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Breast Reconstruction

Breast reconstruction is a type of surgery for women who have had a breast removed (mastectomy) due to breast cancer. The surgery rebuilds the breast mound so that it is about the same size and shape as it was before. The nipple and the darker area around the nipple (areola) can also be added. Most women who have had a mastectomy can have reconstruction. Women who have had only the part of the breast around the cancer removed (lumpectomy) may not need reconstruction. Breast reconstruction is done by a plastic surgeon.

There are often many options to think about as you and your plastic surgeon doctors talk about what is best for you. The reconstruction process often means one or more operations. Talk about the benefits and risks of reconstruction with your surgeon before the surgery is planned. Give yourself plenty of time to make the best decision for you. You should decide about breast reconstruction only after you are fully informed.
  • Types of surgery
One-stage immediate breast reconstruction may be done at the same time as mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant. The implant may be put in the space created when the breast tissue was removed or behind the chest muscles to form the breast contour.

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Two-stage reconstruction or two-stage delayed reconstruction is the type most often done if implants are used. It’s easier than the immediate operation if your skin and chest wall tissues are tight and flat. An implanted tissue expander, which is like a balloon, is put under the skin and chest muscle. Through a tiny valve under the skin, the plastic surgeon injects a salt-water solution at regular intervals to fill the expander over time (about 4 to 6 months). After the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent breast implant.

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The two-stage reconstruction is sometimes called delayed-immediate reconstruction because it allows options. If the surgical biopsies show that radiation is needed, the next steps may be delayed until after radiation treatment is complete. If radiation is not needed, the surgeon can start right away with the tissue expander and second surgery.

  • Tissue flap procedures
A tissue flap is a section of your own skin, fat, and in some cases muscle which is moved from your tummy, back, or other area of your body to the chest area. The 2 most common types of tissue flap procedures are the TRAM flap (or transverse rectus abdominis muscle flap), which uses tissue from the lower tummy area, and the latissimus dorsi flap, which uses tissue from the upper back.

These operations leave 2 surgical sites and scars -- one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but they will never go away completely. There can be donor site problems such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue's blood supply, flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers. In general, flap procedures behave more like the rest of your body tissue. For instance, they may enlarge or shrink as you gain or lose weight. There is also no worry about replacement or rupture.

The TRAM flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). The tissue from this area alone is often enough to shape the breast, so that an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower belly, or a "tummy tuck."

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The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.

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  • Nipple reconstruction
Nipple and areola reconstructions are optional and usually the final phase of breast reconstruction. This is a separate surgery that is done to make the reconstructed breast look more like the original breast. It can be done as an outpatient after drugs are used to make the area numb (under local anesthesia). It is usually done after the new breast has had time to heal (about 3 to 4 months after surgery). The ideal nipple and areola reconstruction requires that the position, size, shape, texture, color, and projection of the new nipple match the natural one. Tissue used to rebuild the nipple and areola also is taken from your body, mostly from the newly created breast.. A tattoo may be used to match the color of the nipple of the other breast and to create the areola.

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