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Breast Reconstruction
is most commonly performed for women that have had a
mastectomy for treatment of breast cancer. Patients
that have had a lumpectomy or partial mastectomy may
also have the need for breast reconstruction procedures.
Breast reconstruction may also benefit other women that
have operations or injuries, such as burns, involving
their breasts. Birth defects resulting in abnormalities
of development may also be reconstructed.
The function of the breast, aside from
the brief periods when it serves for lactation, is an
organ of female sexual identity. The female breast is
a major component of a woman's self image and is important
to her psychological sense of femininity and sexuality.
The ultimate goal of breast reconstruction is to achieve
bilateral symmetry. Because near-equal symmetry is a
prerequisite for "normalcy," reconstruction
on the contralateral or unaffected breast is often required
to achieve the best possible match of size and configuration.
A number of surgical techniques are used
to recreate the breast mound and nipple-areolar complex.
The goal is to create a breast that matches the shape,
size, and feel of the normal breast as much as possible.
The skills that are used to reconstruct a breast after
a mastectomy are also used for other types of breast
reconstruction.
Most patients report that breast reconstruction
has enhanced their lives and contributed to an improved
quality of life.
WHO IS A CANDIDATE
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Most of the women that
undergo a mastectomy for cancer or pre-cancerous
breast disease. |
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Women that have noticeable lack of
symmetry between the operated (lumpectomy or partial
mastectomy) and normal breast. |
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Women who are in good physical health,
psychologically stable, well informed about the
procedure, and realistic about the outcome. |
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Women with localized disease. |
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Women, including teenagers, who have
a failure of one breast to develop. |
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Patients who should be able to stop
smoking for several weeks before and after this
major surgery. |
INTENDED RESULTS
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A breast mound and nipple
with the surrounding pigmented areola. |
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A shape and size that matches, as
much as possible, the opposite breast. |
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Adjustment of size or shape of the
opposite breast, if necessary, to achieve the best
symmetry. |
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An attractive alternative to the
use and discomfort of an external prosthesis. |
TIMING OF BREAST RECONSTRUCTION PROCEDURES
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Immediate reconstruction
is done after the general surgeon does the mastectomy
and removal of lymph nodes. |
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Delayed reconstruction is done several
months or more later, usually after recovery from
additional (adjuvant) therapy, such as chemotherapy
or radiation therapy. Some women also seek delayed
reconstruction after becoming dissatisfied using
an external prosthesis. |
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Teenage women who realize that one
of their breasts is under developing compared to
the opposite breast, can have placement of a tissue
expander or adjustable breast implant (prosthesis)
for reconstruction during adolescence. This is inflated
with saline (salt water of the same type as IV fluid)
to match the size of the normally developing breast.
As the uninvolved breast continues to grow during
adolescence, additional saline is added in Dr.
Weeter’s office to match the size of the
normally developing breast. |
PROCEDURES
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Reconstruction of the
breast mound can use some of the patient’s
own tissues to replace the tissues removed with
the mastectomy, or can use a soft saline filled
implant, made of a silicone envelope, or a combination
of both techniques. |
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Breast
Implants: The most common breast reconstruction
uses an implant placed beneath a covering of muscle
and skin, with its underlying, cushioning fat layer
and blood vessels. Typically a tissue expander is
inserted beneath the covering tissue layers and
partially filled. The overlying tissues adjust to
the changes of surgery. After several weeks of recovery
from the surgery, a series of additions of the saline
gradually inflates the implant to the desired size.
When the desired breast mound size has been achieved,
the tissue expander is removed and replaced by the
permanent breast implant. This is usually done as
an outpatient. Use of an implant usually has the
easiest recovery and the risks are least with this
type of reconstruction. |
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Flap
reconstruction: Use of the patient’s
own tissues moved from other body areas can also
be chosen to reconstruct the breast mound. The skin
and underlying fat and muscle, which supplies the
blood supply, is called a flap. The surgery does
require a longer hospital stay, and recovery is
not quite as easy as with the use of a breast implant
alone. Because the reconstruction is made with the
patient’s tissues, it may feel more like a
natural breast. |
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The Transverse
Rectus Abdominus Musculocutaneous Flap (TRAM flap)
uses the skin and fat layer of the lower
abdomen with its underlying muscle layer to recreate
the breast mound. Because the site that donates
these tissues is then sutured together like when
Dr. Weeter does an abdominoplasty, commonly called
a “tummy tuck”, this method is sometimes
called a “tummy tuck reconstruction.”
A number of factors affect the suitability of this
method, such as previous abdominal surgery and smoking.
It may not be appropriate for all candidates for
breast reconstruction. |
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The Latissimus
Dorsi Musculocutaneous Flap brings the skin
and fat layer with the muscular blood supply from
the back around to the front side of the chest wall
to build up a breast mound. Because this has a thinner
fat layer, a small breast implant may be required. |
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Reconstruction
of the nipple and areola: Reconstruction
of the nipple is generally performed after recovery
from the breast mound reconstruction. The nipple
is created using local skin and underlying tissue
from the breast mound area that is lifted and brought
together for its reconstruction. The pigmented area
around the nipple, called the areola, will have
medical tattooing to complete the reconstruction.
Reconstruction of the nipple and areola are usually
done as outpatient or treatment room procedures.
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RECUPERATION AND HEALING
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Recovery time and resumption
of the activities of daily living varies depending
on the type of procedure. |
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Hospitalization is usually one to
three days. If reconstruction is done at the time
of the mastectomy it may add a day or two to the
hospitalization, depending on the type of reconstruction
that is done. |
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Frequently a drainage tube is used
for a short time post-operatively. |
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Initial discomfort subsides daily
and can be controlled with oral medication. |
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Driving can usually begin within
about a week. |
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Walking exercises may begin in about
2 weeks and slowly increased over the next 6 weeks. |
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Usually, Dr. Weeter’s patients
return to progressively more normal activity within
several weeks. |
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The scars at the incision lines typically
become reddish and firm a few weeks after surgery,
but after many months they usually become pale and
soft. After 8-12 months, the scars are relatively
inconspicuous. |
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The post-operative swelling and tightness
gradually decrease in the weeks following all of
these procedures. |
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When a tissue expander is used for
reconstruction, saline will be added to the tissue
expander to stretch the skin and build up the breast
mound. This begins 3 weeks following surgery and
continues weekly until reaching the final size.
At a second outpatient operation the tissue expander
is exchanged for a permanent breast implant. |
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With the flap reconstruction operations,
the new tissue of the breast area will gradually
lose the swelling and tightness, and gradually develop
a softer feel and look. As the tissues mature, the
breast mound will settle and have a natural contour.
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OTHER OPTIONS
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An
external prosthesis can be worn within the brassiere
or bathing suit. |
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Modification of
the opposite breast may be chosen to achieve improved
symmetry of the breasts. |
INSURANCE GUIDELINES
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Pre-authorization
by the insurance company is required prior to surgery.
Dr. Weeter and his staff will assist you in obtaining
pre-authorization from your insurance carrier. |
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Legislation:
Women's Health and Cancer Rights Act of 1998
In October 1998, federal legislation was signed
into law requiring group health plans and health
issuers that provide medical and surgical benefits
with respect to mastectomy, to cover the cost
of reconstructive breast surgery for women who
have undergone a mastectomy.
The law states:
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The
attending physician and patient are to be consulted
in determining the appropriate type of surgery.
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Coverage must
include all stages of reconstruction of the diseased
breast, procedures to restore and achieve symmetry
on the opposite breast and the cost of prostheses
and complications of mastectomy, including lymphedema.
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| NOTE: The specific risks
and the suitability of this procedure for you may be determined only at
the time of consultation. All surgical procedures have some degree of risk. |
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