What's involved in a reconstruction?

[Kathy Q]

Sorry to have so many questions!  I really appreciate the time you're taking to answer them.  Would you give me a brief description of what would be involved with reconstruction after a mastectomy?  If that ends up being the course of treatment, how soon would they start after the next re-excision on 3/15?  How long would the treatment/recovery period take?  I'm assuming if a mastectomy is required then I wouldn't need the radiation and would begin the Tamoxifen sooner?  I'm 52.  Thanks again for all the helpful information on this forum.

[CCF-RN,MSN-rf]

Dear Kathy Q:  If a mastectomy is recommended, there are several ways to approach reconstruction.  

One way is to use implants.  During surgery, a tissue expander is implanted under the skin and filled in small increments over time until the tissue is appropriately stretched.  Then a permanent implant is placed in a second operation (outpatient).  Additional surgery may be necessary if nipple reconstruction is desired.  Pros are quick recovery.  Cons are that it is not "your own tissue" and implants sometimes need to be replaced over time.

A second technique is to use one's own tissue and make a breast.  The most common procedure is a TRAM flap (which uses the abdomen).  Another similar procedure uses tissue from the back/shoulder area (latissimus dorsi) - used in women who have had prior abdominal surgeries.  In the TRAM flap, the skin, fat and some muscle is removed from the abdomen and either tunneled under the skin or removed and placed in the location of the breast. Additional surgery may be necessary if nipple reconstruction is desired.  Pros are that it feels natural and is your own tissue.  Cons are that it is a bigger surgery with a longer recovery.  

Either procedure can be done at the same time as mastectomy or deferred to later.  Either procedure can be done with or without nipple reconstruction.  Depending on your situation, there is research being done on nipple sparing surgery.  As long as the cancer cells are not adjacent to the nipple, the nipple can sometimes be spared during surgery and be placed on the area of reconstruction.  Of course this is best done on immediate reconstruction.  

If mastectomy is recommended, you should meet with a plastic surgeon for who does many of these procedures prior to making any decisions.

[nurse12hr]

Kathy,

When the decision is made to do a mastectomy, you can be sent to consult with a plastic and reconstructive surgeon at that time.  He/she will help you decide which type of reconstructive surgery you want.  Many can be started right during the mastectomy.

I personally had tissue expanders put in at the time of my mastectomies.  These are expandable saline implants.  I went every week or two and had a nearly  painless injection right into the implant, of saline, until they were stretched fully.  Then after a few more months, the expanders were removed during a simple outpatient surgery and regular saline implants were placed.  

They need to overstretch the breast area to create "pockets" in which to place the permanent implants, so they will hang properly and look realistic.  Later I had nipple reconstructions done (also simple outpatient procedures).  

There are several other ways to go with reconstruction.  Discuss getting a consult with a plastic surgeon to inform yourself fully.

Good luck!

[surgeon]

There are two main ways of doing reconstruction: either by placing an implant, or by bringing tissue into the area from somewhere else. Either method can be done at the time of the mastectomy; neither is finished in one sitting. With expanders, you start with an implant that is pretty flat, and over time more fluid is added (several weeks); when it's big enough, it's removed and a permanent implant is placed. There might be more surgery after that, for nipple reconstruction. Of the methods for bringing tissue in, the most common now is called a TRAM flap (transfer rectus abdominus muscle). Skin, fat, and muscle from the lower belly is brought up to the chest, either by tunnelling it under the skin, or by removing it completely and re-attaching it in the chest. You get a tummy tuck as a result, as well. It's a much bigger operation, with more recovery time, and more chance of complications, but the cosmetic results are usually outstanding. There may be another one or two minor procedures required later for the finishing touches. For some women it gets to be a bit much to try to decide all that at the time of dealing with the cancer and its treatment; so for them, putting off the decision of reconstruction til later can be a good idea. And there's no long-term cosmetic harm from delaying the reconstruction.

[Elfey]

What about the DIEP reconstruction method?  It sounds superior to TRAM because the abdominal muscle isn't used, which eliminates all the problems associated with cutting the abdominal muscle (hernia, etc).  I know there are not many surgeons that do this procedure, but the surgeons that do it are of the opinion that it is a far superior procedure, with significantly less healing time.  I don't know if you are a Plastic Surgeon, but what is your opinion about the DIEP procedure as opposed to the TRAM?  Is the DIEP procedure worth traveling to another state if a doctor in your state is unavailable to do the procedure? Thank you Doctor for your taking the time to answer our questions along with CCF staff.

[surgeon]

DIEP and SIEP are procedures wherein the skin and fat from the same place in the belly as the TRAM are taken, but without the muscle. The adavantages are as you said: no abdominal wall weakness, less pain. The disadvantage is that the technique is more complex (small blood vessels have to be reattached with fine sutures) and there's a higher chance of failure, meaning losing the flap and having to go to another method. It's very good when it works. I'm not sure it's worth it to travel elsewhere to have it done: what matters most in the long run is having a plastic surgeon with plenty of experience and demonstrably good results in whatever techniques he/she does. And I'm a general surgeon, not a plastic surgeon.

[Elfey]

If someone has had an appendectomy (5 inch incision), does this preclude them from having a TRAM? Also, does weight factor in when deciding on a procedure? Thanks again Doctor.

[Kathy Q]

Thank you so much for all of this information.  It will help me make decisions if I get to the point of having to have a mastectomy.  On the same subject, would having had a C-section 21 years ago eliminate me as a candidate for DIEP, SIEP or TRAM?  Just when I was thinking I might get a tummy tuck out of the deal...        
    :-)

[surgeon]

Prior operations in the area might or might not be an issue, depending on the exact location of the scar. If the C-section was a "bikini" incision, it would likely be ok. An appendectomy would also depend on the location, and the amount of skin needed for the transfer. Only your plastic surgeon can advise you accurately.

[ILynnSB]

I had two GAP flaps which is the same procedure except using the butt instead of the abs (DIEP). It is worth the travel and much less painful than I expected. Who would want to loss muscle if not necessary?

[msdg]

I had bilateral masectomy on Feb 27th of this year. My surgeon put expanders in, right after the breast were removed. He has stretched me twice now and next week, I will get saline put into the expander.  My surgeon said that I'm progressing rapidly.   I'm keeping a positive attitude and things are going well.  Matter of fact , my surgeon is very proud of his work and the outcome so far.  Remember, keep your chin up and a positive attitude and things will go well.  If you have any question please write back.  

[jwm]

Is there a big difference in abdominal wall weakness produced by DIEP vs muscle sparing (postage size) free TRAM?  Is there a big difference in necrosis rates between the two proceedures?

[Kathy Q]

I've just gotten the path report back and my lumpectomy on Monday had clear margins.  I've also posted a new question that has to do with my decision path right now.  Thank you everyone for your comments.  Can't tell you how much I appreciate this forum.