At Elite Plastic Surgery, we understand the difficulties when you are notified of breast cancer diagnosis or a genetic predilection of developing breast cancer. There are multiple new stressors physically and emotionally. Meeting multiple physicians and health care professionals all while trying to understand an overabundance of new information can be overwhelming. We strive to provide a service in this time of uncertainty to ease your burden and improve your experience. As your reconstructive team, we take seriously the task of returning your self-identity and pride ourselves in bridging the gap from cancer treatment to the phase of true recovery and a return to normalcy. This is not only your battle but a journey that you will be able to share with fulfillment.
We focus on the individual and utilize our knowledge and experience with all available reconstructive procedures, in order to customize our treatment plan for each patient. We are not only experienced with performing the most complex breast reconstruction procedures, we have also published numerous peer reviewed journal articles to better understand and advance breast reconstruction. Our published peer reviewed articles have covered multiple aspects of breast surgery including the most modern options for breast reconstruction, improving recovery following mastectomy, describing narcotic medication prescription patterns, and assessing risk for complications following breast reconstruction. We also believe that the most informed patients are the most satisfied with their reconstructive results. This is due to the shared decision making between patients and physicians which allows for the most ideal outcomes.
HISTORY OF BREAST RECONSTRUCTION
Advancements in breast reconstruction have coincided with advancement in breast oncological (cancer) care. The goals of oncological care are to remove cancer, prolong life and decrease recurrence. Prior to modern research and advancements in surgical and medical care, more drastic procedures were believed to be required to “cure” a patient of cancer. As we have better understood and managed breast cancer, we have been able to transition to less invasive methods while achieving the same goals. Radical mastectomies involved removal of breast tissue, overlying skin and subcutaneous tissue, underlying chest muscle and lymph nodes. There has been a gradual yet significant change in this approach where patients, when suitable, are offered procedures such as skin or nipple sparing mastectomies (these options are discussed with your breast oncologic surgeons). This has allowed reconstructive surgeons to offer options to better match a natural result.
WILLIAM STEWART HALSTED
Meanwhile breast reconstruction has also evolved. Pedicled muscle flaps (local muscle flaps with overlying skin and soft tissue) such as latissimus dorsi and rectus abdominus flaps helped provided natural options earlier in the evolution of breast reconstruction. A better understanding of skin and soft tissue anatomy combined with progressive surgical techniques to include microsurgical procedures has introduced perforator based free flap options as a completely natural and reliable option for breast reconstruction using your own tissue. Perforator based free flap options (see below) offer reconstructive options using your own tissue while minimizing the risks to the donor site (sites where tissue is taken from). The donor sites also can serve to provide an improvement in body contouring of the site they are taken from (see perforator flap options).
Breast implants and surgical approaches have also improved for improvements in safety and reconstructive results. In addition to these advancements, Fat grafting techniques have now been well described and serve as a reliable option to improve outcomes in conjunction with other techniques.
The overall goals of breast reconstruction revolve around your expectations, a return to normalcy and restoration of your self-identity. An open discussion of your expectations combined with our surgeon’s expectations is a very informative step. This will be reviewed during your consultation. You are unique and although some people look similar or have comparable body types, there will always be small differences. This is why we customize our approach for you.
The surgical goals are centered around the return to normalcy and restoration of self-identity, through providing an ideal reconstruction process for you. The breast mound, or breast size, will differ for body types and your desired size. This is based on your comfort and safety of the desired procedure. Ideal breast shape and position is based on the dimensions and measurements of the different aspects of a natural breast. This includes (1) the natural slope that defines the upper part of the breast involving the transition of chest wall to the breast mound, (2) the breast foot-print, or part of the chest wall that the breast mound “sits” on, (3) the inframammary fold, or crease underneath the breast that is adherent to the chest wall, (4) medial fullness, or middle portion of each breast which provides “cleavage”, and (5) the ratio of the upper portion of the breast compared to the lower portion of the breast. In addition to the size, shape and position of the reconstructed breast an important consideration of the reconstructed breast is the feel.
Our instruments for breast reconstruction (covered in the section below) allow us the opportunity to provide a customized feel of the reconstructed breast. In brief “free flap” or autologous reconstruction can provide a natural feel made with your own tissue. In addition, modern breast implants come in various consistency which allows us to provide a spectrum of options for the feel of individualized breast reconstruction. Fat grafting can be utilized in combination with breast implants for a more natural feel of the tissue overlying implants. At Elite Plastic Surgery we will discuss all the options to customize our approach in order to optimize breast mound, position, shape, and feel for your ideal breast reconstruction results.
In this section we will discuss the different reconstructive tools as a brief description of how they are used. We also discuss some advantages and disadvantages in this section. Full discussion of risks and advantages of your approach will be discussed with you during consultation.
These are usually considered “place holders” in the mastectomy pocket. Fluid or air can be added or removed from these implants. This allows for gradual expansion of the mastectomy flaps (the remaining skin and tissue overlying the removed breast) when additional area is needed to fit the proper implant or flap. Expanders are also useful in deciding what size is appropriate for each person since they are adjustable in the amount of fluid they can hold. Disadvantages of tissue expanders are that although they are safe they are a foreign body and they are temporary. Expanders need to be replaced with permanent implants or flaps. Also, radiated tissue is difficult to expand.
Breast implants come in different sizes and cohesiveness. The sizes help match the breast footprint (where the breast gland sits) volume, and projection. The cohesiveness of the implant is the firmness of the implant. New generation implants offer various options. Disadvantages include possible need for implant removal due to exposure or infection and potential for capsular contracture. All foreign bodies, even surgical grade, cause a response by the human body which forms a capsule. This capsule can become tight (capsular contracture) or painful in some cases. Newer techniques and implants have decreased these rates, however this is an inherent risk to any implant based reconstruction. Again, because implants are foreign bodies, complication rates increase with radiation.
Majority of mesh used is cadaveric dermal products. This is placed within the mastectomy pocket to support implants like a sling or wrap. These biological mesh products incorporate into the body. Research has demonstrated a decrease in capsular contracture rates. A disadvantage is increased serous drainage and seroma rates.
Majority of pedicled flaps classically utilized in breast reconstruction are the latissimus dorsi (from back) or rectus abdominus (from abdomen). A flap is tissue preserved on its blood supply. In pedicled flaps, the blood supply is not disrupted and reestablished. The disadvantage of the commonly used pedicled flaps are related to donor site when rectus abdominus is used and partial flap loss. Disadvantages of latissimus dorsi flap is mild weakness in arm flexion (or downward force) and this flap generally does not have ample tissue to recreate an adequate breast mound by itself.
The advancements in our understanding of anatomy combined with surgical expertise has allowed us to improve the field of autologous breast reconstruction by using perforator based free flaps. Free flaps are tissue in the body that has preserved blood supply, however contrary to pedicled flaps, the blood supply is disconnected at its source and reconnected to vessels in the chest using microsurgical techniques. This allows the free transportation of tissue from one part to a distant part of the body. We describe the perforator flap options below however in this area we will briefly describe the deep inferior epigastric artery perforator (DIEP) flap. The DIEP is the most popular option for perforator based free flaps due to similarities in breast size and shape. This is similar to the tissue used in rectus abdominus pedicled flap, however studies have shown that the dominant blood supply to this tissue comes from an inferior source (iliac vessels), where the pedicled flap is based on superior vessels. This is also similar to the tissue that is removed in an abdominoplasty (tummy-tuck). Freely transporting tissue on its main blood supply has improved autologous reconstruction results while decreasing donor site morbidity as the goal is to preserve the underlying muscle that the perforator vessels travel through. Disadvantages of free flap breast reconstruction include the donor site risks, length of procedure and availability of microsurgical team and capability.
Fat can be attained and simply injected into different parts of the body. The fat is attained using liposuction techniques and infiltrated using syringes. This allows for regular transport of natural tissue without long operative times needed for free flap reconstruction, however there are limitations. The amount of fat that can reliably be transported is less then that of free flaps in general and can require multiple stages of fat grafting to attain adequate results. Fat grafting does allow for finer control of small areas that may require correction or adjustments.
All tools discussed can be used on contralateral (opposite) sides to provide symmetry when only one-sided surgery (unilateral) is recommended. This includes but is not limited to placing implants, performing lifts or reductions or using fat grafting techniques.
The breast is a specialized gland in the soft tissue. Breasts serve to provide lactation to provide for offspring. The overlying skin, nipple an areolar complex have a well described blood supply and nerve supply (sensation of the area). The breast receives most of the blood supply from medial sources, and a contribution from lateral and superior sources. This provides the nutrition to the tissue and this provides a simplified guideline for blood supply that can be used in microsurgical breast reconstruction
Internal Mammary Artery (IMA): The medial source is the internal mammary artery (IMA) which runs on the deep side of the ribs, usually just on the sides of the sternum. In our practice when performing free flaps, we usually perform anastomosis (connection) to these vessels due to their reliable blood flow and size of the vessels.
Lateral Thoracic and Thoracoacromial Artery: The lateral thoracic and thoracoacromial vessels provide smaller contributions of blood supply to the breast and are reserved for special circumstances.
Thoracodorsal Artery: Other vessels in the area that can be used for anastomosis is the thoracodorsal vessel. The thoracodorsal vessels provide blood supply to the latissimus dorsi muscle. These vessels are reserved as a “back-up” option, to preserve the latissimus dorsi muscle flap as a “life boat” for failed breast reconstruction.
Breast sensation is supplied by medial and lateral intercostal nerves. During mastectomies, the nerve supply is often disrupted. This is due to the location of the sensory nerve course in close proximity or through breast tissue that needs to be resected to provide a safe oncological procedure. This can result in numbness of the overlying breast skin and/or Nipple/Areolar Complex (NAC) that is preserved.
SKIN AND SOFT TISSUE
The skin and soft tissue in your body is supplied by small vessels called perforators. Perforator vessels generally branch off of a source vessel before penetrating through fascia and/or muscle to provide blood supply to the soft tissue. Perforator locations and sizes vary from person to person, but there are well described locations. Each perforator feeds an island of skin and soft tissue superficial to the deep fascia. This has allowed description and use of various perforator free flaps (see below). The free flaps can also include sensory nerves which can be preserved and connected to nerves in the chest to possibly provide sensation.