Do I need to have breast reconstruction?
It is never medically necessary to have breast reconstruction. This is considered an elective procedure, meaning you can choose to have it done or not. Some women choose to have a mastectomy (removal of all the breast tissue) without reconstruction. Although it is considered elective, it is not considered solely cosmetic. Federal law mandates all insurance plans pay for breast reconstruction if a mastectomy is indicated.
What is the difference between immediate and delayed reconstruction?
Many patients prefer to have reconstruction done (or at least the process started) at the same time as their mastectomy for a number of reasons. If you have breast reconstruction done at the same time as your mastectomy this is called immediate reconstruction. Delayed reconstruction is the term used if you choose to have the mastectomy done and then wait for reconstruction to be done month, or even years later. We perform both immediate and delayed breast reconstruction at UCSF. With immediate reconstruction you are decreasing your overall number of surgeries, you may have a better chance at an optimal cosmetic result and for many women there is a psychological benefit to immediately pursuing reconstruction.
Are all women candidates for immediate breast reconstruction?
The vast majority of women are candidates for breast reconstruction. There are a variety of reconstructive options and you may not be a candidate for all types. You and your doctor will discuss which type of breast reconstruction best fits your situation.
What are the major types of breast reconstruction available?
There are 3 major types of breast reconstruction. The first is a tissue expander/implant-based reconstruction. The second uses all your own tissues, typically from the abdomen, but it can come from your buttock or thighs. The third less common option is a combination of the 2 methods using your own tissue from the back (latissimus dorsi muscle) with an implant underneath.
What is this pink color to my skin at the base of my breast (Breast Reduction)?
For those patients who elect to have a breast reduction/breast lift to their opposite breast to better match their reconstructed breast, a pink color to the skin of the bottom half of the breast is not uncommon for 2-3 months following surgery. This is the result of increased local blood flow to promote healing and is not related to infection.
I am interested in implant-based reconstruction. What is involved?
Implant-based reconstruction is almost always at least a two-step procedure. At the time of mastectomy, we will put in a tissue expander, which is a balloon device that is placed underneath the skin and muscles of the chest wall. At the time of surgery, your doctor will attempt to inject a small amount of saline into the expander through a valve in the device. However, you will have very little volume and projection when you awake from surgery. You are usually in the hospital for 2 days for this surgery and recovery time is about 4 weeks.
After you heal from the mastectomy, approximately 2-3 weeks after surgery, you will begin the process of tissue expansion. This means that you will need to come into the office on a weekly or every other week basis. At your office visit, a small needle will be inserted through the skin in the chest wall and into the valve in the tissue expander. A small amount of saline is added at each visit. The chest muscle and skin are slowly stretched to accommodate the appropriate sized implant with some discomfort. Once your tissue expanders have the correct amount of saline in them you will need to wait another 4-6 weeks before the second stage of the surgery. If you need to undergo chemotherapy, the next stage is delayed until chemotherapy is completed.
In the second stage, the doctor will go in through the same incision on the breast, remove the tissue expander, and place permanent implants. The permanent implants can be either silicone (gel) or saline filled implants. Both types of implants are made of a silicone shell – the difference is what the implants are filled with. Both are safe products.
The doctor will help you to make the choice of permanent implants that are best for you. This second operation typically does not require an overnight stay in the hospital, and recovery take about 2 weeks. The entire process from time of mastectomy to when the final implants are placed takes an average of 3-6 months.
What types of breast implants do you use?
Breast implants exist as 2 different types, silicone and saline. Both types are made of the same material, an elastic form of silicone. The difference is what they are filled with. Saline implants are filled with sterile salt water; silicone is filled with viscous gel. Despite concerns in the early 1990’s, the FDA has determined silicone to be safe with no increased risk of related autoimmune diseases or any increased cancer risk. The doctor will address the pros and cons of your particular situation at the time of your consult.
Do my implants last forever?
Implants are not lifetime devices and both saline and silicone implants can rupture and leak. If you have saline implant, you will notice a slow deflation of the implant. The body is able to absorb the salt water leaking out of the implant and over a few days to weeks you will notice that your implant gets smaller. If you have silicone implants, there may be a change in the shape of the implant, however, often times, there is no change at all. Many times, the only way to detect a leak in a silicone implant is through MRI. If you choose silicone implants you will be scheduled for periodic MRIs to ensure that your implants are still intact. Implant rupture rates, regardless of saline or silicone are approximately 1% per year; this means that your implant can rupture at any time after being placed. Most implants will need to be replaced every 15-20 years.
Why do you need to do tissue expansion? My friend had breast augmentation and they just put the implants without tissue expansion.
Placing implants after mastectomy is very different than putting in implants for cosmetic augmentation. When women have an augmentation their skin and breast tissue is left intact. These healthy tissues are better able to stretch to accommodate and cushion the breast implant. After a mastectomy your breast skin is very thin. The breast surgeon needs to make sure that all breast tissue is removed and in order to do this you are left with only a very thin layer of breast skin. The breast skin is not able to stretch in the way it needs to in order to accommodate an implant. This is why we have to very slowly and gently stretch the tissues using a tissue expander. Tissue expansion is typically initiated 2 weeks following mastectomy. It tends to not be painful based on the altered sensation from the mastectomy and the control we have over the rate of expansion. However, we do recommend that our patients take Ativan an hour before the first expansion. Expansion can be performed by anyone on the breast reconstruction team, most commonly by the plastic surgery nurse or the doctor.
I may need chemotherapy. Can I still have implants?
Women who need post mastectomy chemotherapy are still candidates for implants. Sometime we need to change surgery dates based on your chemotherapy. If chemotherapy is necessary, chemotherapy is initiated 4-6 weeks following mastectomy and exchange of the expander for implant usually occurs 2-3 months following completion of treatment. Thus, we will postpone your second stage surgery (to remove the tissue expanders and place the implants) until you are a safe period of time from your last chemotherapy. This time period can vary from 3 weeks to several months, and will be determined by doctor and you medical oncologist working together. This gives your body the necessary time to recover. Women undergoing chemotherapy may also take longer to heal their incisions – this is normal and expected.
I may need (or have already had) radiation to my breast area. Can I still have implants?
Radiation and the impact on implants is something that needs to be discussed carefully. It is true that women who have implants and radiation are at higher risk for multiple complications, such as capsular contracture. If postoperative radiation is necessary, final exchange of the expander for the implant is carried out at least 6 months following the completion of radiation treatment. Our data demonstrates that healing rates are better and infection risk is lower compared to exchange prior to 6 months.
What is the risk of capsular contracture and what factors cause that risk?
Capsular contracture is the formation of scar tissue around the expander or implant that can limit a patient’s range of motion and alter the cosmetic appearance of the reconstruction. There is a 20% risk overall of forming capsular contracture during the lifespan of the implant and that risk increases with either a history of radiation to the breast or planned postoperative radiation. We are currently unable to predict who is more likely to develop contracture. Massage to the reconstructed breast is the best way to limit or prevent it.
What is Alloderm?
Alloderm is a product that can be very useful to correct areas of thin skin as a result of the mastectomy. It consists of human tissue which has been processed in a way that removes all of the cells and has been thoroughly tested for disease and infection to ensure safety. There is no risk of rejection. Whether you could benefit from this product should be discussed with your doctor during your visit.
AUTOLOGOUS TISSUE RECONSTRUCTION
I keep hearing about TRAM flap reconstruction. What is this all about?
The TRAM flap stands for transverse rectus abdominus myocutaneous flap. This type of reconstruction is when the skin, fat, and blood vessels are taken from your abdomen as a single unit, and transferred to the chest, where they are molded into a breast mound. There are two very different types of TRAM flap reconstruction and ti is important to understand the difference.
One type of TRAM flap is a pedicled TRAM. This is performed by leaving the flap attached to its original blood supply, and tunneling it under the skin, up to the breast area. This type of surgery can significantly decrease the strength that you have in your abdomen. This type of surgery is not usually performed at UCSF.
The other type of TRAM flap is a free TRAM. This type of flap is performed by dissecting a flap of skin, fat, blood vessels, and only a small portion of the muscle. This is entirely removed from its original location on the abdomen, and the blood vessels are sutured to donor blood vessels in the chest. Although this type of flap requires more skill, and is a longer procedure, it preserves the strength and function of your abdominal wall.
There are two other special flaps that can be taken from the abdomen, and these are the free DIEP or free SIEA flap. These are also free flaps, and thus require suturing blood vessels together under the microscope. These flaps take NO muscle from your abdomen.
At UCSF, the most common flaps performed for breast reconstruction are the free TRAM, DIEP, and SIEA flaps. The remainder of the questions here will only address this type of surgery.
Why do people choose this type of breast reconstruction? Doesn’t it take longer to recover from than implant surgery?
It is true that breast reconstruction using a free flap is more work up front; you are in the hospital for longer (usually 4 days) and have a longer recovery period (6 weeks). However there are many advantages to this type of breast reconstruction. Below is a brief summary of advantages and disadvantages. However, you will need to speak to the doctor to decide the best type of reconstruction for you.
Advantages of a free flap breast reconstruction:
- You have your own tissue being used to reconstruct your breast.
- The flap reconstruction does not deflate, which may occur with a breast implant.
- The flap reconstruction does not need to be replaced, which may occur with a breast implant if the implant is too old.
- You do not have to wear a breast prosthesis.
- Since there is no breast implant, infection from the implant is avoided.
- The bottom half of your abdomen will be less distended; this is similar to a cosmetic “tummy tuck.”
Disadvantages of a free flap reconstruction:
- The surgery time during the operation is long. For unilateral (one breast) surgery is approximately 4 to 5 hours, and for bilateral (both breasts) surgery may take 7 to 9 hours. This includes mastectomy time in immediate reconstructions.
- Rarely, the breast free flap may not survive, as blood flow to the flap may be lost. This is a major complication, but the probability is low. Should this happen, you will be taken back to the operating room, and your flap will be evaluated. If possible, salvage of the reconstruction will occur, to result in a successful reconstruction.
- There will be scars on your abdomen and breast. There is a small risk of abdominal bulge or hernia.
I do not want any muscle taken from my abdominal wall. Can you guarantee this prior to surgery?
Although it is always a priority to take no abdominal wall muscle, in our experience, it is not always the prudent approach. The type of flap you will have will depend on the anatomy of your blood vessels, and the amount of tissue needed to give you an aesthetically pleasing result. If you choose to have this type of surgery, you must understand that there is a chance we will need to take a small piece of muscle from your abdomen to ensure the success of the breast reconstruction. Usually this is approximately 10% of the muscle at most, and is not a clinically-significant amount.
GENERAL: BEFORE THE OPERATION
What do I need to do for surgery?
Once you have decided to undergo mastectomy and breast reconstruction, you need to decide what type of reconstruction you desire. You will then need to contact both your breast surgeon and your plastic surgeon to let them know you are ready to schedule your procedure. A pre-operative appointment will be set up for you in which you will need pre-operative laboratories and other studies. Sometimes, you will require medical or cardiology clearance.
If you choose mastectomy and implant reconstruction, you should plan to be in the hospital for 1-2 days, with recovery at home for approximately 4 weeks. You can expect your first tissue expansion at 2-4 weeks post-operatively.
If you choose mastectomy and autologous free flap reconstruction, you should plan to be in the hospital 3-5 days, with recovery at home of approximately 6 weeks. This recovery consists mainly of no lifting anything great than 10 pounds, and limiting strenuous activity. You can expect to see the doctor approximately in the 1 week following discharge from the hospital.
What medications do I need to stop before my surgery? When can I resume them? (Tamoxifen-Avastin-Sutent-ASA-NSAIDS-Herbals-etc…)
A separate list of medication that needs to be held prior to surgery will be provided along with suggestions for resuming those medications postoperatively.
GENERAL: DAY OF SURGERY
What can I and my family and friends expect on the day of surgery?
You will report to the hospital “Admission Center,” to check in. You will then be escorted to the preoperative holding area in which you will prepare for surgery. Once you are checked in and settled, your family and friends will be asked to re-join you in the holding area.
Once you are called for surgery, you will be escorted to the operating suite, and your family will be escorted to the family waiting area. Your family will check in and leave a contact number. They are welcome to either wait for your surgery to be completed, or leave and wait to hear from the receptionist or the doctor once the surgery is completed.
Should your family wish to wait, there will be a patient liaison that will give updates on the progress of your surgery. There will be plenty of time for your loved ones to get something to eat in the cafeteria, walk around, or go home to take care of important things while you are in surgery, as long as they leave a number in which they can be reached with the receptionist.
Once your surgery is completed, your family can expect to hear from the doctor. They can then expect to see you either in the recovery room or after you have been transferred to your patient room. Often there is a waiting period of 30-90 minutes from the end of your surgery to when you will see your loved ones.
Can my family or friend stay with me at the hospital?
The general rule is that you are not allowed to have overnight visitors. However, this may be waived, but is up to the discretion of the charge nurse.
GENERAL: POST-OPERATIVE PERIOD
Tell me about the hospitalization period:
After free flap breast reconstruction surgery, you will be admitted to the intensive care unit. A nurse will be checking the blood flow to your flap every hour for the first 48 hours. This is done in a noninvasive way and is not painful or uncomfortable.
You will have several drains called Jackson-Pratt or “JP” drains post-operatively. These drains will remove the excess fluid from the surgical sites that would otherwise collect there. You will be going home with some or all of these drains. You will receive education while in the hospital on how to care for these, and record the output daily.
After the first 2 days, you may be transferred to a regular bed. You will be up and walking on the second day after surgery, and should be eating regular food by this time as well. Patients typically spend 4 to 5 days in the hospital after this operation before going home.
How long will I need dressings following surgery?
For most patients a waterproof dressing is applied the day of the surgery and does not need to be changed before the f/u visit.
How long will my swelling last?
Although swelling following surgery can vary depending on the procedure performed and the length of the surgery, typical swelling following most breast reconstruction procedures range from 2-6 weeks.
When will my sutures come out?
The majority of the sutures we place absorb over time and do not need to be removed. However, if sutures are used which require removal they will typically be removed 4-6 weeks following surgery.
How long will I need to be out of work for?
For implant reconstruction, most women take 2- 4 weeks off from work following the mastectomy and placement of the tissue expanders, and one week off from work after the second stage operation (removal of tissue expanders and placement of the permanent implant). Even though you could return to work at 2 weeks, we usually do not recommend returning to work before 3-4 weeks following surgery depending on the physical requirement of your job. Many women are able to return to work during the tissue expansion process.
For free flap reconstruction, women generally take 4-6 weeks off from work.
When can I drive?
It is safe to resume driving when all the drains are out (more about these below), when you are no longer taking prescription pain medication, and when you have regained safe range of motion of your arms. For most women, this is about 3 weeks after the mastectomy.
Tell me about the surgical drains:
Jackson Pratt (JP) drains are placed under the skin during surgery to remove any collection of blood and other fluids. The drain looks like a narrow plastic tubing that connects to a drainage bulb (which is about the size of a closed fist). The JP drains expedite the drainage process and help decrease the chance of infection. You usually will go home with some drains. On average, drains stay in place from 1 to 3 weeks. You will have a t least one drain underneath the arms on the side of your mastectomy. If you use your own tissue for breast reconstruction, you will also have two drains in the abdominal area. The drains are fairly easy to take care of. You and your family members will be taught to care for them while you are in the hospital. Generally, three times per day, you will need to strip the tubing (clean it from the outside to make sure the tube stays open), and empty the fluid in the collection bulb. You will need to keep track of the 24 hour total of fluid coming out of each drain. The doctor will use these totals to determine when the drains are safe to be removed. We usually wait until a drain output is less than 30cc/24hours for 2 consecutive days as criteria for removing the drain. The drains are easily removed in the office.
Do I need to have any special supplies at home for my recovery?
Bring to the hospital a shirt that either buttons or zips up the front. Just after surgery, it can be painful to raise your arms overhead. Sometimes your surgeon will request that you buy a special supportive bra to wear after surgery. This should be a bra without underwire, and preferably one that closes in the front. Many department stores sell these in the sports bra section. Some women are also more comfortable in a camisole with a shelf bra.
In the immediate postoperative period following implant placement, usually no bra is necessary. At 1-2 weeks after surgery a bra without an underwire (athletic bra) is preferred for a total of 4-6 weeks. Beyond that point, whatever support garment that is most comfortable is encouraged. Some patients prefer to never wear a bra again.
Will smoking tobacco, chewing nicotine gum or using nicotine patches and/or smoking marijuana be harmful to me?
All of these products can be detrimental to the healing process by decreasing the delivery of sufficient oxygen to blood flow to the operative site. This can result in wound healing problems, increased risk of infection, and expander/implant loss. Most studies suggest that these products need to be discontinued for a minimum of 4 weeks before and after surgery to minimize the incidence of complications.
When can I have my nipple reconstructed? When can I get my areolar tattooing?
If your type of mastectomy requires the nipple and areola to be removed, the reconstruction to recreate the nipple is typically performed at the time the expander is exchanged for the permanent implant. Areolar tattooing can be performed once the nipple reconstruction heals 2-3 months later.
What are some usual signs of infection?
Following any surgical procedure, infection is a risk, and the ability to recognize an infection early can impact the outcome of your reconstruction, particularly when implants are used. Classic signs of infection include redness that increases with time, swelling, discomfort and flu-like symptoms. Fever may be a late manifestation of the problem. If these symptoms develop, contact us as early as possible since antibiotic treatment may be necessary.
If I require other treatment such as chemotherapy or radiation when does that usually take place?
If chemotherapy and/or radiation are parts of your treatment, they are typically not started until 4-6 weeks following mastectomy. During that time, the filling of your expander is completed. The exchange of your expander for the implant occurs following the completion of all of your treatment.
What activity limitations do I have?
Your drains must be removed and your incisions must be well healed before submerging in a bathtub, hot tub, pool, or the ocean. Therefore, typical time to return to submerging in water is 4-6 weeks following surgery. Showering with the drains in is fine. You also want to limit reaching and excessive stretching of your arms immediately after your mastectomy. Once the drains for the breasts are removed, you may be given exercises to start. Generally, these range of motion exercises are not started until 48 hours after the drains are removed. If you have had tissue taken from your abdomen, you will not be able to lift anything more than 7-10 pounds or do any strenuous exercise for 6 weeks. Walking is fine, and can actually speed your recovery.
Swimming restrictions and when can I start?
Swimming is a good form of exercise following breast reconstruction, particularly for increasing range of motion around the chest and shoulder. Swimming following reconstruction can resume 4-6 weeks following surgery.
Will physical therapy be part of my recovery from surgery?
Physical therapy has become a routine part of recovery for most of our patients. It can be used to address limits to range of motion of the arm and shoulder, to soften the areas of reconstruction, and to decrease discomfort related to surgery. It typically will be initiated 3-4 weeks following surgery.
What do I need to do for the dentist following my implant surgery?
For one year following expander/implant placement antibiotic prophylaxis (a single dose the morning of your dental appointment) for dental visits is required to decrease the risk of infection.