Reconstructive Breast Surgery - Part I - Tissue Expanders, Breast Implants and Alloderm
By: Dr. Minas Chrysopoulo
This post is the first of a 3-part series on reconstructive breast surgery discussing the reconstructive options available to women facing mastectomy for breast cancer.
Every woman has a right to breast reconstruction. This has now actually become a federal mandate and insurance companies have to cover all types of breast reconstruction by law. Having said that it is also important to remember that it's not up to the health insurance to decide which reconstruction a woman receives. That's determined by the patient and her surgeons.
Breast reconstruction is not a form of cosmetic surgery, it restores something that nature has provided but cancer has taken away. There is also no age limit, as long as there are no medical conditions making the surgery unsafe and the breast cancer is diagnosed at an early enough stage, most women are candidates for the surgery.
Breast reconstruction can be performed as an "immediate" or "delayed" procedure. As the term implies, immediate reconstruction is performed immediately after the mastectomy while the patient is still under anesthesia. Once the general surgeon has completed the mastectomy the plastic surgeon begins creating the new breast. Advantages of this approach include the option of preserving most of the breast skin ("skin-sparing mastectomy" ) and a shorter scar. The patient also wakes up "complete" and avoids the experience of a flat chest. Immediate reconstruction provides the best cosmetic results.
Delayed reconstruction generally takes place several months following mastectomy. Patients required to undergo radiation after mastectomy may be advised to delay reconstruction in order to achieve the best results. This delay may last several months in order to allow the tissues to recover as much as possible from the radiotherapy.
There are several reconstructive options, ranging from breast implants to "autologous" techniques using the patient's own tissue to recreate a more natural, warm, soft breast. The nipple and areola can also be restored.
Tissue Expanders and Breast Implant Reconstruction
This is the most common method of reconstructive breast surgery currently being used in the United States. Most surgeons perform this is a two-stage procedure. The tissue expander is essentially a temporary breast implant which can be placed either at the same time as the mastectomy or after the mastectomy has healed.
The expander is used to stretch the skin envelope and recreate the size of breast the patient wants. The expander is ultimately replaced by a permanent implant (saline or silicone) at a separate procedure several months later. Some patients undergoing immediate breast reconstruction are candidates for one-step breast implant reconstruction whereby a permanent implant is inserted at the time of the mastectomy and the patient avoids going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and Alloderm (a cadaveric acellular dermal graft).
This is specially treated skin from a cadaver that is used to provide a sling and coverage of the lower part of the implant. Two types of implants are available to patients: saline and silicone. There are many opinions regarding both types of implants and it is advised that you speak with your surgeon as to which implant would be best for you. Patients who undergo implant reconstruction should be aware that their breast implants may need to be replaced at a future date.
Implant reconstruction can be the best option for some patients. However, tissue expanders and implants can be fraught with complications long-term, particularly if the patient has had or is going to have radiation therapy as part of her cancer treatments. For these reasons, many surgeons and patients prefer autologous reconstruction, i.e. reconstruction using the patient's own tissue taken from another part of the body. These will be discussed in upcoming posts.