Denver Plastic Surgery, Breast Reconstruction Surgery Following Mastectomy
Denver Colorado Plastic Surgeons

Breast reconstruction following mastectomy is performed to create a simulated breast and restore a sense of "wholeness" to the individual. Since breasts are paired organs, the ultimate result is to achieve bilateral symmetry. This may require surgery on the contralateral breast in cases of unilateral mastectomy. Restoration of both breasts following mastectomy is considered reconstructive surgery and should be eligible for coverage by insurance policies that cover reconstructive surgery.

PROCEDURES:

To replace a breast that has been surgically removed, a breast mound must first be reconstructed using alloplastic (non-self) materials such as implants; or, autogenous (self) tissues, such as flaps and grafts. A new nipple/areola can be reconstructed when the breast mound has "settled" and its final position has been established. Breast reconstruction may be performed immediately (at the time of mastectomy), or delayed (several months or even years following mastectomy). The timing should be determined by the surgeon, in consultation with the patient and other involved physicians.

A variety of techniques for breast reconstruction are available to accommodate the wide range of deformities resulting from mastectomy. Choice of the appropriate surgical technique must be made by the surgeon and will depend on the individual circumstances and needs of the patient.

Currently accepted techniques for reconstruction of a breast include:

In some patients with adequate soft tissues, insertion of an alloplastic breast prosthesis underneath the skin or muscle of the chest will create a satisfactory breast mound.

Tissue Expansion

In some patients, the skin covering their chest does not have enough elasticity to accommodate insertion of a breast prosthesis. To increase the amount of soft tissue available, a silicone tissue expander is placed beneath the skin or chest muscle. Over a period of time, saline is injected into the expander, causing the tissue to stretch. A second surgical procedure is usually required to remove the tissue expander and replace it with a permanent breast prosthesis.

When muscle and skin are insufficient or missing, it may be necessary to use an adjacent skin flap from the chest, abdomen, or back. The transverse rectus abdominis musculocutaneous (TRAM) flap is frequently used. It has the advantage of providing relatively large amounts of tissue for reconstruction, usually avoiding implant use, and leaving an acceptable donor site defect. Microsurgical techniques may be useful to augment TRAM-flap circulation when necessary to ensure flap viability. The latissimus dorsi flap is another regional flap that is used frequently. This flap, while it provides additional tissue, often requires an implant as well to provide adequate contour.

Sometimes, when adequate local or regional tissues are unavailable for reconstruction, it is necessary to use a free-flap transfer. This technique involves transplanting distant skin and underlying tissue along with the veins and arteries and reconnecting this flap to a "new" local blood supply under microscopic magnification. Microsurgical free-tissue transfer, using one of several donor sites, may be used to avoid implants in certain individuals. However, placement of a breast implant may be necessary as an adjunct to any flap procedure when insufficient tissue is obtained.

Secondary surgery to provide optimal results involves restoration of a simulated nipple and surrounding areolar complex on the reconstructed breast mound. Available techniques include skin grafts, flaps, tattooing, and occasionally, transplantation of tissues from the opposite breast.

Prophylactic mastectomy may also be necessary in circumstances in which the risk of cancer in the remaining breast is unacceptably high.

Miscellaneous Procedures

Frequently, additional surgical procedures may be required to achieve an optimal final reconstructive result. These may include excision of redundant tissue, repositioning of an implant, release of internal scar tissue, creation of an inframammary fold, scar revision, and other tissue arrangement.

The decision to have breast reconstruction following mastectomy should be made by an informed patient after examination by, and consultation with, a plastic surgeon.

The timing and choice of reconstructive procedures must be made by the plastic surgeon in conjunction with the patient and her general surgeon, oncologist, and family physician (when appropriate).