Breast Reconstruction/Difficult Cases

 Background
 Classfication Of Reonstruction Cases
 Patient Concerns and Planning
 Preparing for Surgery
 The Operation
 Recovery
 At Home
 Office Visits and Follow-up
 Outcome and Complications
 Case Histories (Before and After)

THE OPERATION
Surgery time for breast reconstruction can vary. The numerous reconstructive concerns in this section including implant-related cosmetic operations, and those for restoration after mastectomy can include surgical strategies that can take from 3 to 6 hours. Anesthesia is a general method whereby a tube is either inserted into the back of the throat only or into the airway itself. Intravenous fluids are administered as well as medications for comfort, infection control, and relaxation of the chest muscles when indicated. Surgeries for complicated problems or where surgical time exceeds 5 to 6 hours, in older patients, or those with medical problems can require the patient to stay overnight or longer at the discretion of the surgeon. Blood transfusion in extensive reconstructive breast surgery is indeed rare.


1. MAJOR BREAST ASYMMETRY (One side may be reduced while the opposite side is lifted and implants may be inserted) SEE ALSO OPERATION SECTIONS FOR BREAST LIFT AND BREAST REDUCTION.

4 key landmarks are joined in a tear configuration for each side so that all surgery is performed within the perimeter of the design to permit closure in a circle. In this diagrammatic case the left side requires a smaller design since it is only to be lifted, while the right side will require skin and breast tissue to be removed. The measurements should permit a reasonable alignment of nipple height, and shape of the breasts when the operation is completed. When implants are inserted, the less skin is removed illustrated by the smaller inner dotted area. on the left.

After an internal bra is fashioned on each side with or without the insertion of implants, the skin is closed in a purse string circle depicted in blue. The vertical and horizontal white lines represent the vertical and t scar method of skin closure for extreme forms of reduction and lift. For any case of minimal to marked asymmetry, despite careful planning and surgical technique, there still may be slight differences in each breast. This is illustrated here.



2. IMPLANT DROP BELOW THE BREAST FOLD (FROM SURGERY OR TRAUMA TO THE BREAST)
Whether the breast implants are inserted behind the breast or behind the muscle, on rare occasion,the lower fold may loosen and the implant may slip downward. In thin elastic tissues, and when when the normal lower fold is released at surgery to prevent upward slippage of the implant, the fold may give way and cause the implant to slip downward.


As seen in this cross section, the fibers holding the lower portion of the breast implant in place may loosen or the pocket may fail to support the implant. On the left, the implant is placed behind the breast, and on the right, the implant is placed behind the muscle. As a result, the implant may fall below the breast fold. A reconstruction is required to repair this defect.


The correction involves placement of internal sutures to reconstruct the lower breast fold. The implant is temporarily removed during this maneuver to permit proper exposure and suture attachment. When the implant is reinserted, it will lie at the proper position as seen in this illustration. The pocket may appear to be overcorrected shortly after surgery. The final improvement will usually be seen about 4 weeks after surgical correction. There may also be some swelling on the corrected side as things heal.



3. MASTECTOMY RECONSTRUCTION
Patients may present with small to normal, sagging, or enlarged breasts, so that mastectomy and reconstruction should be customized to address symmetry including surgery to the opposite breast. In the case of bilateral mastectomy, when a patient has small, sagging, or large breasts to begin with, they may desire a reconstruction that exceeds a simple restoration and request an enhancement above and beyond perceived inequities of size and shape that existed beforehand. Skin and nipple sparing is usually the case for protective high risk mastectomy although some patients require a full mastectomy for extremes of cancer risk.

For selected cases of minimal breast cancer, the nipple and areola are removed, but any spared skin can provide a better foundation for reconstruction by the Plastic Surgeon. When only the skin of the nipple and areola is removed during skin sparing mastectomy, a circular opening is left for placement of living tissue which is termed a peg flap. The peg tissue will be the site of reconstruction of the new nipple and areola, and thus the only scar on the mastectomy side will be around the areolar peg. The peg can be closed with a blocking purse string suture to prevent stretch of the peg, much in the same way as purse string breast lift and reduction.

A. PROTECTIVE (PROPHYLACTIC MASTECTOMY) FOR HIGH CANCER RISK
(Left) Breast tissue is removed either through the areola or from an incision below when the nipple and areola is to be preserved. If the cancer risk is high, a simple mastectomy is performed in which the nipple and areola is removed and only enough skin to facilitate a good reconstruction. (Center) Either an implant or breast tissue expander implant is inserted behind the muscle. (Right) The expander can be filled sequentially after surgery, until the desired shape and sized is obtained. An expander may be preferred to permit the skin to heal before the full size of the desired breast is realized.

To manage the skin including patients with sagging or enlarged breasts, a periareolar skin resection may be used. The areola remains attached to a small tongue of breast tissue thereby facilitating an 85% mastectomy (lower chance of skin healing failure) while the skin is then closed in a circular pattern with a blocking purse string suture. For more difficult skin management in cases of markedly droopy or large breasts, a vertical or T scar skin resection and repair may be warranted. Illustration of the periareolar approach is depicted by the dotted and solid blue lines from left to right. For vertical and T scar pattern skin management, the white vertical and solid lines are depicted from center to right.


B. MASTECTOMY RECONSTRUCTION FOR CANCER
1.A. Mastectomy with insertion of Implant behind the muscle.


1.B. Mastectomy with Insertion of Breast Tissue Expander Implants which are filled after surgery until desired size and shape is obtained.

1.C. Mastectomy with Reconstruction by use of muscle and skin from the back (Latissimus Dorsi Myocutaneous Flap)


Mastectomy with Reconstruction by use of muscle, fat, and skin from the abdomen (TRAM flap) If skin sparing is possible, the amount of skin is depicted by the white circle (peg flap) on the right figure. Nipple reconstruction would be planned at another operation.