Breast Cancer

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Breast Reconstruction

If you need surgery for breast cancer, you may be considering breast reconstruction.

Breast surgery, such as lumpectomy or mastectomy, for Seattle Cancer Care Alliance (SCCA) patients is performed by breast surgeons at University of Washington Medical Center (UWMC). Reconstructive surgery for our patients is performed by plastic surgeons at UWMC who work closely with our team of breast surgeons.

Keep in mind that some women choose not to have reconstructive surgery; of these, some decide to wear a breast prosthesis, or breast form. (The American Cancer Society has resources about breast prostheses.)

Here is some information about your reconstruction options.

Timing

The timing for breast reconstruction depends in part on the surgery you have to remove your tumor. It may also depend on other factors about your health or on the cancer treatment your doctor recommends having after your surgery.

  • If you are having a lumpectomy, your surgeon may be able to perform a procedure called donut mastopexy at the time of your lumpectomy. This procedure is described below.

  • If you are having a mastectomy, in some cases breast reconstruction can be done immediately afterward so that you wake up from surgery with a breast mound already in place. This is often possible for women whose cancer has been detected early.

    For other women, the medical team may advise delaying reconstruction. The women who may be advised to wait include women whose cancer is more advanced and will require additional treatment, such as radiation and chemotherapy, and women who have high blood pressure, who are obese, or who smoke. These issues can complicate breast reconstruction.

Procedures

These procedures, described below, are used in breast reconstruction:

Donut Mastopexy

The donut mastopexy is a type of lumpectomy. The procedure allows surgeons to remove an entire segment of the breast through an incision at the edge of the areola. The final scar circles the areola and is virtually hidden.

The term donut refers to the way the procedure is done. The surgeon makes a circular incision around the areola. Then the surgeon separates breast tissue from the overlying skin and the underlying chest muscles. The cancerous segment of breast tissue is removed, and the surgeon shifts the remaining healthy breast tissue on the chest wall to remold the breast underneath the skin. The ring of skin around the nipple is pulled together with a purse-string suture and tightened up like a drawstring, leaving a circular scar that is hidden around the nipple.

SCCA physicians have performed this new procedure on more than 40 women thus far, with cosmetically excellent results. The operation causes some degree of lifting of the breast, which some women find they like better than the appearance of their breast before surgery. If necessary, you can have a breast reduction on the other side to restore symmetry.

This surgery is considered a good alternative to a mastectomy or traditional lumpectomy for some women. Ask your surgeon if this procedure is right for you.

DIEP Flap

If you are considering breast reconstruction after a mastectomy, you may want to ask your surgeon about a reconstructive surgical procedure called the DIEP (deep inferior epigastric perforator) flap. In this procedure, the surgeon takes skin and fat from the abdomen to recreate a breast mound. (The surgeon does not take muscle from the abdomen, as in older procedures.) A nipple is reconstructed later, in a separate procedure.

Advantages of the DIEP Flap

Our surgeons prefer the DIEP flap to other types of tissue reconstruction of the breast. The reason is that only skin and fat are used to recreate the breast. The abdominal muscles are left intact. Although the surgery is more complex and takes more time than other types of breast reconstruction, the advantages include faster recovery and less pain after surgery, and long-lasting results because an implant is not used. With the older TRAM (transverse rectus abdominis muscle) flap surgery, which our surgeons no longer routinely perform, abdominal muscles were cut. As a result, many women experienced loss of strength in the abdomen and had abdominal hernias. Risk of a hernia after the DIEP flap surgery is 0.5 percent; risk after the TRAM flap surgery is 4 percent to 9 percent.

Disadvantages of the DIEP Flap

The DIEP flap is major surgery that involves a long and complex operation. It takes about five hours to reconstruct one breast and up to eight hours if you are having reconstruction on both breasts. Most women stay in the hospital for three to four days after surgery and need four to six weeks at home for full recovery. In addition, you will be left with permanent scars on your lower abdomen and around your belly button.

There is a small risk (less than 2 percent) of “flap loss” if a clot develops in the blood vessels in the tissue being used to reconstruct your breast. Also, hard lumps of fat may develop in the reconstructed breast that will need to be removed at the time the nipple is reconstructed.

You may also need an additional surgery to restore symmetry with your other breast. This surgery is usually done three months after your initial surgery.

The DIEP flap may not be suitable for women who are very overweight, who are heavy smokers, or who have had previous abdominal surgery.

This method of reconstruction is preferred for women who have had radiation therapy to the chest wall to treat their breast cancer.

SGAP and IGAP Flaps

Women who are not candidates for the DIEP procedure may have other tissue options. Tissue can be taken from the upper part of the buttock (SGAP, or superior gluteal artery perforator) or from the lower part of the buttock (IGAP, or inferior gluteal artery perforator) to reconstruct the breast.

The resulting scar is usually well hidden. In the upper buttock the scar is visible, but it doesn’t deform the contour of the buttock. In the lower buttock the scar is typically hidden in the buttock crease, between the buttock and the thigh.

The SGAP and IGAP flaps are more difficult technically, so they are generally used only in women without enough abdominal tissue for the DIEP flap. Hospital stay and recovery is similar to that following the DIEP flap.

TUG Flap

The TUG (transverse upper gracilis) flap is another alternative used for breast reconstruction in women without enough abdominal tissue for the DIEP flap. The TUG flap is taken from the top of the inner thigh. It includes skin, fat, and the gracilis muscle. This muscle brings the thighs together. However, it is the smallest muscle in a group of muscles that perform the same function, so removing the gracilis doesn’t affect thigh movement.

The scar is generally well hidden in the groin crease, which makes the upper thigh a good donor site. However, not all women have enough tissue in this area to reconstruct a breast. Hospital stay and recovery is similar to that following the DIEP flap.

Tissue Expander and Implant

A saline or silicone implant is another option after having a breast removed. To make room for an implant, most women need a temporary tissue expander placed first. The expander is a balloon-like implant that can be inflated with saline to expand the skin and muscle in the breast area.

The tissue expander can be put in place at the time of your mastectomy, or it can be placed weeks, months or even years later.

The tissue expander is placed behind the pectoralis major muscle. It has a valve that is used to gradually fill the expander with sterile saline during visits to the clinic over several weeks. Once the skin and muscle have stretched enough, the expander is removed and a permanent implant is inserted.

Patients have the option of having a saline implant or a silicone implant. Following a moratorium on the use of silicone implants in the 1990s, most women chose saline implants. However, more recently the fear of silicone has decreased, and most women now choose silicone. Your surgeon will discuss the differences and show you samples of each type of implant during your consultation.

Advantages of the Implant

The implant is placed during an outpatient surgery. The recovery time is relatively quick: Most women take off only one week from work. In addition, there are no donor-site scars (scars caused when surgeons take tissue from your abdomen to make a breast mound, such as with the DIEP flap). Your surgeon will follow your mastectomy scar so that no new scars are created.

Disadvantages of the Implant

The disadvantages of this procedure include the possibility of infection, leakage, and capsular contracture (hardening of the tissue around the implant). With any of these problems, the implant may need to be removed and replaced. Women who have had radiation therapy to the chest wall to treat their breast cancer generally are not good candidates for implant reconstruction. They are usually better candidates for tissue reconstruction (one the flap procedures described above).

Surgery for Lymphedema

In addition to performing breast reconstruction, plastic surgeons at UWMC now offer surgery to treat lymphedema in the arm. Read more.