Most patients, when given a diagnosis of breast cancer, are referred to a plastic surgeon for a consultation, but with all the new & often unexpected facts running through your mind it's easy to get confused. I would like to begin by clarifying some terms.
Lumpectomy – only the cancerous portion of the breast is removed. If you have a lumpectomy you will have radiation after surgery. Once your breast has been radiated it makes future surgery more difficult. If you are considering a lumpectomy, I am always glad to tell you what kind of aesthetic result you will get from this procedure.
Mastectomy – In a mastectomy the entire breast is removed. Whether or not you need radiation depends on your tumor. Most patients do not need radiation. A nipple sparing mastectomy means the breast surgeon keeps the nipple & areola. Whether or not you are a candidate for this depends on your tumor & the amount of droop or ptosis your breast has. The decision on unilateral or bilateral mastectomies should be made between you and your breast surgeon. We can always make your remaining breast match the reconstructed side (yes insurance covers this).
Types of Reconstruction
Tissue expanders: These are a stiffer version of saline implants that can be put in at the time of a mastectomy or years later. They stretch the skin and muscle until we have the size we want & then they are exchanged for a permanent implant at a second surgery. This is the most common way to do breast reconstruction, and is the procedure of choice in nearly 100% of bilateral reconstructions.
Flaps: this means some of your own tissue is brought in from somewhere else on your body to reconstruct a breast. There are 3 different types
Free Flap: Tissue is totally removed from one area & transferred to the chest where the blood vessels are sewn to vessels on the chest wall. The surgery is lengthy, only certain doctors do it & the risks are higher.
TRAM Flap: In this operation a portion of your abdomen, along with a muscle to give the tissue blood supply, is tunneled under the abdomen into the chest. Not everyone has enough tissue here to make a breast, taking the muscle weakens the abdominal wall & the operation takes longer & isn’t always successful. I no longer do this for bilateral reconstructions as this weakens the abdomen too much.
Latissimus Flap: In this surgery skin and muscle from the back are passed under the arm & into the front part of the chest. You still need an implant with this surgery. If you need to have radiation it may be necessary to use this flap to bring in soft, pliable skin and to cover an implant. It is also useful to make a breast that is a little lower & more natural looking to match an opposite breast.
Which of these types of reconstruction is best for you is a decision made between you, your breast surgeon, & your plastic surgeon.