Our breast reconstruction program focuses on the a return back to wellness through an integrative approach via plastic surgical procedures for reconstruction as well as functional medicine fundamentals.
At Ong Institute for Plastic Surgery & Health, our goal is to listen, understand where you are and to suggest options and educate you on the various procedures, recovery and provide you a stable process to begin again.
Our program is divided into three fundamental steps:
- Reconstruct: As an expert in breast cancer reconstructive surgery, Dr. Ong works closely with your other treatment specialists. This yields a collaborative treatment protocol to obtain the best aesthetic outcome without compromising any cancer treatments.
- Rejuvenate: Part of a woman’s journey through breast cancer goes beyond the “reconstruct” phase. It includes the focus on optimizing health, bringing back feminity, and the feeling of being “whole” again. This may include rejuvenation of the physical and mental aspect of one’s self.
- Regenerate: We encourage the use of our bodies own natural healing potential. The use of Platelet-Rich Plasma in tissue regeneration, food as medicine, science based supplements, and stress reduction strategies are some examples of tools we use to guide you back to health.
All aspects are intertwined and work together to fulfill the goal of creating a person who is in a better state of health than she was when she first started the breast cancer journey.
Do I need reconstruction after mastectomy or lumpectomy?
Reconstruction after a mastectomy is a choice that women have. Some women choose to have reconstruction, some do not. It is important to understand what a reconstruction entails so you can make the best decision for yourself. It is best that you seek a consultation with an experienced board-certified plastic surgery surgeon regarding your reconstructive options before you make that final decision.
Many women nowadays choose to have reconstruction after mastectomy to replace the shape and form of their chest area, to bring back self -confidence, a sense of being “whole” again and feminity. The Women’s Health and Cancer Rights Act, or WHCRA, is a federal law that was passed in 1998 in order to provide certain protections and coverage to patients who choose to have breast reconstruction surgery following a mastectomy.
There are reasons to consult with a plastic surgeon:
- They can help plan your mastectomy and reconstruction. Planning the surgery with your breast surgeon is helpful to allow for superior aesthetic outcomes. Procedures than can be planned include the designing of incisions and skin reduction patterns if necessary to optimally shape the breast and improve the final outcomes of the reconstruction.
- If a partial mastectomy or lumpectomy is planned, a plastic surgeon can also help “lift” or reduce the breast with tissue rearrangement to help shape the breast prior to radiation therapy.
How many surgeries do I need for reconstruction?
Anywhere from one to three typically. Breast reconstruction is considered a process of rebuilding the missing pieces and each stage is a continuum of the previous. Typically:
- A tissue expander is placed at the time of the mastectomy.
- Implant placement and any adjunct treatments such as fat grafting and tweaks are done at a second surgery.
- Nipple reconstructive surgery is done at a third surgery.
However sometimes there are fewer surgeries that need to be done based on the needs of the patient. For e.g. if an implant is placed instead of a tissue expander at the first surgery or the nipple is saved as a nipple-sparing mastectomy. On average, two surgeries are required.
The most common reasons for revision are the patient’s desire for improvement in aesthetic outcomes, a size change or additional adjunctive treatment such as fat grafting to improve the thickness of the mastectomy flaps after reconstruction to improve the contour of the skin.
Today the bar has been set to a very high standard in terms of outcomes for breast reconstruction after mastectomy. Patients have high expectations for the outcomes of this surgery. Fortunately many can be met with the improved technologies and surgical techniques we have today. Breast reconstruction has come a long way since the 1970s and the results today are proof of that.
What is the healing time for breast reconstructive surgery?
The short answer is 4-6 weeks depending on the type of reconstruction that is performed. Patients heal differently but typically the recovery for the first stage of reconstruction is about 4-6 weeks. There will be a period of reduced activity.
There are certain things that can be used to reduce postoperative discomfort including:
- The use of neurotoxins e.g. Botox® to “weaken” the chest muscles for reducing pain and allowing for less painful postoperative tissue expansion.
- The use of long-acting local anesthetics at the time of surgery to reducing the need for postoperative pain medications (Exparel®).
- Use of a multi-modality postoperative pain regimen.
Typically patients stay overnight in the hospital for mastectomy and reconstruction and are discharged home the next day. The expansion process takes several weeks. Typically, expansion is perform as a quick office visit depending on the patient’s desire for the final volume and the anatomical factors that affect the size of the final implant. This process can take anywhere from 4 to 12 weeks.
The purpose of expansion is to create a footprint and shape for the final implant. A postoperative plan as to the various restrictions are given to each patient prior to surgery.
How does radiation and chemotherapy affect my reconstruction?
Chemotherapy is a systemic treatment where drugs are administered into your body to reduce the spread of disease. The purpose is to “kill”any cancer cells that may have escaped out of the breast or lymph nodes. Chemotherapy drugs affects cell replication which directly translates to poor wound healing in terms of healing from surgery. Some of the effects of breast cancer chemotherapy include diarrhea and hair loss. This is due to the effects of the normal cells unable to regenerate or replicate. Any surgery around the time of chemotherapy is subject to issues for wound healing. Due to this , it is best that surgery is performed about 4-6 weeks after the completion of chemotherapy. If chemotherapy is given after surgery, sufficient time is given for the incisions to heal properly before chemotherapy is started.
Radiation is given as a form of direct or local control meaning preventing the cancer from recurring (coming back) at the site. Radiation is given directly to the breast area or the lymph node area and it affects breast reconstruction because it causes a medical condition called fibrosis. What that means is scar formation and destruction of blood vessels in the area. It is sometimes difficult to reconstruct a radiated area since the pliability of the tissues are reduced, and the reduction in blood vessels in the area result in a higher risk of infection and wound healing problems.
Besides radiating the entire chest area (whole breast radiation), some patients who undergo partial mastectomy/lumpectomy are candidates for partial breast radiation where only a portion of the chest area is radiated. The treatment is usually shorter and the radiation effects on the reconstruction are reduced.
In my practice, I prefer to complete the reconstruction prior to the radiation treatment being given, if possible. This is done by closely communicating with your breast surgeon, medical oncologist and radiation oncologist to ensure that breast cancer care is not compromised. Once the reconstruction is completed, the patient goes on to radiation therapy. After radiation treatment, adjunct procedures can be performed to improve the condition of the skin such as fat grafting or platelet-rich plasma treatment. The radiated side may appear stiffer, and the medical condition called capsular contracture may occur. Scar forms around implant, which can cause hardening of the implant or pain. However, not all patients have the full spectrum of the radiation effects and many patients have good outcomes. Sometimes, autologous or tissue-based reconstruction using muscle or fat and skin from another area of the body is required in order to complete the reconstruction. Examples of these are the latissimus flap, DIEP or TRAM flap.
What type of reconstruction will I have?
The most common type of reconstruction done today the United States is implant-based reconstruction i.e using a breast implant to shape your breasts. The safety and performance of breast implants have improved over the last several years. They have superior ability to create a great breast shape- the new cohesive gel implants that are anatomically shaped provide the footprint to create the optimal breast shape for patients. The risks of implant wrinkling and rippling has also been reduced with these new cohesive implants and the risk of rupture is very low.
Other options for breast reconstruction include autologous reconstruction in which tissue from another part of the person’s body part is used to create a breast. Examples include the abdominal (DIEP, SIEP, TRAM), buttock (SGAP, IGAP) flaps.
There are upsides and downsides for each type of reconstruction. It is best to discuss the expectations of each with a surgeon experienced in breast reconstruction.
Will I have a tissue expander or implant?
The decision to place a tissue expander or an implant at the time of mastectomy depends on many factors. The ultimate goal is to produce a good breast shape and to have the surgery performed in the safest manner for you. Many times we need to place a tissue expander in order to help shape the breast and create a footprint so that your final reconstruction will achieve the highest aesthetic goals that most patients have. Sometimes we can place an implant at the time of the mastectomy. This is called immediate reconstruction with direct implant placement. There are certain criteria that we look at in order to allow us to safely perform the procedure.
Firstly, you have to be healthy and have good blood supply to the skin. During a mastectomy, the blood vessels to the skin are removed as part of the breast tissue removal. Due to this, we have to ensure there is enough blood supply to the skin to allow for healing if we were to place an implant. Other things to consider are the degree of ptosis (droopiness) of your breast and your overall health.
If a nipple or areolar sparing mastectomy is performed, often we can place an implant at the time of the mastectomy and have a good cosmetic outcome. There are benefits of performing an implant directly:
- It allows one to proceed with the treatment plan of chemotherapy or radiation quickly.
- There is less discomfort as we can avoid the tissue expanding process which at times can be quite uncomfortable and time-consuming for the patient.
However, sometimes a tissue expander reconstruction can give better aesthetic outcomes as we are able to shape the breast the way we want using the expander as a tool.
I always tell my patients that even though we were to proceed with direct implant-based reconstruction at the time of the mastectomy, many times they will be adjunctive treatments performed during the second surgery in order to help improve the aesthetic outcomes. Commonly fat grafting is used.
However, while there are benefits to direct implant reconstruction, there will also be risks. The largest risks are related to perfusion or blood supply to the skin . This can result in skin loss which can be a larger problem to deal with.
The options are there. It relies on your aesthetic goals, and your medical condition. Ultimately it should be the option that the surgeon performing the procedure determines what is the safest for you.
Breast reconstruction: What can I do to heal well?
Optimal wound healing after a mastectomy and reconstruction depend on adequate blood supply as well as optimizing the factors for wound healing. Having adequate nutrition in terms of protein, minerals and vitamins necessary for the wound healing process is crucial.
At Ong Institute for Plastic Surgery and Health, we implement a few things to help our patients heal better:
- All patients are encouraged to optimize their current state of nutrition, and to quit smoking.
- Preoperative education, nutrient testing and nutrient support in the form of intravenous and oral supplementation to help with surgical healing are offered.
- The use of intra-operative imaging techniques to assess blood supply is performed at the time of surgery performed to determine if is adequate blood flow to the area for reconstruction and healing.
- Adjunctive treatments such as platelet-rich plasma to enhance wound healing.
- Use of a negative pressure wound management systems (Prevena®) postoperatively if necessary. A negative pressure dressing reduces swelling, enhances healing and keeps the area protected for up to a week.
What is the “latest” in breast reconstruction?
Breast reconstruction has come a long way since the first reconstruction was performed in the 1970’s. Implants and tissue expanders are better engineered to create better shape. We now have improved tools such as imaging technology that allow us to evaluate the blood supply of the skin during surgery to reduce wound healing complications. Improved pain control with the advent of long acting numbing medications allow for improved pain control postoperatively. Also, microsurgical techniques have allowed us to reconstruct the breast without sacrificing a functioning muscle as in the case of perforator flaps. Perforator flaps are reconstructive surgery performed using skin and fat without the need of a muscle. This reduces the morbidity of the donor site. Common examples for breast reconstruction include the DIEP or SIEP flap.
The use of fat grafting as autologous stem cells, and human acellular dermal matrix have also allowed us to “engineer” the breasts using human allografts for regeneration. The use of platelet-rich plasma and other human allografts is also showing great promise.
One of the newer techniques of reconstruction is the “pre-pectoral” breast reconstruction. This is reconstruction performed where the implant is placed above the chest muscle instead of under the muscle. I have performed this procedure on appropriate candidates. The main benefit of this technique, is the minimal amount of postoperative pain experienced by the patient. Most do not need more than a day of oral pain medication. The muscle “animation-deformity” is eliminated. The major disadvantage of the procedure is the lack of tissue “coverage”. Since there is no muscle coverage in front of the implant, there is more visible implant wrinkling.
Other advancing technologies in the horizon include the CO2 expanders such as the AeroForm® expander where the patient controls the expansion process through the use of the wireless dose controller at home.
Does Dr. Ong take my insurance plan?
Insurance plans can be very complex, confusing and stressful. We try to make the financial aspects of breast reconstruction as simple and straight-forward as possible for you.
Our focus is on our patients and their outcomes. Therefore, we are not contracted with a majority of insurance carriers. Through our concierge medical billing program, we do not balance bill you for your “out-of-network” benefits. A predetermined cost expectation is presented prior to surgery. This is often times less costly than a contracted provider. We want to make this process as stress-free as possible for you. Details of the program can be made available to you during the consultation visit.