Breast Reconstruction (cont.)
Allen Gabriel, MD, FACS
William C. Shiel Jr., MD, FACP, FACR
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
In this Article
When is breast reconstruction performed?
If the patient is a good candidate for “immediate” reconstruction, optimally, it should be performed concurrently with a skin-sparing or even a nipple-sparing mastectomy. Nipple-sparing mastectomy should be considered if the patient is a good oncological and reconstructive candidate. The breast and plastic surgeon team will determine the safety of a nipple-sparing mastectomy. Immediate reconstruction allows the surgeon to replace the breast tissue with an implant while the skin is still pliable and makes it possible to recreate the original natural shape of the breast. Nipple-sparing mastectomy can only be offered if an immediate reconstruction is planned.
What are the different types of breast reconstruction procedures that are available?
The two types of breast reconstruction are implant of a prosthetic device and the use of one's own tissue to reconstruct the breast (autologous reconstruction). According to The American Society of Plastic Surgeons statistics, 75% of women in the U.S. have prosthetic reconstruction and 25% have autologous reconstruction.
Implant reconstruction: This procedure replaces the patient's tissue with a saline or silicone implant. Depending on the patient's chest wall characteristics, the implant can be placed immediately at the time of the mastectomy. However, in a majority of patients, a temporary implant known as an “expander” will be placed into the pocket of empty space of the mastectomy breast. The expander's role is to keep the future pocket for the implant open as the skin heals from the mastectomy. Expansions will be performed to create a breast mound that is generally smaller than the final implant. Patients often find this process helpful as they can progressively decide what size of implant they may want to have. Some surgeons also utilize Botox to paralyze the pectoralis muscle, in order for the expansions to be more comfortable for the patient and overall have less pain. (Patients are responsible for the cost of the Botox as insurance carriers do not reimburse for the procedure since it is considered an off-label use of the product.) Once the patient is fully expanded, then the choice between three types of implants can be made. One choice includes saline implants which have a silicone shell on the surface with saline inside. The second choice includes round silicone implants which have the same external shell except for they are filled with “cohesive silicone” on the inside. The third choice includes the next generation of silicone implants (5th generation), known as the “highly cohesive silicone” implants or as the “gummy bear” implants. The highly cohesive nature of the gel makes the implant more stable giving it a more anatomical look.
Autologous reconstruction: This group of procedures includes procedures where one's own tissue is used. The options of tissue that can be used include tissue from the following areas: abdomen (TRAM vs. DIEP vs. SIEA), back (Latissimus), upper (SGAP) or lower buttock (IGAP), and inside of the thighs (TUG). Another type of reconstruction that has been recently utilized is a series of procedures that utilize the patient's own processed fat to create a breast. This procedure is termed “fat injection” and is sometimes used in a combination with implant-based or autologous reconstruction.