implant(s) are in place and correctly positioned, the incisions are closed with dissolving stitches so that no stitches need be removed later.  Long acting local anesthetics are injected into the tissue about the operated site to reduce or eliminate discomfort postoperatively for 10-12 hours.  Following recovery in the Recovery Room, you are released to go home to your own bed for a day of snoozing. 

Post Surgery and Recovery

An adult will need to be with you for 24 hours.  So long as you live within an hour’s drive of the IAS Surgery Center you may then return to your own bed for 24 hours of bed rest.  Sleeping or snoozing for a day is the best way to get off to a good recovery and rapid healing.  Pain is usually not too severe, however, submuscular placement of implants will require more pain medication as muscles have many more pain fibers than breast tissue.  You will be given prescriptions for pain meds and antibiotics and muscle relaxants which you will begin once you are at home.  For a week, no driving the car, no work, no cooking, cleaning, lifting or reaching.  Take a vacation from all that!  You will have been given a 2 page instruction sheet when surgery was scheduled with before and after surgery instructions and you must follow those instructions exactly.  Nobody wants a complication and these instructions have been specifically designed to prevent postop complications.

Your postop visits will usually be at 2 days postsurgery (to remove the bandages and put you into a postop bra), each week for the next several weeks (until the tissue expander is a optimum size).  At that point the 2nd surgery is scheduled and we will start all over with the postop visits. Ultimately you will be seeing me on an annual basis.  The skin incision will heal in about 10 days but the interior area about the implant will require 6 weeks to heal.  Don’t expect the breasts to look perfect when the bandages come off.  This isn’t the movies.  Implants frequently have to “drop” into the option position and that will only happen after all the swelling created from surgery has occurred – anywhere from 3 days to 6 weeks.  There are “exercises” to facilitate removal of edema and assist the implants to “drop”.  Warm soaks to cover the breasts will help also in getting rid of swelling.  All of these things will be covered in your instruction sheets.  Photographs will be taken frequently.

During the postop period, it is necessary that you continue your care under your oncologist.  Never forget, reconstruction is secondary to treatment for cancer.

Risk and Complications

This is a surgical procedure and therefore complications may occur.  I can’t imagine how many times I have said this to patients during the consultation.  Frequently about this time, a glaze comes over the eyes and the patient “tunes out”.  Risks of surgery and possible complications are not the most pleasant thoughts when you are excited about getting your new look but my advice, pay attention.  The cause of a complication may not be something done at surgery, but rather something you inadvertently do in the postop period.  Simply reaching over your head to get something out of the cupboard in the early postop period, or picking up the baby – these things stretch the pec major muscle and stretching the muscle can cause bleeding or a hematoma that sets off a string of complications.  The list of usual complications and their causes are covered in detail at the consultation so listen attentively.

One specific complication, over which neither you nor the doctor have any control, is the possibility of an implant leak.  A very small percentage of implants leak.  Whether it is gel or saline, the implant should be replaced and the manufacturer will provide a new implant and some funds to assist with the fees related to replacing the implant so long as the manufacturer’s conditions are met.  You will be given a booklet with the guarantee provided by the manufacturer of your implants.  While it may not be a real page turner, it is best to read it so that if something does happen, you are in the know.

The Cost

When budgeting for breast reconstruction surgery, remember there is the fee for the surgeon, the fee for the implant manufacturer, the cost of the surgery facility and the fee for the anesthesiologist – and most of these things are covered by health insurance.  There are miscellaneous other costs such as lab tests, medications, preop physical, postop bras, etc.  Once you are seen in consult and all factors evaluated, a estimated cost will be quoted for you.  If you would like to get a general range of fees, please call the office at 404-252-3672 and ask for the patient coordinator as she will be able to ascertain your general needs and give you a baseline average cost.

back to top