Breasts are part of what defines femininity and the loss of a breast can have significant psychological consequences. For most women, mastectomy (removing the whole breast) or lumpectomy (removing part of the breast) for cancer, cancer prevention, or other breast disorders can damage a woman’s self-image and serve as a reminder of the disease. Breast reconstruction is performed to restore a normal form to women who have undergone mastectomy or lumpectomy. The goal of breast reconstruction is to make women look normal in their clothing while also optimizing the appearance of the breasts while not clothed. Breast reconstruction has evolved tremendously in recent years and there are many options for treatment, which are based on the underlying diagnosis, plan for breast surgery and associated treatments, and the patient’s preferences and goals. Breast reconstruction is usually performed in multiple stages.
THE BEST CANDIDATES FOR BREAST RECONSTRUCTION
Patients who undergo mastectomy or lumpectomy are often good candidates to undergo reconstruction of the breast during the same procedure, avoiding an additional surgery. The best candidates for reconstruction are women who have early stage breast cancer which has been completely eliminated by the mastectomy or lumpectomy. The best candidates have adequate support, are nonsmokers, and are relatively healthy without major medical problems. Patients who are well-informed of the reconstructive options before surgery can make a better judgement and have a more positive outlook on their breast cancer treatments and decisions.
PLANNING YOUR SURGERY
The treatment of breast cancer is always through a multidisciplinary approach, usually involving a medical oncologist, breast surgeon, plastic surgeon, and sometimes a radiation oncologist. It is essential that all the team members communicate with one other to ensure the patient receives the best treatment that is available. The breast surgeon and plastic surgeon have an especially close relationship and evaluate the patient together to determine the optimal approach for surgery. After evaluating the patient’s medical conditions and cancer prognosis, the various breast reconstruction options will be discussed.
PREPARING FOR YOUR SURGERY
It is important to research the various breast reconstruction options prior to meeting with both your breast and plastic surgeon. Carefully evaluate the advantages and disadvantages of various breast reconstruction options to see what fits your goals. Assess what you like and do not like about the appearance of your breasts, considering the size, shape, and degree of ptosis (drooping of the breast). It is usually possible to be the same size, smaller, or even larger than your current cup size and may even be possible to do a simultaneous breast lift. It is important to discuss these factors with your surgeons.
You also need to consider whether or not you wish to save the nipple and or areola (the pigmented portion around the nipple). Preserving the nipple and areola significantly enhances the natural appearance of the reconstructed breast and, while they can be reconstructed at a later time, the appearance of a reconstructed nipple and areola is never as good as preserving the natural nipple and areola. Not all patients are candidates for nipple-sparing mastectomies, the characteristics of your cancer and the breast itself will be evaluated by the breast surgeon to determine if it is safe from a cancer perspective to save the nipple and/or areola. Also, be sure to discuss the location of any scars with your surgeons.
It is important to maintain a healthy diet prior to your surgery to optimize the healing capabilities of your body. Your surgeon will give you specific instructions to prepare for the procedure, including guidelines on diet and medications. Patients using tobacco or other nicotine-containing products must stop at least four weeks before and after surgery, including any subsequent surgeries. Carefully following these instructions will help your surgery and your recovery proceed more smoothly.
WHERE YOUR SURGERY WILL BE PERFORMED
Your surgery will be performed at the hospital. If you are undergoing a mastectomy or lumpectomy, Dr. Elswick will coordinate a date with your breast surgeon if you wish to have immediate breast reconstruction. In addition, if you are undergoing any staged breast reconstruction or revision of your breast reconstruction, these will also be performed at the hospital. Dr. Elswick has privileges at William Beaumont Hospital of Royal Oak, William Beaumont Hospital of Troy, and McLaren Macomb Hospital.
TYPES OF ANESTHESIA
Most types of breast reconstruction require a general anesthetic. Smaller revisions and nipple areola reconstruction can be performed under local anesthetic with or without sedation.
There are numerous types of breast reconstruction, but they are generally divided into implant-based breast reconstruction or autologous reconstruction (using your own tissue). The types described in detail below are:
TYPES OF BREAST IMPLANTS
Breast implants are medical devices with a solid silicone shell. The implant shell may be filled with either silicone gel or saline solution (sterile salt water). Both silicone and saline breast implants are approved by the U.S. Food and Drug Administration (FDA).
Silicone breast implants are the most common implant that is used in both breast reconstruction and breast augmentation. There are several different types of silicone gels that are utilized in breast implants. Old silicon had the consistency of honey, whereas newer generation breast implants have a consistency more similar to jello. You may have heard of these new implants being called “gummy bear” implants; other names include cohesive gel implants or form-stable implants.
A major difference between silicone and saline implants is the feel of the implants. Silicone implants feel more natural. They are also less likely to show rippling (surface irregularities that can be seen through the skin). If a silicone implant ruptures or breaks, it is usually silent (i.e. you do not know it is broken). If a saline implant ruptures, the patient usually notices it shortly thereafter because the body will absorb the fluid and the breast will look deflated.
Generally, it is thought that breast implants last about 10 years. The reasons to get them removed and/or exchanged include rupture or capsular contracture. If you are not having a problem with you implants, they do not need to be removed just because they are 10 years old.
AFTER YOUR SURGERY
The incisions on the breast are closed with sutures under the skin which are absorbed by the patient’s body so there is no need for suture removal post-operatively. Dressings typically consist of surgical glue and tape which remain in place until they begin to fall off in the first 2-4 weeks post-operatively. Sometimes a large foam pad is placed on the chest wall, under the armpits, to apply compression to this area and support the tissue expander or implant. You will also be given a special surgical bra, which can be washed and re-used. The surgical bra should be worn for at least two weeks post-operatively. From there, you can switch to a sports bra that fastens in the front (we do not want you lifting anything over your head). You should avoid an underwire bra for at least three months after surgery.
If you have fat grafting, you will have some sutures from the liposuction donor sites that need to be removed approximately one week after surgery. Lastly, you will either have a compression garment or ACE bandage in the areas where the liposuction was performed. The compression garment is usually worn for 4-6 weeks post-operatively. Then, you may switch to Spanx or a similar compression garment.
A drain is comprised of a long tube, one end of which is placed in the area where the surgery was performed and the other connected to a bulb that collects the fluid that you body produces after surgery.
One to two drains are used during the reconstruction, depending on whether or not an axillary lymph node dissection was performed. The instructions on how to care for your drains will be reviewed by the nursing staff prior to leaving the hospital. Your drains are generally removed once the output has decreased to less than 30 cc per day for two consecutive days. Usually drains come out 7-10 days after your surgery. For second stage or revisional surgeries, drains are usually not required. Since the incisions are covered, it is ok to shower the first day after your surgery.
Mild to moderate discomfort and pain is to be expected after surgery, which will usually subside in the first few days to weeks after your surgery. You will likely to feel tired and sore for 1-2 weeks after breast reconstruction. Most of your discomfort can be controlled by medication prescribed by your doctor in addition to taking regular Tylenol. It is important to note that the mastectomy skin and nipple (if preserved) generally have decreased or no sensation after a mastectomy.
If you are having a tissue expander placed at your first surgery, Dr. Elswick fills the expander to a safe level, which means you leave the hospital with some volume in the breasts so you are not completely flat. Bruising and swelling is expected after surgery. Generally the major bruising and swelling subsides 1-2 weeks after surgery. However, the final result of your reconstruction will not be evident until 3-6 months after surgery.
You should not participate in any strenuous exercise, heavy lifting, or repetitive upper extremity activities for 4-6 weeks after surgery. Strenuous exercise includes any activities where your heart rate exceeds 100 beats per minute. We highly encourage our patients to remain activepost operatively, doing activities such as walking. You should not lift anything heavier than 10 pounds (about a gallon of milk). Activities with repetitive arm motions include vacuuming, dishes, laundry, etc. It is ok to type and work at a computer. You can slowly work back into your normal activities at 4 weeks post-operatively and should be back to your normal self at 6-8 weeks post-operatively. Recovery is about two months for flap-based breast reconstruction.
YOUR NEW LOOK
Our goal is to give you restored confidence in your body. Your reconstructed breast will look different from your breast pre-operatively. If you have a tissue expander placed, the shape of the final implant is dramatically different. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery. Dr. Elswick works with her patient’s one on one and will ensure that she understands your goals and you understand the procedure every step of the way.
RISKS ASSOCIATED WITH BREAST RECONSTRUCTION
Every surgical procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit.
The most common complications after breast reconstruction are bleeding and infection, the latter of which can occur throughout the remainder of your life with a breast implant (although the chances of this happening lessen with time). Other complications include seroma (fluid accumulation), wound healing problems, skin and/or nipple loss, asymmetry, contour irregularities, implant complications (rupture/breakage, capsular contracture- abnormal hardening of the scar tissue around an implant). Loss of nipple sensation occurs in all patients undergoing mastectomy and can occur in patients undergoing a lumpectomy. Sometimes you may require additional surgeries to address these complications.
You may have also heard about a rare type of lymphoma called Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). This is a lymphoma that can occur in the capsule around breast implants. To date, this has only been associated with textured breast implants and Dr. Elswick only uses smooth implants.
“Dr. Elswick is an awesome surgeon! She is very caring, down to earth and has excellent skills with breast reconstruction. I have had fantastic results and even with having a few issues healing (not her fault at all) she has given me wonderful care. I can’t say enough good things about her and recommend her highly!” G.
INTERESTED IN SETTING UP A CONSULTATION?
Dr. Elswick is highly trained and skilled in Breast Reconstruction. She has contributed to several publications and research projects in this field and is passionate about helping women through this difficult time and restoring their confidence. Dr. Elswick personally meets with all of her patients in our office located in Troy, Michigan. Call us today to schedule your complimentary consultation. 248-524-0620