Breast reconstruction is an imperfect art, and sometimes a reconstruction that is technically “complete” can be improved surgically. There are various modalities to do this, and this letter is an overview of the various techniques available to enhance a reconstruction. Of course no reconstruction can achieve perfection by definition, and at times after I meet and examine you, we may decide together that another surgery would be a bad idea either because the improvement would be so minimal or the effort too risky or involved. The tools we have for revising your breast reconstruction are not perfect either. Nonetheless, I will be able to give you my best estimate of how much of an improvement we are likely to expect with any given surgical intervention.
Statistically the most commonly revised reconstruction is probably an implant-based reconstruction on one side and a normal breast on the other. Over time the normal breast tends to get larger and droopier (ptotic) as women gain weight over the years. A breast that has been radiated tends to look the same or contract more over time, so the non-radiated breast will also get larger and more ptotic compared to the radiated side. Surgery for symmetry is currently covered by insurance, and in this case would usually involve a lift or a reduction on the non-cancer side. For more information, please refer to those letters and images elsewhere on the website. These are fairly straightforward procedures. Sometimes an implant may be placed on the non-cancer side so that the top of both breasts will have the more rounded contour of an implant based reconstruction.
Another common problem is rippling. This is most often in slender women with no body fat. We have a number of techniques that help rippling, although none of them is perfect. Fat grafting, or liposuctioning fat and transferring this fat to the rippled or indented areas is very helpful, but slender women often have very little fat to donate. Additionally, some insurance companies are reluctant to pay for fat grafting as an isolated procedure. It may take several sessions to fill the area optimally. Switching the implant out for a firmer or anatomic cohesive gel implant may help as well. These implants are firmer so they don’t ripple as much. I will have you feel one in the office to decide for yourself whether or not it feels too firm to you. Sheets of allograft (irradiated dermis) can also be placed to stiffen and lend support to the mastectomy flaps. Lastly, either placing a larger implant or tightening the skin can also help with ripples.
Irregularities or dents in the surface of the skin can also be fat grafted. I am somewhat reluctant to fat graft a lumpectomy defect (dent where the cancer was) because I am uneasy about putting fat in the exact spot of the breast that we want to monitor most closely for cancer recurrence.
Liposuction is another technique that is can be used to enhance a reconstruction. Often there is fatty tissue on the side of the breast under the armpit (axilla) that will be removed. I also feel that the implant reconstruction itself seems to create or push up a lump of fat on the breast toward the armpit. This can easily be liposuctioned as well. Unfortunately, every implant-based reconstruction “twitches” to some degree with pectoralis contraction. This is called an animation deformity. I don’t know of anything that really helps this significantly, although fat grafting can help to mask it somewhat.
Occasionally a woman wishes that she were a different size. I can go somewhat larger without another expander by placing a larger implant and fat grafting. If you want to be significantly larger, we may have to place another expander, and two more operations may or may not be worth it to you. Going smaller is not as easy as it would seem because there is extra skin that needs to be addressed, otherwise the skin will ripple and the implant will fall to the bottom of the pocket. Therefore, a seam of extra skin often has to be removed somewhere on the breast. If you had a nipple-sparing reconstruction or a nipple reconstruction, placement of that incision can be a problem.
One of the most exciting developments in breast reconstruction recently has been nipple-sparing mastectomy. These are some of the most natural looking reconstructions to date. However, one of the difficulties that has arisen is occasional nipple placement asymmetry. I have several techniques to address this and can tell you in person how successful we are likely to be in getting more symmetry depending on the quality of your skin and the location of you nipples.
There are also multiple techniques available for moving the fold under your breast upward or downward or making it more distinct. This can be done with simple liposuction, surgical release or internal suspension sutures depending on your anatomy.
I think the most challenging reconstructions involve patients who have had radiation. The irradiated tissue has a diminished capacity to heal. The radiated implant tends to be higher, rounder and firmer. Sometimes the easier solution is to make the other side closer to the radiated breast reconstruction. Fat grafting can help to soften irradiated tissue perhaps by bringing in stem cells, but sometimes the best answer, although the most involved, brings fresh healthy tissue from another part of the body into the area (autologous reconstruction). I will discuss the pros and cons of those options which include tram flaps, latissimus flaps and DIEP flaps and guide you to make the best decision.
Smokers heal poorly in terms of infection, implant loss and wound breakdown. You are advised not to smoke for a least 1 month before and after surgery. Nicotine screening may be necessary the day of your surgery. IF THE TEST IS POSITIVE, YOUR SURGERY WILL BE CANCELLED.
I know that this is an overwhelming amount of information to process. I will be happy to meet with you to discuss the various options and to decide which, if any, make sense in the context of your present reconstruction, general medical condition, family life and work responsibilities. Please do not hesitate to contact me if I can be of further assistance (804-320-8545).