Tools and pathways

Breast Reconstruction Surgery – Phoenix and Scottsdale, AZ

Reconstruction can be performed in immediate (at time of mastectomy) or delayed (at latera date than mastectomy) setting. In the immediate setting tissue expanders can be placed, direct to implant (permanent implant placed), or free flap reconstruction can be performed. In the delayed setting, implant-based reconstruction usually includes a stage to insert expanders prior to permanent implants. Delayed free flap reconstruction can be performed without first placing tissue expanders. Implant placement generally has up to one day of inpatient observation for pain control and observation. Free flap reconstruction generally has two to three days of inpatient stay for monitoring and pain control. A second stage reconstruction is performed to improve aesthetic appearance of the reconstructed breasts as well as donor sites, which is combined with nipple reconstruction as needed. Second stage surgery is usually an outpatient procedure. Below we will describe common pathways of reconstruction.

Direct to implant

In select patients, we can consider placement of permanent implants at the time of mastectomy. This may also include fat grafting to the mastectomy pockets at the same time. Direct to implant reconstruction is an attempt to minimize the number of overall surgeries required but may need additional procedures to refine the aesthetic outcome.

■ Direct to implant reconstruction at the time of mastectomy

■ Possible second stage procedure 3 months post-reconstruction to refine results

Immediate tissue expander placement

Tissue expanders placed at the time of mastectomy allow for a controlled reconstruction effort. This is an option for patients who will require expansion of the native mastectomy flaps prior to placing appropriate sized implants or a free flap. Tissue expander placement also allows a final review of pathology removed at the time of surgery to assess need for further treatment including radiation therapy, which can affect the final aesthetic outcome.
■ Tissue expander placement at the time of mastectomy

■ Fill the expander to appropriate size in clinic weeks 2-6

■ Exchange expanders for permanent implants or free flaps 2-3 months post-mastectomy

■ Exchange expanders for permanent implants or free flaps 2-3 months post-mastectomy

Possible second stage procedure 3 months post-permanent implant placement to refine results.

Immediate free flap reconstruction

When immediate free flaps are performed, generally two plastic surgeons and a breast oncologic surgeon is involved. This includes the removal of the breast with free flap placement to reconstruct the breast at the same time. Free flap procedures require an additional “second stage” surgery to optimize breast and donor site aesthetics and for possible nipple reconstruction when required.
■ Free flaps at time of mastectomy

■ Second stage surgery 2-3 months post-reconstruction to refine results of breasts and donor site

Delayed implant-based reconstruction

When breasts are reconstructed in delayed setting with implants tissue expanders are usually placed followed by implants, this can include fat grafting at the time of permanent implant placement.
■ Tissue expander placement

■ Fill to appropriate size in clinic weeks 2-6

■ Exchange expanders for permanent implants 2-3 months post expander placement

Delayed free flap reconstruction

Perforator based free flaps can be used for reconstruction in the delayed setting and o not necessarily need tissue expander placement.
■ Free flap reconstruction

■ Second stage surgery 2-3 months post reconstruction to refine results.
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