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Breast Reconstruction Overview

Dr. Spiegel Sketching a Breast

Breast Surgery

A Team Effort

Your breast surgery should be a combined effort of both the general surgery and plastic surgery teams. Breast cancer surgery is performed by the general surgeon, and breast reconstructive surgery is performed by the plastic surgeon. The goal of breast cancer surgery is to remove the tumor, along with a portion of the surrounding tissue, while preserving as much of the skin as possible. A specific breast cancer surgery may be recommended to you based on the tumor type, size, location, whether it has spread (metastasized), and your own personal preferences.

Regardless of the type of breast cancer surgery you undergo, you should discuss breast reconstruction with your doctor up front. Fully exploring your options for breast reconstruction, before undergoing breast cancer surgery, will empower you as a patient and help you make an informed decision. It is very important that women across the nation have access to information about breast reconstruction. Evidence shows women who are informed about their breast reconstructive surgery options, before a mastectomy, experience less psychological distress than women who are not informed.

Discussing breast reconstruction options at the onset of your cancer treatment will help reduce any fear or concerns you may have about life after breast cancer surgery. Ideally, your breast cancer surgeon and Dr. Spiegel will collaborate to develop a plan to achieve the best possible results.

Breast Reconstruction Awareness

Every year, over 254,000 American women face a breast cancer diagnosis. Fortunately, today’s technology and treatment advances give women a broader spectrum of options when it comes to breast cancer treatment and breast reconstruction surgery. Despite multiple breast reconstruction options, improved surgical technique, and significant developments in the field of breast reconstruction over the years, 70% of women eligible for breast reconstructive surgery do not undergo breast reconstruction. This high number is largely due to the fact that many breast cancer patients are not properly informed about their options. Of the approximately 80,000 American women who undergo a mastectomy each year, up to 20% of these women do not know that breast reconstruction is an available option.

Steps are being taken to increase breast reconstruction awareness:
  • The Women’s Health and Cancer Rights Act (WHCRA) of 1998 is a federal law that mandates coverage of reconstructive surgery after a mastectomy for all health plans that offer medical and surgical benefits. Since the WHCRA is mandated by the federal government, health plans are required to provide notice of these benefits.
  • National Breast Reconstruction Awareness Day, or BRA day, was established to spread awareness of breast reconstruction. The Breast Reconstruction Awareness Campaign was established in Canada in 2012, and quickly adapted in the United States in 2013.

We support the BRA Campaign and their mission:

Breast reconstruction following a mastectomy or lumpectomy is not for every woman, but every woman should be informed of the options to which she is legally entitled.”

Types of Breast Reconstruction

Breast reconstruction surgery can include a variety of procedures used to restore the shape and form of your breast(s) after a mastectomy or lumpectomy. Breast reconstruction generally involves the use of either breast implants, donor tissue, or a combination of the two to reconstruct the breasts.

The goal of breast reconstruction is to restore a woman to a sense of feeling whole, by creating a breast that has the same shape, softness, symmetry, and sensation as the original.

Breast reconstruction can be broken down into categories:
  1. Natural Tissue Reconstruction
  2. Implant Based Reconstruction
  3. Combination Surgery (A Combination of Both Natural Tissue and Implant Reconstruction)
  4. Oncoplastic Reconstruction (Breast Tissue Rearrangement Combined With a Lumpectomy)

Natural Tissue Reconstruction

What is Autologous Reconstruction?

Autologous reconstruction is when the patient’s own tissue (skin, fat) from one area of the body is used to reconstruct the breast. This tissue can be taken from the abdomen, buttock, back, or thighs. We call the area where the tissue is taken from the “donor site”. Breast reconstruction using tissue flaps has an added benefit of aging naturally with your body. In some cases, the reconstructed breast may age at a different rate, due to the thickness of the skin (such as tissue from the buttocks or back). Tissue from the abdomen used for breast reconstruction tends to age in a way that is similar to breast tissue.

Advances in microsurgery have truly brought breast reconstruction to a new era, resulting in less invasive surgical procedures that offer a natural, soft, breast with the potential for return of breast sensation.

Free Flap Tissue Transfer

Tissue is completely disconnected from its original location, and blood supply, and moved to a new location on the body. The blood supply is then reconnected. This is possible through surgical expertise and requires microsurgical technique.

Types of Free Flap Tissue Transfers:
  • DIEP/SIEA Flap
    • Excess abdominal skin and fat are used to reconstruct the breast.
    • The tissue is removed without injury to the underlying muscles.
    • Using abdominal fat and skin to mold the breast results in a natural look and feel to the reconstructed breast and improves abdominal contour through a “tummy tuck” closure.

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  • SGAP Flap
    • Excess buttock skin and fat are used to reconstruct the breast.
    • The tissue is removed without injury to the underlying muscles and the scar on the buttock is easily hidden in a bikini.
    • This technique is lengthier and more complicated than other reconstruction techniques, but is a good option for patients who would like to use their own tissue and are not a candidate for DIEP flap reconstruction.

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Pedicled (Rotational) Flap

Tissue from one location of the body is rotated to a new, nearby, location, filling a defect. This type of reconstruction does not require the blood supply to be detached and reattached and thus, is a simpler procedure. This type of reconstruction may be a good option if you are not a candidate for a more complicated breast reconstruction.

Types of Pedicled Flaps:
  • Latissimus Dorsi Flap
    • The latissimus dorsi muscle is located on your back, just below the shoulder and behind your underarm.
    • This reconstruction involves rotating the latissimus dorsi muscle, overlying fat, and skin from the back, under the arm and to the chest to reconstruct the breast.
    • There is typically not a lot of fat present in this area of the back and in most cases an implant is placed under the flap to achieve desired breast shape and size.
    • Skin and fat located on the back is typically firmer than the tissue that makes up the breast or other areas of the body, such as the abdomen. This may result in a tighter feeling breast, as compared to other types of reconstruction.

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  • TAP Flap
    • A small amount of excess fatty tissue and skin located on the side of the breast, extending to the back, is used to reconstruct the breast.
    • Like the latissimus flap, the TAP flap is rotated from the upper back and positioned on the chest to fill an area where tissue was removed.
    • Unlike the latissimus flap, the TAP flap leaves all the underlying muscle intact, which makes it a longer and more technically challenging procedure.
    • This is a small flap that is best used for small defects resulting after a lumpectomy, or as a combination procedure with implant placement and/or fat grafting.

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Fat Grafting

Fat grafting is a procedure where fat cells are harvested from one area of the body, processed, and then injected with a small needle to another area of the body. The fat cells are harvested by liposuction. Liposuction is performed in an area where excess fatty tissue is present, such as the abdomen or thighs.

Fat grafting is used both to reconstruct the breasts primarily, and also as a supplement to other types of breast reconstruction to improve symmetry and contour of the breasts.

Fat Grafting Techniques
  • Fat Grafting After a Lumpectomy
    • Depending on the size of the defect present, fat grafting alone may be an option to release the underlying scar tissue present and replace the volume that was lost during the lumpectomy.
    • In order to achieve enough volume, more than one session of fat grafting is typically required.
  • Fat Grafting to Supplement Reconstruction
    • Fat grafting can be used to supplement other forms of breast reconstruction, including flap and implant based reconstruction.
    • Fat grafting is used to camouflage irregularities in the breast and fine-tune symmetry.
    • Fat has the added benefit of improving skin quality, which is especially beneficial after radiation therapy.
    • Liposuction is performed resulting in improved contour at the donor site.

Implant Reconstruction

Implant based breast reconstruction involves reconstructing the breast with an implantable device. Breast implants are FDA-approved devices and are an important option for breast reconstruction. Breast implants can be placed either in the subpectoral or prepectoral plane. The difference between the two is the location of the breast implant. The implant can either be placed above or below the chest muscle.

Implant Reconstruction Techniques:
  • Prepectoral Breast Reconstruction
    • New advanced technique that is less invasive and results in a more natural breast reconstruction.
    • The breast implant is placed above the pectoralis muscle and is supported with a dermal matrix, or internal brassiere.
    • In most patients, it is possible to place a breast implant at the same time as the mastectomy and a tissue expander may not be required. This is referred to as the Direct to Implant Technique.
  • Subpectoral Breast Reconstruction
    • The breast implant is placed below the pectoralis muscle and is supported by the muscle.
    • This is a two step technique that first requires a tissue expander to be placed.
    • The tissue expander is placed to expand the muscle, creating a pocket to place a permanent implant in the future.
    • The tissue expander is filled in the office by injecting solution into the expander until the desired breast volume is achieved. Then a second procedure is performed exchanging the expander for a breast implant.

Dr. Spiegel has been on the forefront of prepectoral breast reconstruction and routinely places breast implants above the chest muscle, using a dermal matrix she designed to support the implant. This advancement in breast reconstruction allows the implant to be placed where the breast tissue naturally was located prior to the mastectomy, above the muscle. This innovative technique results in a softer, more natural, reconstructed breast and is less invasive, resulting in an easier recovery for the patient.

Combination Surgery

Dr. Spiegel specializes in both advanced microsurgical procedures and implant based breast reconstruction. She has pioneered innovative techniques in both flap and implant reconstruction and is dedicated to continually improving the field of breast reconstruction.

We understand that not all patients will fit perfectly into the category of autologous or implant based reconstruction. Due to this, Dr. Spiegel also offers combination procedures, to optimize physical and cosmetic results.

Types of Combination Surgery:
  • Flap based reconstruction combined with implant placement
    • This may be an option for a patient that needs a significant amount of skin transferred to reconstruct the breast after a mastectomy, but has minimal excess fat at the donor site.
    • During the first stage, the tissue is transferred to shape and reconstruct the breast.
    • During the second procedure, an implant is placed to supplement volume and achieve the patient’s desired breast size.
    • This can be beneficial after a radical mastectomy or if a bilateral reconstruction is required but there is minimal donor tissue available.
  • Implant based reconstruction combined with a mini-flap
    • This may be an option for a patient who has had a skin sparing mastectomy and prefers the aesthetic of implant reconstruction or has minimal excess fatty tissue present.
    • During the first stage, implant based reconstruction is performed.
    • During the second procedure, a small amount of tissue is transferred to replace the tissue removed during your breast surgery.
    • The tissue that is transferred improves the breast contour and can be used to reconstruct the areola and nipple, if needed.
    • This reconstruction allows for the aesthetic of an implant and the benefit of replacing the tissue that was lost during the mastectomy.
  • Flap or implant based reconstruction combined with fat grafting
    • Fat grafting can be used to supplement other forms of breast reconstruction and has the added benefit of improving skin quality.
    • In implant based reconstruction, fat grafting increases soft tissue coverage over the implant, camouflaging the breast implant, and resulting in a softer and warmer feeling breast.
    • In flap based reconstruction, fat grafting can improve the contour and symmetry of the breasts and also can be used to build volume when injected in stages.

During your consultation, Dr. Spiegel will work with you to tailor a plan to your needs so you can return to being you as quickly as possible.

Oncoplastic Reconstruction

Oncoplastic reconstruction combines breast reconstruction with a lumpectomy. This type of reconstruction involves rearranging the breast tissue to hide the defect created from the lumpectomy.

The goal of oncoplastic reconstruction is two-fold:
  1. The breast tissue is rearranged by the plastic surgeon at the time of the lumpectomy to camouflage the tissue defect.
  2. The other breast is addressed to achieve symmetry, typically by performing a breast reduction or breast lift.

This type of reconstruction is typically performed on patients with larger breasts. In smaller busted patients, the lumpectomy defect may be too significant with minimal tissue available for rearrangement. Like other forms of breast reconstruction, Dr. Spiegel works closely with your general surgeon to determine if this procedure is best for you.

Innovations in Breast Reconstruction

Lymph Node Transfer

The lymphatic system helps create white blood cells and filter out pathogens. Lymph nodes in the underarm region can be removed or damaged by breast cancer surgery or radiation treatments.

Lymphedema is the accumulation of lymph fluid that causes swelling in the extremities and can lead to infections.

Dr. Spiegel offers lymph node transfer as a standalone procedure and in combination with DIEP flap breast reconstruction. During this procedure, lymph nodes from the groin area can be transferred to the underarm, along with the supporting blood vessels. Patients will usually start to see improvement in soft tissue swelling within a week and continue to see improvement for up to six months.

Innervation Techniques

During traditional breast cancer surgery, the nerve that transmits sensation to the breast may be severed. It is normal for patients to have some degree of decreased sensation to the breast skin, nipple, and/or areola, and some patients may lose all sensation.

Numerous studies have shown that the presence of sensation in the reconstructed breast can improve patient quality of life after having a mastectomy. Dr. Spiegel has been a pioneer in breast re-sensation and is an advocate for bringing breast sensation into the conversation as being an essential component of breast reconstruction.

Dr. Spiegel is well-known for her work on sensation recovery after a mastectomy and routinely performs DIEP flap neurotization, a technique that allows for the transfer and connection of a sensory nerve during reconstruction.

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