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Breast Cancer and the Option of Breast Reconstruction
The psychological trauma associated with the diagnosis of any type of cancer is significant. For women diagnosed with breast cancer, the trauma is even more severe. The issues of biopsy, surgical and oncologic evaluation is daunting and sometimes frightening. The patient must confront not only the physical loss of her breast, but also emotional stress associated with the loss.
Not all breast cancer patients require total removal of the breast and elect to have a lumpectomy and radiation with or without chemotherapy. This is a very attractive option for many women. Some patients, however, require a mastectomy. It is this group of women who may benefit from a discussion with a plastic surgeon regarding breast reconstruction as an immediate procedure performed at the same time as the mastectomy, or as a delayed procedure. Breast reconstruction is not for every woman. It is an option which is worth discussing. In fact, depending on the technique, there may be medical issues which preclude the operation. For the vast majority of patients, it is one of the positive experiences associated with an otherwise difficult issue. Fortunately, breast reconstruction is considered to be an appropriate medical procedure and it is approved by all insurance plans. In the state of Maryland and in almost all states, surgery to “match “ both breasts is also an insurance covered expense.
The question of performing an immediate versus delayed reconstruction is a decision made jointly with the patient, medical oncologist, general surgeon, and plastic surgeon. Only after collecting all the necessary information regarding the tumor type, size, location and medical work-up, does the plastic surgeon become involved. Breast reconstruction can be performed either immediately after completion of the mastectomy or delayed, one to three months following mastectomy or after radiation or chemotherapy.
View before-and-after pictures of real patients of Don Fontana, MD
Immediate Breast reconstruction
The most favorable situation, in my opinion is to perform immediate reconstruction; that is, immediately at the time following the mastectomy. The advantages of this are a single hospitalization, reducing the recovery time as well as the psychological benefit of awakening in the recovery room wearing a bra with a reconstructed breast present. The deformity of mastectomy is not present and the patient is able to wear a bra when she leaves the hospital. Dr. Fontana follows the patient closely while her incisions are healing and the patient benefits from a surgical scar sutured by Dr. Fontana.
Single Stage Immediate Breast Reconstruction
Immediate breast reconstruction is a combined operation with a general surgeon and Dr, Fontana. Not every patient is a candidate for single stage reconstruction, although the majority are. Immediate breast reconstruction can be performed either with a breast implant or using the patient’s own tissue.
If the patient has enough skin to reconstruct a breast of adequate size a relatively simple procedure using a breast implant can be considered. Dr. Fontana designs and marks out the incision lines for the mastectomy to assure adequate margins for cancer removal and breast reconstruction. Dr. Fontana is either present during the mastectomy or “ first assists” the general surgeon for the operation. Prior to the surgery, Dr. Fontana discusses with the patient her options regarding size, shape, projection and implant type, either a saline or silicone gel. Dr. Fontana will discuss the advantages and disadvantages of choosing either silicone gel or saline implants before the surgery so that an informed decision can be made. The patient is admitted to the hospital on the day of surgery and is discharged the 1 – 2 days post op.
Immediate breast reconstruction techniques range from procedures requiring approximately an additional 2 to 5 hours following the mastectomy. The major difference in the techniques hinges on whether an implant is used or the patient’s own tissue is used to create a breast shape. If the patient is large breasted, Dr. Fontana and the patient will determine the appropriate reconstructed breast size. In most cases the patients prefer a smaller more youthful breast. Dr. Fontana discusses the possibilities with the patient in detail.
If the patient wishes to use her own tissue to reconstruct the breast, a more involved procedure must be considered. Dr. Fontana uses a technique in which the skin and fat of the patient’s lower abdomen is transferred onto the chest and used to create a breast. This operation is called a TRAM (Transverse Rectus Abdominis Myocutaneous) flap reconstruction. The operation requires an additional 4 hours of general anesthesia. The patient is admitted to the hospital and usually remain for 2-3 days. Since the skin and fat of the lower abdomen is used, the patient will essentially get a tummy tuck as well. This technique may also be employed in patients who lack sufficiently excess skin to create a breast mound. Patients who have an “ extra roll “ without being obese are excellent candidates for this technique.
– Written on May 17, 2019
Over the years my family members have come to you for various problems. I have always come knowing that we have found the very best. To me, the best includes not only your talents as a surgeon; it includes other qualities as well. You are genuinely kind and caring. Your kindness is reflected by your ladies out front and how your office is run. Yes, it is a business that manages to be warm and considerate and always on time. Another quality is trust. I never have second thoughts. My mind is at rest with complete confidence and trust because I knew you would do your best for us. Okay this is getting a little too sappy so I just want to say I consider you a great guy and happy to call you my friend. Thanks for all you have done for us.
Two Stage Immediate Breast Reconstruction
Some patients are not candidates for single stage reconstruction and require a two stage breast reconstruction. In most cases, the patient has small breasts and after the mastectomy, there is not enough skin to create an a breast of adequate size. In most instances, a technique called tissue expansion is employed. An expander implant is placed beneath the chest wall muscle and a pocket is created using a material called “acellular dermal matrix.” The expander implant is slowly enlarged by injecting sterile saline solution into it. This process of expansion may take 2 – 6 months depending on the amount of expansion needed. When an adequate volume is reached, the expander implant, and adjacent scar tissue around it are removed and a permanent silicone or saline implant is placed. This method is used when the patient does not have enough skin to reconstruct a breast.
Clinical Course following Breast Reconstruction
After the reconstructed breast has healed, the patient chooses whether she wishes to address the shape and size of her opposite breast. In most cases, the woman will require a reduction and/or a mastopexy (breast lift) to bring both breasts into balance in terms of size and shape. There are instances when Dr. Fontana can reconstruct a breast of the same size and shape as the opposite breast , thereby eliminating an extra operation.
The last procedure is the surgical creation of a nipple and areola on the reconstructed breast. The projecting part of the nipple is created surgically from the skin of the reconstructed breast, and the areola is tattooed to match the size and color of the opposite breast.
Although it may seem as though there are multiple procedures to finally complete the reconstruction, the good news is that other than the initial mastectomy and reconstruction, all of the subsequent procedures are done as an outpatient. Most patients have a list of questions regarding breast reconstruction, all of which are discussed with Dr. Fontana.