Breast Reconstruction Scottsdale & Phoenix, AZ

Breast reconstruction after a mastectomy is a choice that women have. Some women choose to have breast reconstruction, some do not. It is important to understand what a breast 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 breast 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 femininity. 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:

1. They can help plan your mastectomy and breast reconstruction. Planning the surgery with your breast surgeon is helpful to allow for superior aesthetic outcomes. Procedures that 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 breast reconstruction.
2. 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.

The short answer is 4-6 weeks depending on the type of breast reconstruction that is performed. Patients heal differently, but typically the recovery for the first stage of breast 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:

1. The use of neurotoxins e.g. Botox® to “weaken” the chest muscles for reducing pain and allowing for less painful postoperative tissue expansion.
2. The use of long-acting local anesthetics at the time of surgery to reducing the need for postoperative pain medications (Exparel®).
3. Use of a multi-modality postoperative pain regimen.

Typically patients stay overnight in the hospital for mastectomy and breast reconstruction and are discharged home the next day. The expansion process takes several weeks. Typically, expansion is performed 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 the expansion is to create a footprint and shape for the final implant. A postoperative plan as to the various restrictions is given to each patient prior to surgery.

• • Chemotherapy is a systemic treatment where drugs are administered 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 affect 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 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 breast 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 the 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.

• The most common type of breast reconstruction done today the United States is implant-based breast 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 have 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 breast reconstruction. It is best to discuss the expectations of each with a surgeon experienced in breast reconstruction.

• • 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 breast 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 a 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:

1. It allows one to proceed with the treatment plan of chemotherapy or radiation quickly.
2. 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 breast 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 breast 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.

• Optimal wound healing after a mastectomy and breast 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:

1. All patients are encouraged to optimize their current state of nutrition and to quit smoking.
2. Preoperative education, nutrient testing and nutrient support in the form of intravenous and oral supplementation to help with surgical healing are offered.
3. 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.
4. Adjunctive treatments such as platelet-rich plasma to enhance wound healing.
5. 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.

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 a better shape.
• Improved pain control with the advent of long-acting numbing medications allows for improved pain control postoperatively.
• 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 has 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.
• We now have improved tools such as SPY Elite imaging technology that allows us to evaluate the blood supply of the skin during surgery to reduce wound healing complications.  Poor tissue circulation, for example, can result in serious healing problems, additional surgery, or even the loss of the newly created breast.  SPY Elite provides us with clinically relevant, real-time images of microvascular blood flow that may assist in critical decision making during surgery.

One of the newer techniques of breast 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 on 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.

• 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 href=”https://www.onginstitute.com/resources/insurance-financing/”>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.