Breast

Breast Reconstruction

Breast reconstruction after removal of the breast (mastectomy) is an optional process. It is generally a multi-stage process involving multiple surgeries spaced several months apart. The entire process can take over one year. If desired, the nipple and areola are reconstructed in a later procedure, once the breast shape is finalized. The major goal of breast reconstruction is to look normal in clothing. When naked, there will always be scars and other signs of the breast reconstruction process. Also, it is important to keep in mind that no one starts with symmetric breasts. Several operations may be needed, including surgery to the non-cancerous breast, to get the best result possible.

Immediate or Delayed Reconstruction


Breast reconstruction can be performed at the time of mastectomy or any time afterward. Some women feel better waking up from their mastectomy with the process already started, and some need years to reach a decision about reconstructing their breast. Cancer treatments after mastectomy, like chemotherapy and radiation will factor into decisions about how and when the breast is reconstructed. The decision is one you make with your team of doctors. There are positives and negatives with each approach, and there is no correct choice. 


Techniques of Breast Reconstruction

• Tissue expander/implant based Breast Reconstruction
• Flap reconstruction – using your own tissue

Tissue expander / Implant based Breast Reconstruction

Following mastectomy, a tissue expander is placed under your skin and chest muscle. Once the incisions have healed, salt water solution is injected weekly to gradually fill the expander over several weeks or months (depending on the size of the expander and how well you tolerate the fillings). After the skin and muscles have been stretched, a more permanent implant is inserted. A saline or silicone implant can be used (for more information about implants…link to breast aug). This surgery is usually an outpatient surgery with a much faster recovery than the first surgery. It is much less common, but some women do not require tissue expansion before receiving an implant, and the implant can be inserted during the first surgery.

Flap reconstruction

For patients who do not want to have prosthetic implants or who have radiation damage to the chest that makes using an implant too risky, tissue from other parts of the body, such as the back, abdomen, or buttocks, can be used to make the breast mound. In some cases, the tissue is left attached to blood vessels and simply repositioned to the breast. Other times, it is completely detached from the blood supply and transplanted to the chest using microsurgery. Sometimes an implant is used with flap reconstruction for additional volume. There will be scars at both the tissue donor site and on the reconstructed breast, and the initial recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about problems with an implant like rupture or capsular contracture down the line.

Risks associated with breast reconstruction

• Infection
• Bleeding/hematoma
• Implant related complications
• Donor site related complications
• Effect on cancer recurrence

Infection


Despite the use of sterile methods and the use of antibiotics around the time of surgery, every surgery has a risk of infection. When infection occurs, the implant may need to be removed in order to treat the infection. The implant could be replaced after several weeks to restart the process. Smoking and radiation both increase the likelihood of an implant infection since they both interfere with the blood supply to the skin.

Hematoma


If bleeding after surgery is significant enough, it can result in a hematoma. If one of your breasts is more painful and becomes larger, call the office immediately. You may need surgery to stop the bleeding and clear out the clotted blood to prevent possible problems, such as slow recovery, infection, and capsular contracture.

Implant related complications:

Capsular Contraction


When an implant is placed, your body forms a fibrous layer of scar tissue around the implant called a capsule. Sometimes, an abnormally thick capsule forms around the implant. As the capsule contracts, the breast gets tight and firm, and starts to look round. Capsular contraction can be fixed surgically, but there is a chance it could recur.

Rupture


There’s a risk of about 1% per year that your implant will rupture. With saline implants, the fluid is absorbed by your body and the breast will deflate over several hours. With silicone implants, you may not notice a rupture if the gel stays within the scar tissue capsule. If it leaks out, you may notice a change in the shape of your breast or you may feel lumps. If you have silicone implants, the FDA recommends an MRI every two years starting three years after your implant surgery to detect rupture. Your insurance will usually not cover the cost. The two main suppliers of breast implants, Mentor and Inamed (Allergan), both have warranties that cover the cost of new implants and even the payment of your surgical fees if your implant ruptures.

Rippling


Visible fluid waves can occur. They are most common with saline implants in women with a small amount of fat and thin skin.

Implant Malposition


Implants can migrate too high, too low, too far toward the middle of the chest, or off to the side. These problems can be minimized at the time of surgery by careful dissection of the implant pocket and after surgery by following the aftercare instructions closely.

Donor site related complications from Breast Reconstuction:

There is a risk of wound healing complications or fluid collections at the donor site after flap reconstruction. Smoking increases these risks. If severe enough, these problems could require further treatments, including surgery. When the tissue is taken from the abdomen, there is also a risk of developing either an abdominal bulge or a hernia after surgery, even years later. This is because the lining of the abdominal wall, called the fascia, has to be cut in order to move the tissue. Even when it is repaired appropriately, some women will develop complications, possibly requiring further surgery.

Effect of Breast Reconstruction on Cancer Recurrence and Screening

Wound healing problems after breast reconstruction have the potential to delay chemotherapy, so the type and timing of your reconstruction will be planned with your future treatment in mind. Breast reconstruction has no known effect on the recurrence of disease in the breast, and it does not generally interfere with chemotherapy or radiation treatment should cancer recur. When breast cancer recurs, it is often superficial (on the skin), so reconstruction generally does not affect the ability to diagnose a recurrence.

Expected Recovery after Breast Reconstruction

You will have drains after your surgery to prevent a fluid collection at the surgical site. If you undergo reconstruction with a flap, there will also be drains at the donor site. They stay in place for 1-3 weeks after surgery and are removed when the amount of fluid draining out is low enough. You will be in the hospital at least overnight. Patient with implant based breast reconstruction generally stay 1 or 2 days, and patients with flap reconstruction may stay as long as a week. You will feel tired and sore for a week or two after reconstruction, and there will be activity restrictions based on the type of surgery you have. It may take you as long as 6-8 weeks to fully recover from flap surgery, and about 2-4 weeks from implant based surgery.

Your breast will be fairly numb after surgery. Over time, sensation may return, but it is different for every person. Most scars will fade over a year or two, but they'll never disappear entirely.

Breast Reduction

Also, known as reduction mammaplasty, breast reduction surgery removes glandular breast tissue and fatty tissue from the chest to help eliminate the psychological and physical stress of large, pendulous breasts. Breast reduction can make your breast and areola size more proportional to the rest of your body. Also, symptoms such as back, neck, and shoulder pain, rashes, and headache can be alleviated.

Incision Patterns

• Vertical
• Wise pattern

The vertical reduction results in a “lollipop” incision that goes around the areola and down the front of the breast. This technique can be used when a moderate amount of reduction is required but there is not too much excess skin. There is a tendency for the skin to bunch at the bottom of the scar, and this can take several weeks to months to smooth out completely.

The Wise pattern reduction (named for the surgeon who developed it) results in an anchor shaped scar, and the bottom part lies in the fold under the breast. This removes the most skin, but results in the longest scar.

Risks for Breast Reduction

• Unfavorable scarring
• Bleeding (hematoma) that may require drainage or surgery to stop the bleeding
• Fluid collection (seroma) that may require drainage
• Infection
• Changes in nipple or breast sensation (may be temporary or permanent)
• Breast contour and shape irregularities
• Breast asymmetry
• Fatty tissue could die (fat necrosis) causing lumps
• Potential partial or total loss of nipple and areola
• You may have more difficulty breastfeeding after this operation

Expected Recovery after Breast Reduction

Swelling and bruising are common after breast reduction surgery. You will be sore for a few weeks, but the discomfort is usually well controlled with prescription pain medication in the first few days and over the counter medications after that. You will have a surgical bra to wear for several weeks after surgery to provide support, and you should not wear an underwire bra until everything is healed. The final results of your breast lift will take months because the breast shape and position continue to settle. The incisions will lead to permanent scars, but they will continue to fade over time. Breast reduction lifts the breasts, but it cannot prevent the breasts from continuing to sag in the future. Keeping a stable weight will help your results last as long as possible.

Mastopexy (breast lift)

Mastopexy, also known as a breast lift raises and firms the breasts by removing extra skin and reshaping the breast tissue. If you are happy with your breast size, but do not like the amount of sag you have, then a breast lift alone will give you the results you want. The mastopexy, or breast lift, will require making incisions on the breast. There are several different types of incisions, and the choice of which incision to use will be made based on the quality of your skin and the amount of lift you need. Here are the three most common types of incisions.

Incision Patterns for Mastopexy

• Periareolar
• Vertical
• Wise pattern

The periareolar incision can be done if the skin quality is good and the nipple needs raised only a small amount. The vertical mastopexy results in a “lollipop” incision that goes around the areola and down the front of the breast. This technique can be used when a moderate amount of lift is required but there is not too much excess skin. There is a tendency for the skin to bunch at the bottom of the scar, and this can take several weeks to months to smooth out completely. The Wise pattern mastopexy (named for the surgeon who developed it) results in an anchor shaped scar, and the bottom part lies in the fold under the breast. This removes the most skin, but results in the longest scar.

Breast Augmentation with Mastopexy (Breast Lift)

A breast implant can be placed to improve the amount of fullness you have in the upper part of the breast either at the same time as the mastopexy or in a staged fashion. Some surgeons will not perform these procedures together because there is increased risk that the nipple and areola will not get enough blood supply after surgery and will turn into scab. I do perform these procedures together, but I limit the size of the implant to reduce the risk. (linkto breast aug for more info on implants)

Risks of Mastopexy (Breast Lift)

• Unfavorable scarring
• Bleeding (hematoma) that may require drainage or surgery to stop the bleeding
• Fluid collection (seroma) that may require drainage
• Infection
• Changes in nipple or breast sensation (may be temporary or permanent)
• Breast contour and shape irregularities
• Breast asymmetry
• Fatty tissue could die (fat necrosis) causing lumps
• Potential partial or total loss of nipple and areola
• Breast lift surgery does not normally interfere with pregnancy, but if you are planning to have a baby, your breast skin may stretch and offset the results of mastopexy, and you may have more difficulty breastfeeding after this operation

Expected postoperative course after Mastopexy (Breast Lift)

Swelling and bruising are common after mastopexy surgery. You will be sore for a few weeks, but the discomfort is usually well controlled with prescription pain medication in the first few days and over the counter medications after that. You will have a surgical bra to wear for several weeks after surgery, and you should not wear an underwire bra until everything is healed. The final results of your breast lift will take months because the breast shape and position continue to settle. The incisions will lead to permanent scars, but they will continue to fade over time. Mastopexy, or breast lift surgery, corrects breast sag, but it cannot prevent the breasts from continuing to sag in the future. Keeping a stable weight will help your results last as long as possible.

Breast Augmentation

There are many reasons you might be considering breast augmentation.

• You want to look more proportional in clothing
• You want dresses, tops, and bathing suits to fit better
• Your breasts are a different size or shape, and you want to balance things out
• You want to recreate cleavage and firmness that you’ve lost after pregnancy, with weight loss, or with age

These common desires are all very good reasons why women choose to undergo breast augmentation with breast implants despite numerous misconceptions. There are many horror stories on the internet, but here is the truth about breast implants. Most implants look and feel pretty natural. You don’t have to massage them every day or replace them every ten years, though some women end up having more than one breast surgery in their lifetime for a variety of reasons (including changing size or getting a breast lift). Implants don’t cause cancer or any other disease. Although implant rupture occurs in a small percentage of patients, it isn’t dangerous and is easily managed. Every implant I use has a warranty to cover the cost of new implants and most of the costs of surgery to replace them. Breast augmentation is a common procedure, and many women are happy to have made a choice that makes them feel better about the way they look. Once you decide to undergo breast augmentation, you will have a few decisions to make in planning your surgery. During your consultation at my West Palm Beach office, you will have a chance to feel the implants in several sizes. I will evaluate your anatomy, discuss your preferences, and customize your implant and operative plan to give you the results you want.

•Type of Implant
•Implant Placement – under or over the chest muscle (subpectoral or subglandular)

•Size
• Incision location


Type of Implant

All implants have a silicone shell. Saline implants are filled with salt water, which is absorbed by your body if the implant leaks. Saline implants can feel firm and show rippling under the skin when they are not covered by enough breast tissue. Silicone implants feel more like breast tissue. There is no association between silicone implants and autoimmune disease or cancer, although ruptured implants can cause contracture, calcification of the capsule, and leakage of silicone outside of the immediate area. This is more common with older implants and is much less likely to occur with new implants.

Implant Placement – Subpectoral or Subglandular


Breast implants can either be placed under the pectoralis muscle, called subpectoral; or over the pectoralis muscle, called subglandular

Subpectoral:
• The implant is less prone to sagging
   
• Mammograms are more accurate 
 
• Rippling through the skin is less likely
• The breast appears more natural in those with little breast tissue
• The risk of capsular contracture is lower

Subglandular:
• With looser breast skin (like after a pregnancy or with age), an implant under the breast tissue will fill out a sagging breast and give the illusion of a very slight breast lift.

Size


You will need to decide your size keeping a few key points in mind.

• The larger the volume, the wider the implant. There are several sizes that will fit your chest, and larger sizes will stick out to the side and may be incompletely covered by the muscle.
• The larger the implant, the more stretch and sag to your breast and skin over time
• There is never a guarantee for a specific bra size since manufacturers are so different




Incision Location in Breast Augmentation


An incision always leads to a scar, though most scars heal to a fine line, and they are designed to be hidden. There are four different incisions (two for silicone implants).

• Inframammary – underneath the breast
• Periareolar – a half circle where the areolar skin meets the normal skin
• Transaxillary – at the edge of the hair bearing skin in the armpit
• Transumbilical (TUBA) – placed with a scope from the belly button

The inframammary incision allows for good visualization, and usually does not show when you are wearing a bra or bikini top. There will be a 1-2 inch scar under your breast. The incision is smallest for saline implants and gets larger with larger silicone implants.



The periareolar scar is usually well camouflaged where pigmented skin of the lower half of the areola meets the normal breast skin. Very small areolae cannot be used for silicone breast implants.



The transaxillary approach places the scar behind the fold in your armpit crease. Although theoretically this scar is visible when you lift up your arms, it is usually very difficult to find. Because the implant is placed from the top, the implant will tend to sit high. The incision and dissection may also interfere with diagnosis of breast cancer in your lymph nodes, so I prefer not to use this incision. 



The Transumbilical approach is done through a tube passed from the belly button to the breast. There is no direct visualization, and the pressure of the filled up implant is used to stop any bleeding. The placement of the implant under the muscle is unreliable, silicone implants can’t be used, and repeat surgery always requires a different incision, so I do not offer TUBA.



Risks of breast augmentation


There are risks with every surgery. These are the most common risks associated with breast implants.
• Hematoma
• Infection
• Capsular Contraction
• Rupture
• Rippling

• Implant Malposition

Hematoma


If bleeding after surgery is significant enough, it can result in a hematoma. If one of your breasts is more painful and becomes larger, call the office immediately. You may need surgery to stop the bleeding and clear out the clotted blood to prevent possible problems, such as slow recovery, infection, and capsular contracture.

Infection

Despite the use of sterile methods and the use of antibiotics around the time of surgery, every surgery has a risk of infection. When infection occurs, the implant may need to be removed in order to treat the infection. The implant could be replaced after several weeks.

Capsular Contraction


When an implant is placed, your body forms a fibrous layer of scar tissue around the implant called a capsule. Sometimes, an abnormally thick capsule forms around the implant. As the capsule contracts, the breast gets tight and firm, and starts to look round. Capsular contraction can be repaired surgically, but it could always recur.

Rupture


There’s a risk of about 1% per year that your implant will rupture. With saline implants, the fluid is absorbed by your body and the breast will deflate over several hours. With silicone implants, you may not notice a rupture if the gel stays within the scar tissue capsule. If it leaks out, you may notice a change in the shape of your breast or feel lumps. If you have silicone implants, the FDA recommends an MRI every two years starting three years after your implant surgery to detect rupture. Your insurance will usually not cover the cost. The two main suppliers of breast implants, Mentor and Inamed (Allergan), both have warranties that cover the cost of new implants and even the payment of your surgical fees if your implant ruptures.

Rippling


Visible fluid waves can occur. They are most common with saline implants placed above the muscle in women with a small amount of breast tissue and thin skin.

Implant Malposition


Implants can migrate too high, too low, too far toward the middle of the chest, or off to the side. They should be right under your nipples. These problems can be minimized at the time of surgery by careful dissection of the implant pocket and after surgery by following the aftercare instructions closely. It is normal for implants to look too high immediately after your surgery. Swelling from the surgery will go away, and the implants will settle in the first few months after surgery.

Expected postoperative course

Your chest will feel tight for several days after surgery, but prescription medication is usually very effective in preventing pain. You may have decreased sensation to your nipples and the skin of your breast. This usually returns to normal, but rarely, it is permanent. You can’t drive after surgery until you are off narcotic pain medications and feel comfortable handling the wheel (about a week). You shouldn’t lay on your side, lift anything over 10 pounds, or lift your elbows above your shoulders for two weeks after surgery.

A note about breast cancer

Implants do not increase your risk of breast cancer or delay your diangosis. Women with breast cancer are diagnosed at the same stage on average as women without implants and have the same survival rates. When you get your mammogram, you will need to tell them about your implants so special techniques can be used to visualize as much breast tissue as possible. Having implants makes it more likely that you will need a mastectomy instead a lumpectomy and radiation. You will need to get a mammogram before your implant surgery if you are over age forty or if you have a family history of breast cancer before age forty.