Breast Tissue expansion
An elastic “balloon” can be placed beneath the chest muscle(pectoralis muscle) either during the mastectomy procedure or at a later operation. When performed later it is usually done as an outpatient surgical procedure so that following recovery from the anesthetic the patient returns home the same day. The device has a valve that allows the surgeon to place saline(salt water) periodically and the muscle and overlying skin will expand just as the skin does in pregnancy as the fetus grows. The process requires a variable number of outpatient visits to achieve the desired amount of expansion. This may take several weeks or even several months depending on a variety of circumstances. Some of the available expanders can be left in place but the majority are replaced at a second outpatient operation by an implant designed to last longer. Patients should be aware that despite the manufacturers best efforts these man made devices are not fool proof and cannot “heal” like human tissue. In the rare event of expander failure it can be replaced at an outpatient procedure.
Risks associated with tissue expansion are similar to any operation and include bleeding, infection, and the risks associated with administration of anesthetic agents. On rare occasion the expansion may cause enough internal pressure to interfere with skin blood flow which could lead to skin loss. On rare occasion it is necessary to remove the expander due to infection or loss of overlying skin and muscle. The surgeon will explain these risks during the preoperative consultation.
Breast prostheses
Breast implants have been used for cosmetic purposes such as enlargement of small but otherwise normal breasts and for reconstruction of a breast following mastectomy. All implants currently available have a silicone outer shell. The implant may then be filled with saline(salt water) or with a silicone gel. Studies concerning the safety of silicone have been prompted by the Food and Drug Administration and are ongoing. At present the gel filled implants are available only to patients undergoing reconstruction and participating in approved studies. At the time of this writing the FDA is preparing to review the saline filled silicone implants as well. Studies currently in progress may answer the questions raised about the safety of silicone. Information available at the time of this writing would seem to indicate that silicone does not cause a significant increase in the risk of auto immune disease.
There are a number of possible undesirable consequences when any foreign material is implanted in the body. The body will form an internal scar around the foreign material whether it is a glass or wood sliver from an accident, or a deliberately placed silicone implant. If bacteria are carried in during implant insertion, or arrive later via the blood stream, an infection will occur and the body cannot eliminate the infection unless the implant is removed. Failure to recognize the infection could lead to the erosion of the weakest part of the wound with the implant working it’s way out through the resulting weakened area. All surgeons use standard antiseptic techniques and most use some antibiotic administration to decrease the risk of implant infection, but the risks cannot be reduced to zero.
The most common and troublesome problem involving implants is tightening of the scar the body makes around the implant. This is referred to as capsular contracture. A capsule (internal scar) forms around every implant. This capsule may remain soft and symmetrical which gives a soft and realistic breast mound, or it may tighten by varying degrees and this may result in a firm or even hard breast mound. If the implant tightens more on one side the implant can be displaced toward the shoulder or armpit. Some degree of capsular contraction occurs in 40% or more of the patients undergoing breast implant insertion. The majority of these patients are still satisfied with their breast reconstruction. In about 10% the degree of contraction is severe enough to produce discomfort or to displace the implant to a level that leads the patient to seek some type of surgical correction. These problems can occur with either saline or gel filled implants.
The implant comes in a variety of shapes and sizes but the number of choices available to the surgeon is finite and the size and shape of the remaining breast in mastectomy patients is infinite. Fortunately, even natural breasts are seldom perfectly symmetrical. Sometimes the plastic surgeon may recommend surgery on the normal breast to obtain better symmetry. It is impossible to match the mature drooping breast with an implant technique so a mastopexy is sometimes needed to provide a better match. Implant availability and surgeon preference may influence the implant choice so these matters should be discussed with the surgeon in detail.
Breast FLAP RECONSTRUCTION
It is often possible to reconstruct the breast using the patient’s own tissues. Common donor sites for this tissue are the back, lower abdomen, buttocks, or lateral hip region. These operations offer the advantage of not needing to insert a foreign body in many cases. Thus they may avoid some of the problems noted in the section on implant reconstruction. The trade off is that these operations are more extensive, generally require longer hospital stays, and are more expensive as well. They create a scar at the donor site as well.
Breast LATISSIMUS FLAP
The Latissimus dorsi muscle is a broad muscle that arises from the spinal column and the top of the hip and attaches to the arm in back just below the shoulder. It gets much of it’s blood supply from vessels in the arm pit. It is frequently used in reconstructive surgery because of it’s large size and it’s versatility. This muscle along with some overlying skin can be tunneled to the front of the chest and used to replace skin and breast tissue which is missing. Usually it is neccessary to use a small breast implant when using this muscle. In our practice patients usually go home at 48 to 72 hours following this procedure.
Breast TRAM FLAP
This acronym stands for transverse rectus abdominis myocutaneous flap. The rectus abdominus muscles are the paired flat muscles running from the rib cage down to the pubic bone. Arteries running inside the muscle provide branches at many levels and these branches supply the fat and skin across a large expanse of the abdomen. If we leave an ellipse of the fat and skin attached to the muscle over the lower abdomen(below the belly button) we can make a tunnel to the chest wall and use the skin and fat to replace breast skin and fat removed due to cancer. To do this we have to cut the muscle just above the pubic bone and this can lead to some weakness of the abdominal wall. Despite careful repair of the abdomen a small percentage of women undergoing this procedure may develop an abdominal hernia which would require surgical repair.
Breast FREE FLAPS
A team of plastic surgeons working together can reconstruct the breast using tissue from distant sites on the body. If there is an area of fat and skin supplied by a single artery and drained by a single vein that tissue can be transferred by attaching the artery and vein to vessels in the chest region. This technique is often referred to as microsurgery and the flap moved in the fashion is called a “free flap”. The TRAM flap discussed above can either be moved as describe previously, in which case it is called a pedicled flap, or it can be completely separated and using microsurgery can be placed in the chest as a free flap. Other common donor sites for breast reconstruction using the free flap technique are the buttock region and the laterl thigh region. This is a complex operation requiring an experienced team of surgeons, anethesiologists, and operating room nurses. It also requires special equipment and supplies. The hospital stay following this technique is longer than for the tissue expansion and breast prosthesis technique. In experienced hands this technique has a high success rate and provides a very satisfactory reconstruction in most cases. If there is adequate donor tissue one can avoid the problem of capsular contracture altogether with this approach.
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