Presented by: Gordon Lee, MD
Assistant Professor, Plastic and Reconstructive Surgery
Stanford University Medical Center
July 24, 2013
Plastic surgery in one form or another has been around for hundreds of years. Although most people today think primarily of cosmetic procedures, the fundamental premise is to reconstruct or repair parts of the body. The “plastic” comes from the Greek, plastikos, which means “to mold or to shape.”
For the one in eight American women dealing with the aftereffects of breast cancer treatment, such as a mastectomy or lumpectomy, reconstructive surgery can restore their body’s natural shape and form, and provide life-enhancing psychological benefits, such as improved self-esteem and confidence. Breast reconstruction can be done at the same time as the cancer surgery or it can be done as a delayed procedure.
“The goal of any reconstructive surgery is to restore symmetry and balance,” said Gordon Lee, MD, an assistant professor of plastic and reconstructive surgery and director of Stanford’s microsurgery program, at a presentation sponsored by the Stanford Hospital Health Library. “It’s a personal choice. It’s not about chronological age, but about physiologic age, as long as the woman is in relatively good health.”
The most common breast reconstruction option is implants, and in fact almost two-thirds of all women choose some form of implant at some point after breast cancer surgery, he said.
“Implants are considered a safe procedure for both cosmetic and reconstructive surgery,” he added. “They require only a brief surgery and can be done at the same time as the mastectomy or can be done later. Recovery is relatively rapid, and the result can be quite good.”
Breast implants are made of either silicone gel or saline. Saline implants are filled with sterile salt water, while silicone implants are filled with a thick Jell-O-like fluid. Most women feel that silicone breast implants look and feel more like natural breast tissue, said Dr. Lee, and about 95 percent of his patients chose silicone over saline.
The implants first require tissue expansion, a process that stretches the chest skin and soft tissues to make room for the breast implant. The process takes place gradually, typically over several months, as the cavity is stretched in stages. Once the implant is in place, surgeons can construct and tattoo a nipple as an outpatient procedure.
There are some complications to implants, including the possibility of infection, asymmetry, ripples, hardness, and the need for revisional surgery later on. Implants can also rupture. If a saline breast implant ruptures, the implant will deflate, causing the breast to decrease in size and shape. The saline is absorbed by your body, with no health risks. If a silicone breast implant ruptures, it is often not noticed since the silicone tends to remain trapped in place. Women with a silicone implant need to get an MRI every three years to ensure it remains intact.
Using Your Own Tissue
Women can also use tissue transplanted from another part of the body, a process called autologous reconstruction. A flap of tissue is detached, usually from the abdomen, thighs, or butt, and moved to the chest, where it is formed into the shape of a breast. Using specialized surgery techniques such as microsurgery, the tissue is stitched into place along with its blood vessels and subcutaneous fat.
Breast reconstruction using transplanted tissue usually lasts a lifetime and looks natural. However, the procedure can be lengthy and requires a longer recovery time, and not every woman is a good candidate, Dr. Lee said.
The most common approach is the TRAM flap, which transfers tissue, vessels, and sometimes some muscle from the transverse rectus abdominis, a muscle in the lower abdomen. Surgeons can either cut the tissue and reconnect it (a free TRAM flap) or move it up under the skin (a pedicle TRAM flap).
“A TRAM flap is great for some women because they get a tummy tuck along with the breast reconstruction,” said Dr. Lee, “sort of like a two-for-one surgery.”
In another technique called a DIEP flap, fat, skin, and blood vessels—but no muscle—are cut from the lower belly and moved up to rebuild the breast. Because the DIEP flap requires highly specialized training and expertise in microsurgery, not all surgeons can do the procedure and it’s not available at all hospitals.
Another variation is called a SIEA flap, named for the superficial inferior epigastric artery, a blood vessel that runs just under your skin in the lower abdomen. This approach works in only a small number of patients, said Dr. Lee.
For women who do not have sufficient abdominal fat, flaps can also be taken from the thighs, hips, or butt, although these options are much less common. Stanford is one of only a few comprehensive medical centers on the West Coast to offer the full range of procedures for patients to choose from.
Using Your Own Tissue With an Implant
Another tissue transplant option uses the latissimus dorsi muscle, which is located in the upper back. An oval flap of skin, fat, muscle, and blood vessels is moved under the skin around to the chest to rebuild the breast. The blood vessels remain attached to their original blood supply in the back. The transplanted skin can then be stretched to accommodate an implant.
Because there’s usually not much fat on this part of the back, a latissimus dorsi flap is a good option for women who have had radiation, since radiated skin does not stretch. The procedure leaves a scar, but most surgeons try to place the incision so that it’s covered by a bra strap or leave a scar within the natural lines of the skin.
Research has shown that the more a surgeon performs a procedure, the better the results, said Dr. Lee, so be sure to ask your doctor how many reconstructions he or she has done. Be sure your surgeon is Board Certified by the American Board of Plastic Surgery and ask about areas of expertise and specialized training in microsurgery.
Women considering breast reconstruction should be aware of the possible risks associated with surgery, advised Dr. Lee. Complications range from infection to clot development, flap necrosis (where the transplanted skin dies), seroma (a fluid-filled mass), or ripples under the skin. Recovery times vary, and women who smoke, are diabetic, or are greatly over- or underweight are not good candidates for surgery.
Some women prefer to have breast reconstruction immediately, which has less scarring and often shows better results, but can delay follow-up chemotherapy or radiation therapy if complications occur. Others choose to delay reconstruction. Since every woman is different, only an individualized consultation with an experienced plastic surgeon can help you decide which option is best for you.
For women who do not want to undergo additional surgery, an external prosthesis or foam bra can be used for a natural appearance. Available in many colors, sizes, and shapes, these prostheses can be made of silicone, foam rubber, fiberfill, or cotton.
About the Speaker:
Gordon Lee, MD, is an assistant professor, associate chief of clinical affairs in plastic and reconstructive surgery, and director of Stanford’s microsurgery program. He is nationally recognized for his contributions to surgical education and training in plastic surgery, and conducts ongoing research in surgical outcomes of breast reconstruction. Dr. Lee received his medical degree from Stanford and did his internship and residency at UCLA, followed by a fellowship at MD Anderson Cancer Center in Texas. He is Board Certified in Plastic Surgery by the American Board of Plastic Surgery.
Plastic and Reconstructive Surgery
Breast Cancer Surgery
Division of Plastic and Reconstructive Surgery