Breast Reconstruction

Breast reconstruction surgery is a procedure performed to restore the shape of the breast following treatment for breast cancer.

Breast reconstruction can be performed for women undergoing lumpectomy or mastectomy. After a mastectomy, it is generally performed using a prosthetic implant, the patient’s own tissue, or a combination of the two. The reconstruction process can begin at the time of the tumor removal or in a subsequent procedure, depending on the circumstances and patient’s preference.

Hoag offers the full range of reconstructive techniques available today including:

We also offer nipple-areola sparing mastectomies with discreet scars and use advanced techniques with breast implants, tissue expanders and acellular dermal matrix to create additional support and protection.

Comprehensive Program at Hoag

At Hoag, breast cancer patients meet with a multidisciplinary team of specialists including a breast surgical oncologist, reconstructive plastic surgeon, medical oncologist and radiation oncologist. Hoag’s expert medical staff is complemented by a highly trained team of oncology nurses and nurse navigators to help guide patients through treatment.

Choosing the best treatment option is an important decision that no one should navigate alone. Women should seek treatment at a center that offers the best surgical options enabling them to make an informed decision.

Hoag Breast Program is the first and only breast center in Orange County to be designated as a Certified Quality Breast Center of Excellence™ by the National Consortium of Breast Centers and will help you every step of the way.

SURGICAL OPTIONS

Oncoplastic Reconstruction

Oncoplastic surgery is an innovative technique that combines oncologic and plastic surgery principles into the same procedure to both remove the tumor and allow for a better cosmetic result from breast cancer surgery.

It should be performed in tandem with a lumpectomy in most breast cancer cases where the tumor is less than 5cm. It can also be performed in lieu of a mastectomy when a tumor is exceptionally large. Called “extreme oncoplasty,” this technique was pioneered at Hoag. In either case, oncoplastic surgery allows for breast conserving surgery with an excellent cosmetic outcome, and is done as a single outpatient procedure.

Learn more about the benefits of oncoplastic surgery and the differences between standard and extreme oncoplasty.

Mastectomy Reconstruction

Breast reconstruction can be performed immediately following a mastectomy (“immediate reconstruction”) or delayed and performed in subsequent procedures (“staged reconstruction”).

There are three areas of the breast that may require reconstruction:

  1. Breast tissue
  2. Any skin deficit resulting from tumor removal
  3. Nipple and areola if necessary

During mastectomy, the nipple is either spared or removed, depending on the degree to which the cancer has spread. In the case of a nipple-sparing mastectomy, the nipple and areola, as well as the skin, is saved – only the tissue beneath is removed. Otherwise, nipple reconstruction is an option.

Implant-Based Reconstruction

Reconstructive surgery with implants is a common procedure at Hoag.

Direct-to-Implant

If there is sufficient skin remaining following mastectomy, direct-to-implant reconstruction may be a viable option since the permanent implant can be placed at the same time as mastectomy. The entire procedure can be completed in a single surgery.

Direct-to-implant reconstruction is performed utilizing acellular dermal matrix.

Acellular Dermal Matrix (ADM)

Acellular dermal matrix (ADM) is a sheet of collagen derived from a donor and is utilized to form a more realistic breast. The procedure enables the surgeon to extend the reach of the pectoral muscle during reconstruction to fully cover the implant – bridging any gaps that may exist otherwise. Without ADM, the muscle may be stretched too tightly over the implant, creating a misshapen result.

A tissue expander may not be necessary when using ADM, eliminating the need for a follow-up surgery and sparing the patient added discomfort. As a result, both the mastectomy and reconstruction can be completed in one procedure.

Staged Reconstruction

If there is a small deficit in skin or if the skin is too fragile after the mastectomy is completed, a tissue expander can be used as a temporary spacer to stretch the area over time. As the patient heals, the expander is slowly filled to eventually house an implant. The tissue expander will later be exchanged for an implant once the patient has recuperated.

Fat Grafting

Fat grafting, also called autologous fat transfer, is a procedure performed following mastectomy. The surgeon removes droplets of fat from another area of the body through liposuction and adds them to the existing layer of fat in the reconstructed breast or breasts. Fat droplets are cleared of blood and impurities and then injected under the skin to fill voids, creating a more natural breast shape.

The procedure enables surgeons to fill gaps to create a more aesthetically pleasing appearance, or to customize the breast shape to more closely match the other breast.

Fat grafting provides multiple benefits to the patient, including a more individualized, natural appearance and is virtually scar-free. It can also pose some potential risks such as the fat cells not surviving (necrosis) or fat being reabsorbed in other areas of the body.

Recovery

Patients generally spend one night in the hospital following breast reconstruction with a tissue expander or implant.

Recovery times vary based on the procedure. After oncoplasty, a patient may take pain medication for about a week, be able to drive by the following week, and be back to full mobility four weeks after the procedure.

Following a reconstruction involving a tissue expander, patients can expect an eight-to-12-week recovery. After a direct-to-implant reconstruction, in which mastectomy and reconstruction were done in one surgery, patients can expect six to eight weeks of recovery time.

Patients may feel tired and sore for a few weeks following surgery, so your doctor will prescribe pain medication.

Autologous (or Flap) Reconstruction

Autologous tissue breast reconstruction – also referred to as flap reconstruction – involves tissue being taken from another area of the body to reconstruct the breast. Tissue is most commonly taken from the abdomen.

The two methods of flap surgery include:

  • Pedicle flap surgery: In this procedure, the surgeon cuts some blood vessels connecting the tissue and transfers them to the chest, while keeping other vessels intact. Relocating the tissue beneath the skin, the surgeon positions a new mound of tissue at the chest to form a breast.
  • Free flap surgery: In this newer approach, the surgeon completely disconnects the tissue’s blood vessels and reconnects the tissue to new blood vessels near the patient’s chest.

Types of Autologous (Flap) Reconstruction Surgery

There are multiple types of autologous reconstruction surgery, most of which pull excess tissue from the abdomen. Other less common types pull tissue from the back, buttocks or inner thigh.

Abdomen-Based Flaps

One common type is the transverse rectus abdominis muscle (TRAM) flap, where the surgeon removes both the tissue and muscle from the patient’s abdomen, which can be performed as either a pedicle or free flap.

The pedicle TRAM flap uses the patient’s entire rectus muscle, one of the four major muscles in the abdomen, which can result in patients loosing significant muscle strength following surgery. Blood supply can come from the ribs coming down to the abdomen or the groin up to the abdomen. This option is limited in the amount of tissue that can be moved and the extent to which it can be repositioned.

An alternative is the muscle-sparing free TRAM (msTRAM) flap, in which the surgeon removes only a portion of the muscle, saving the patient’s muscle strength in the abdomen.

A more recently developed procedure called the deep inferior epigastric perforator (DIEP) flap spares the muscle entirely, removing only the skin and fat.

The superficial inferior epigastric (SIEA) flap uses the same abdominal tissue as the DIEP flap but is dependent on blood vessels located on the outer layers of the abdomen. Not all women have sufficient blood vessels in that area to lend itself to this procedure.

Other surgical flap options include:

  • Latissimus dorsi flap: This technique takes the skin, muscle and fat from the upper back/shoulder area and tunnels it beneath the skin to the chest area. Due to the decreased amount of skin and tissue available in this region of the body, this approach is used only for small-to-medium-sized breasts or implant pockets.
  • Gluteal flap: This approach is a free flap procedure that takes tissue from the buttocks and relocates it to the chest, and is more common for patients who have insufficient tissue in their abdomen or back.
  • Transverse upper gracilis (TUG) flap: A newer approach, the TUG flap relocates muscle and fat from the inner thigh and lower buttocks to the chest area. This procedure lends itself best to patients with excess thigh tissue and small-to-medium-sized breasts.

Flap surgery generally takes four to six hours for a unilateral procedure or upwards of 10 hours for a bilateral, due to the intricate level of detail required for microsurgery.

A successful flap breast reconstruction never needs to be replaced. Because it uses natural tissue, it becomes part of you.

Recovery

Following autologous tissue or flap surgery, patients generally stay in the hospital for four to seven days. After returning home, they can expect about four to six weeks of recovery (or more depending on their daily routine).

Patients may feel tired and sore for a few weeks following surgery, so your doctor will prescribe pain medication. You will likely have drainage tubes after surgery to drain excess fluids and wear an abdominal binder to assist with healing. After a few weeks, your surgeon may recommend physical therapy to return to full mobility.

Once the patient has recovered, they can return to their normal routine.

Nipple Reconstruction

There are multiple options for nipple reconstruction for both autologous and implant surgery. Surgeons can form a section of skin from the reconstructed breast into a nipple or create an areola using skin from another part of the body. The skin can also be tattooed a darker color to more closely resemble a natural areola.

Risks

As with any surgical procedure, there are inherent risks associated with breast reconstruction – both with implant and autologous tissue (flap) surgery. It is important to discuss these risks with your plastic surgeon to help you come to the best decision for you.