BREAST RECONSTRUCTION NEW JERSEY

Breast Reconstruction After Mastectomy

The diagnosis of breast cancer causes a tremendous amount of fear and anxiety. After various tests, scans, MRIs, biopsies, partial mastectomies, and consultations with the surgical and medical oncologist, the patient is totally exhausted and psychologically drained. The thought of losing a breast is added to all the fears and concerns of the patient. I really feel all these anxieties and fears when I first see the patients in my office. Luckily what I have to tell a patient is something positive. We talk about rebuilding what is going to be taken away. This message helps the patient cope with all that lies ahead. I hold the patient by the hand and go through this journey with them. They require a lot of tender love and care. In fact, I am the last person they see when all the treatments are done. That is when we put the final touch on their reconstructive process. At that point, they have completed all their treatments and are looking as good as they looked before the mastectomy and sometimes even better.

The reconstruction is normally done immediately after the mastectomy for breast cancer, but in rare cases it is deferred to a later date. Most of the time, the reconstruction involves two stages. The first stage is to create the breast mound; the second is to complete the symmetrization and the nipple reconstruction.

There are many advantages to the immediate reconstruction. The most obvious is that when the patient wakes up from anesthesia, the breast is not missing. This has an enormous psychological benefit, but there is also one less step to the surgery and one less recovery. I used to favor autologous (using patient’s own tissue) reconstruction for almost everybody, but ever since the advent of the Acellular Dermal Matrix (Alloderm, Flex HD, Allomax), the expander-implant reconstructions have become so much more successful that today many of my reconstructions are done with this technique. The TRAM flap reconstruction still remains the workhorse of the autologous reconstruction. I have refined the techniques to obtain minimal deficits in abdominal strength, even in bilateral cases.

The other aspect of breast reconstruction is the symmetrization of the opposite breast. In many cases, the opposite breast is too small, too big or too saggy. In these cases, something is done to the other breast to improve the symmetry. This is done as a second stage procedure, during which the nipple and areola are reconstructed.

Breast Reconstruction Tissue Expander

The patient is seen before the operation and marked for the pattern of the mastectomy. After the mastectomy, the pectoralis muscle insertion on the chest wall is divided and a space is created below the muscle. A piece of Acellular Dermal Matrix (ADM) is sewn to the chest wall in the area of the infra-mammary fold and the lateral breast fold. The expander, or in some cases the implant, is placed under the muscle, supported by the ADM from below. The ADM is then wrapped over the implant and sewn to the free edge of the muscle. The expander or the implant can be filled almost to the maximum volume. By saving most of the breast skin during the mastectomy, one can achieve a natural look to the breast immediately. The patient usually stays a night in the hospital. Drains are removed in about five days. Several months later, when the chemotherapy or the radiation is completed, the final stage is performed. This operation consists of symmetrization and the nipple reconstruction. The availability of ADMs and the very appropriate anatomic shaped, form stable implants available today have made the prosthetic breast reconstruction so successful that autologus reconstruction is rarely needed and is reserved for complicated post radiation cases.

Autologous Breast Reconstruction

I still favor the pedicle TRAM flap reconstruction because it is simpler than the microsurgical free flaps and can be done in less time. Due to the simplicity, there are fewer complications. In this operation, the excess tissue from the lower abdomen is transferred to the chest and turned into a breast shape. The abdomen is closed like a tummy tuck. It offers the side benefit of using the tissue from the lower abdomen that most women don’t care for, and the results of over several hundreds of patients have been excellent.

Under my care, the complications have been minimal and the donor site deficit negligible. I normally work at the same time as the surgeon. While the mastectomy is being done, I prepare the flap, which is transferred to the chest immediately while the abdominal wall is reconstructed. The most common complication has been the fat necrosis, which can be corrected at the second stage. I have patients after bilateral TRAM flaps doing sit ups, some as early as two months postoperative. Patient selection is very important; the younger and more athletic patients do better and recover faster.

The hospital stay is two nights for a unilateral and three nights for a bilateral case. The drains are removed in five days. Patients have returned to work as early as two weeks. All the sutures are dissolvable.