Cosmetic Surgical Procedure
Breast reconstruction is the plastic surgical creation or modification of all or part of a breast removed because of cancer or incompletely formed due to a congenital defect.
What About the Other Breast?
Sometimes, the breast surgeon recommends bilateral mastectomies if there is a risk of developing cancer later in the remaining breast. It can also be considered to maximize symmetry. If bilateral mastectomies are performed, both breasts are reconstructed similarly. If mastectomy is performed on one side, modification of the remaining breast, by augmentation, reduction or uplift can be performed simultaneously or at a later date.
What About the Nipple?
The nipple can be left in a nipple sparing mastectomy or removed. This is decided by the patient with the advice of the breast surgeon. Everything is done to maximize chances of total cure. If the nipple is removed, it can be reconstructed with local tissues and a skin graft or tattooing at a later date.
What Type of Implants Are Used?
As with breast augmentation, saline (salt water) implants or silicone implants are almost always used. The relative merits vary with the particular patient.
What Are the Risks?
Implant reconstruction is associated with infection, firmness of the tissue around the implant (capsular contracture), leakage or rupture of the implants and malposition of the implants due to wound healing. Infection can occur with any type of reconstruction but is particularly serious with implant reconstruction as it may require removal of the implant and another reconstruction at a later date.
Does Insurance Pay for Breast Reconstruction?
Typically, all insurance carriers pay for breast reconstruction, surgery on the other breast and any events afterwards over the patient's lifetime.
Who is a Candidate?
A woman or less commonly a man who has had a total or partial mastectomy. This includes women having preventative mastectomies because of genetic markers or family history. Also, someone whose breast has not fully developed from birth producing an asymmetry with the other breast.
At the consultation, the procedure recommended for cancer cure by your breast surgeon will be reviewed and options for reconstruction are discussed. Relevant medical history that might impede wound healing and the possible need for chemotherapy and radiation are reviewed. Your breast surgeon and Dr. Gewirtz will discuss your case and propose an individualized plan.
When and Where Is It Performed?
Most initial procedures are performed as inpatients most commonly at the same time as the mastectomy. It is sometimes delayed for medical reasons or the patient's desire.
What Procedures Are Possible?
There are several procedures performed for total mastectomy:
Direct to Implant
Direct to implant is an older procedure that has become popular again due to biologic matrices such as alloderm that allow for better coverage of the implant. This is somewhat limited by the woman's original breast size and shape. As the name implies, it is done at the time of mastectomy. The implant can be either in front of or behind the pectoral muscles.
Two Stage Implant Reconstruction
Two stage implant reconstruction is the placement of an adjustable implant or tissue expander at mastectomy, enlargement of the expander over several weeks in the office with saline injections and final reconstruction with permanent implant as an outpatient. The second procedure is sometimes delayed if chemotherapy or radiation are necessary. Flap reconstruction is the use of the patient's own tissues with or without implant. This can be because of patent desire to avoid an implant or if the patient is very thin and better implant coverage is necessary. Abdominal muscle and fat or back muscle and fat are the most common choices. Oncoplastic surgery is a relatively new technique in which the breast surgeon and Dr. Gewirtz plan partial breast removal and immediate reconstruction using a variant of a plastic surgical procedure such as breast reduction or breast lift. It also includes the use of internal modification of remaining tissues after lumpectomy.