This is one of Dr. Tang’s favorite operations, because she find it so rewarding. For breast cancer survivors, it often helps them regain their femininity, hope and self esteem. After a mastectomy for breast cancer, there are several ways to reconstruct the breast.
Autologous Reconstruction (using your own tissue) – TRAM flap
The first way to reconstruct a breast is using your own tissue. The area we most commonly take tissue is from the fat of the lower abdomen. This is called a pedicled TRAM flap. The skin and fat from the lower abdomen is kept attached to one of the rectus muscles (stomach muscle that gives the “washboard abs”), and it is transferred to the chest to reconstruct the breast. This operation take about 2 ½ hours. The patient typically is required to stay in hospital for 3 days after surgery. The beauty of this surgery is that you get a tummy tuck and a new breast all in one operation. In a second operation, 3 months or more after the first operation, touch ups can be done to make both breasts look more similar. Sometimes the non-cancer breast is either lifted, or reduced or enlarged with an implant. The nipple is also created in this operation.
Fat Grafting
Fat grafting is the process by which fat cells are harvested from one part of the body and injecting into another part of the body. Fat transfer and fat injection are other names for fat grafting. In breast reconstruction, fat grafting can be used to:- fill defects in after lumpectomy
– soften around implants or flaps
– improve breast shape
– improve skin texture
– reverse radiation changes – making it possible to put implants in radiated breasts
– making entire breasts out of fat in some patients
Fat is liposuctioned out of one part of the body, then fat is injected in tiny droplets into the breast. Each droplet of fat needs to be surrounded by healthy tissue so that it survives in its new area. If the droplet of fat is too large, and does not survive, it will die and form fat cysts or fat necrosis.
The incisions for both the liposuction and the fat grafting are only a few mm in length. The incisions are usually stitched and the stitches removed after 2 weeks. Usually a binder is used to wrap the donor site for 4 week, which is normal after liposuction to help reduce swelling. The amount of fat that can be injected in the breast depends on how much fat is already present. The amount of fat that survives depends on several factors; radiation, blood supply to the breast/chest, etc can change how much injected fat survives. By 3 month the fat that is present is likely to remain.
Advantages of fat grafting:
It is an all natural filler
Liposuction of the donor area. This can be any area on the body
The incisions for liposuction as well as the fat grafting are only a few millimetres.
Low complications
Disadvantages:
Requires multiple sessions of fat grafting to see a change depending on size of defect
The amount of fat that survives is not predictable
Multiple sessions of fat grafting are usually required
– After a mastectomy, to reverse radiation changes may take 2 or more sessions of fat grafting before an implant/expander can be used
– To make an entire breast may take 3 to 6 sessions of fat grafting
– To correct lumpectomy defects may take 2-4 sessions of fat grafting
Complications of fat grafting
Donor area complications:
bleeding, hematoma (blood clot), serum (collection of fluid), excess skin, ripples and dimples
Breast complications:
fat cysts, fat necrosis, calcifications on mammogram
Implant/Expander Reconstruction
Another way to reconstruct a breast after a mastectomy is using an implant/expander. An expander is a balloon, which is inserted under the pectoralis muscle. In the office, several weeks after the operation, the expander is inflated slowly to stretch the skin. We inflate the expander every week until it is the size that you want to be. In a second operation, the expander is removed and a permanent implant is inserted and the nipple is reconstructed. The permanent implant is usually a silicone cohesive gel implant, which gives a more natural look and feel. Saline (salt water) water implants can also be used. In this second operation, touch ups can be done to make both breasts to look more similar. Sometimes the non-cancer breast is either lifted, or reduced or enlarged with an implant. The nipple is also created in this operation.
Immediate Reconstruction using Alloderm and Implant
When immediate reconstruction is done (ie. the mastectomy is done at the same time as the reconstruction), one of the ways to reconstruct the breast is with Alloderm and an implant. When the mastectomy is done, the skin can be saved. Sometimes even the nipple and the areola can be saved, because it may not contain breast tissue. If there is enough skin to cover an implant, we can reconstruct the breast using Alloderm and implant at the same time as the mastectomy. If an implant size is chosen than is larger than the existing breast, or if skin needs to be removed during the mastectomy, then there may not be enough skin to cover the implant, and an expander needs to be used to expand the skin first.
Alloderm is a matrix made from cadaveric dermis. It is donated human skin in which all the cells have been removed. It looks like a piece of leather. After the mastectomy, the chest muscle, the pectoralis, is lifted off of the chest wall and detached on the bottom and side. Alloderm is stitched to the chest wall where the bottom of the breast was and stitched to the leading edge of the pectorals muscle. The Alloderm acts like a hammock to support and cover the implant. The skin of the breast is then redraped over the alloderm and implant.
Below are some before and after photos for comparison.