Breast Reconstruction

This guide serves as a short overview on several aspects of breast reconstruction, including partial breast reconstruction after lumpectomy/partial mastectomy. As a health practitioner, Dr. Tavin believes it's important for medical diagnosis and treatment of any type of cancer to be the primary focus. Therefore, he will always support the recommendations of the cancer doctors even if they might diminish the results of the reconstruction.

Most reconstruction we perform are done at the time of the mastectomy. The mastectomy incision is designed for the breast surgeon and is usually assisted by the cosmetic surgeon in the mastectomy surgery. During this procedure, close attention is paid to the preservation of the fold under the breast and restoration of the outer border of the breast to improve the shape of the reconstruction.

We perform three types of breast reconstructions:

• temporary tissue expander to be replaced by breast implant
• back muscle (latissimus dorsi flap) plus tissue expander
• abdominal muscle (transverse rectus abdominis muscle or TRAM flap)

All patients are offered the option of nipple and areola reconstruction, but not everyone chooses to have it done.  Each woman’s decision is her personal choice.

Temporary Tissue Expander

Expander/implant reconstruction is the most common type performed in the US. Most of our patients spend one night in the hospital and can return to work within two weeks. Prescribed muscle relaxants in addition to pain medication are given as the stretching of the overlying pectoralis major muscle by the expander is the chief cause of discomfort.

For women who have a one-sided mastectomy, we typically do a lift on the other side to improve the symmetry at the time of expander replacement. For those who are having both breasts reconstructed, expanders followed by implants provide the best symmetry and give the woman the option to choose her breast size.

Pre-Pectoral Breast Reconstruction

Since the late 1980s plastic surgeons have been placing tissue expanders and breast implants below the pectoralis major muscle to avoid capsular contractures (hard scars) that had been noted to form when implants were placed underneath the skin and fat after mastectomies.  A downside of the standard sub-pectoral breast reconstruction is the abnormal motion of the whole breast when the arms are moved (termed animation deformity). How noticeable this is varies from person to person.

Around 2014 a number of plastic surgeons began creating a pocket formed from acellular dermal matrix (cadaver skin from which the donor’s cell have been extracted) above the pectoralis muscle (pre-pectoral) that had the benefit of minimizing development of capsular contracture while avoiding animation deformities.  Additional benefits of pre-pectoral reconstruction include the ability to place the implants closer to the breast bone than in sub-pectoral reconstruction and a shorter time period to fill tissue expanders.

Pre-pectoral reconstruction can be performed at the time of the mastectomy or at a later date if issues arise with a sub-pectoral reconstruction.  Dr. Tavin was the first surgeon at Plastic Surgery Group of Memphis to perform pre-pectoral breast reconstruction.

Back Muscle Plus Tissue Expander

The back muscle with expander/implant is a technique to help avoid a hard scar from forming in women who have previously had radiation to the breast in conjunction with a lumpectomy/partial mastectomy or will need radiation following the mastectomy.

If post-operative radiation will be necessary, reconstruction is deferred until 6-12 months after the radiation. This combination technique can also create a larger breast than an implant or muscle flap alone. Women usually spend one night in the hospital can return to work in 2-3 weeks.

Abdominal Muscle

The TRAM flap allows creation of a reconstructed breast that can match the natural ptosis or droopiness of the remaining breast. This operation is not a good option to reconstruct two breasts as it eliminates the ability to sit up normally forever. Although I have had many women refer to the TRAM flap as the tummy tuck operation, the appearance of the abdomen after a TRAM flap does not look as good as that after a real tummy tuck.

Women spend about 3 days in the hospital and may need a several weeks to months to return to work.

Partial Breast Reconstruction

Most women undergoing lumpectomy/partial mastectomy do not need reconstruction, but some women have so much tissue removed that they would benefit from surgery to restore shape and symmetry.

This might range from rearranging the remaining breast tissue, reducing the opposite breast, transferring fat to the operated breast, or using the back muscle without an implant. Unfortunately whereas reconstruction after complete mastectomy is mandated by Federal Law, partial breast reconstruction may or may not be covered by the woman’s insurance company. We will always make efforts to obtain coverage in such cases.

Before and After Photos

Tissue Expander/Implant

50-year-old woman who had a left partial mastectomy for LCIS, then one year later had findings of atypical ductal hyperplasia. For risk reduction, she opted to have bilateral mastectomies and immediate tissue expander reconstruction. Her tissue expanders were then replaced with 800cc High Profile Gel implants. She later had nipple reconstruction, tattooing, and had to have one touch-up tattoo on the right breast Photos taken 1 year after implant replacement.

*Results may vary and are not guaranteed*

38 year olds. 5'7" 160 lbs. Diagnosed with ductal carcinoma insitu of her right breast. She underwent immediate tissue expander reconstruction. The expanders were replaced with 800cc high profile silicone gel implants, and a left reduction mammoplasty was done for symmetry. Nipple reconstruction and tattooing were also performed.

*Results may vary and are not guaranteed*

41-year-old woman 5'4" 112 lbs. Previously had subglandular augment. After finding cancer in her right breast decided to undergo bilateral mastectomies with immediate tissue expander reconstruction. The expanders were replaced with 350cc high profile gel implants. Nipple reconstruction and tattooing was performed along with multiple fat transfers to bilateral breasts to correct rippling and shape.

*Results may vary and are not guaranteed*

29-year-old woman. 5'8" 153 lbs. Underwent bilateral mastectomies with immediate tissue expander reconstruction. She had previously had a left partial mastectomy and chemotherapy. The expanders were replaced with 425cc high profile silicone gel implants. Nipple reconstruction and tattooing was performed along with fat transfer to the left breast.

*Results may vary and are not guaranteed*

50-year-old woman underwent bilateral mastectomies with immediate tissue expander reconstruction. The expanders were replaced with 475cc high profile silicone gel implants. Nipple reconstruction and tattooing were also performed.

*Results may vary and are not guaranteed*

38-Year-old woman underwent bilateral mastectomies with immediate tissue expander reconstruction with the "Wise" pattern. Pre-operatively the patient was a DD-cup, and wished to be smaller. Had to debride her left breast, and replace her left tissue expander 1 month after initial placement due to break down of skin and an infected implant. Went on to do fine, and the tissue expanders were replaced with 650cc high profile silicone gel implants. Her right implant was exchanged 3 weeks later due to a seroma. Nipple reconstruction and tattooing were also performed without complications.

*Results may vary and are not guaranteed*

53-year-old woman underwent bilateral nipple-sparing mastectomies with immediate tissue expander reconstruction. The expanders were replaced with 550cc high profile silicone gel implants. She had thickening of the left mastectomy scar, which was treated with a few steroid injections.

*Results may vary and are not guaranteed*

PRE-PECTORAL BREAST RECONSTRUCTION

70 year old woman.  5’3” 165 lbs.  Underwent left mastectomy for DCIS with microinvasion.  She opted for immediate reconstruction with tissue expander placed underneath her muscle.  Patient then had a significant animation deformity (movement of implant when left arm is used), which also caused her pain.  When replacing tissue expander, her implant was converted to prepectoral (above the muscle).  A 590cc ultra high profile gel implant was placed.  SPY was used to confirm vascularity.  Right mastopexy was done at the same time for symmetry.  It was later offered to revise left breast for better contour, and reconstruct a nipple, but patient is happy at this time.  Photos taken 7 months postoperative.

Before:

After:

LATISSIMUS FLAP

55-year-old woman that had a right partial mastectomy and radiation for DCIS. 6 months later, a new area of cancer was discovered, at which time she had a complete right mastectomy. She underwent a right latissimus dorsi flap, and tissue expander reconstruction. The tissue expander was replaced with an 800cc high profile gel implant, and a 1,113 gram reduction was performed on her left breast for symmetry. She then chose to have nipple reconstruction, and tattooing. Photos taken 3 months after tattooing.

*Results may vary and are not guaranteed*

71-year-old woman. 5'4: 136 lbs. Had recurrent right breast cancer after previous partial mastectomy and radiation. She elected to undergo bilateral mastectomies. She was reconstructed with latissimus dorsi flap on her right breast and tissue expander on the left. Patient did not desire nipple/areola reconstruction.

*Results may vary and are not guaranteed*

45-year-old woman. 5'5" 150lbs. Prior history of right partial mastectomy and radiation. She then presented with a new suspicious area in right breast and patient elected to have bilateral mastectomies. Right breast reconstructed with latissimus flap and tissue expander, left breast with tissue expander. Tissue expanders were then replaced with silicone breast implants. Reconstruction was completed by creating artificial nipples and areola tattooing.

*Results may vary and are not guaranteed*

52 year old woman.  5'4", 145 lbs.  2 children.  D-cup breasts with previous cosmetic submuscular augment.  Prior history of right partial mastectomy and radiation.  Now has DCIS of left breast, and opted to have bilateral mastectomies.  She was reconstructed with a right latissimus flap and tissue expander, and tissue expander and acellular dermis on the left.  The tissue expanders were then replaced with silicone breast implants.  She had 2 separate procedures to perform fat grafting to the upper pole of her breasts for symmetry, and completed the reconstruction by creating artificial nipples and areola tattooing.

*Results may vary and are not guaranteed*

35 years old. 5'2", 120 lbs.  2 children.  Patient discovered a lump in her right breast when she was 12 weeks postpartum.  She had preoperative chemotherapy, followed by bilateral mastectomies and radiation to her right breast.  6 months following her radiation she was reconstructed with a right latissimus flap and tissue expander, and a tissue expander and acellular dermis on the left.  The tissue expanders were then replaced with a 350cc high profile gel implant on the right, and a 430cc ultra high profile gel implant on the left.  She underwent 1 revision surgery to adjust her right inframammary fold for symmetry.  She is not interested in nipple/areola reconstruction at this time.  Photos taken 6 months after last procedure.

*Results may vary and are not guaranteed*

52-year-old-woman.  5'1" 140 lbs.  Originally diagnosed with right breast cancer, and was treated with right partial mastectomy and radiation.  2 years later she was diagnosed with the BRCA gene, and opted for bilateral prophylactic nipple sparing mastectomies.  Right breast was reconstructed with latissimus flap and tissue expander, left breast with tissue expanders.  At the time of her implant exchange fat grafting was also done to make her breasts more symmetric.  NOTE:  The right breast has continued to shrink, due to previous radiation.  She may need further revisions in the future, but the patient is happy at this time.

*Results may vary and are not guaranteed*

TRAM FLAP

41-year-old woman, 5'10" 230 lbs. Previously underwent a partial mastectomy and radiation. She was reconstructed with a TRAM flap, and had a delay procedure to improve blood supply. These are intermediate photos 4 months postoperative, and before scheduled breast lift.

*Results may vary and are not guaranteed*

PARTIAL RECONSTRUCTION

57-year-old woman that underwent a left partial mastectomy after being diagnosed with infiltrating ductal carcinoma. She was reconstructed with a latissimus dorsi muscle flap. The scar on her back was designed to be covered by her bra. Photos were 7 months postoperative, and 3 months following her last radiation treatment.

*Results may vary and are not guaranteed*

43-year-old woman. 5'6" 171 lbs. Underwent right lower-inner quadrant and nipple-aerola removal for breast cancer. Reconstruction performed by rotating remaining breast tissue. Patient subsequently underwent radiation therapy. Once the patient was ready, a left reduction for symmetry was performed. Patient is considering right nipple/areola reconstruction.

*Results may vary and are not guaranteed*

62-year-old woman. 5'5" 180 lbs. Underwent a partial mastectomy and radiation for breast cancer. After a subsequent biopsy she developed a non-healing wound, and displacement of her nipple/aerola complex. Reconstruction performed with a latissimus dorsi flap and right breast lift for symmetry.

*Results may vary and are not guaranteed*

52-year-old woman 8 years status post right partial mastectomy and radiation therapy. She had a new mass in her breast that had to be removed, and she desired reconstruction. She would not allow her back muscle to be used. She underwent 2 local flaps using skin and far below her breast to begin replacing volume and lost skin. She later underwent 5 fat transfer procedures that restored symmetry with the opposite side while maintaining softness of the breast.

*Results may vary and are not guaranteed*

50 year old woman. 5'1" 136 lbs. Ductal carcinoma insitu upper pole of her right breast. Reconstructed with medial pedicle reduction technique to fill the partial mastectomy defect. Mirror image reduction was performed on the left side for symmetry. 250 grams removed per breast. Photos taken 7 months postoperative.

*Results may vary and are not guaranteed*