Breast Reconstruction After Mastectomy View Photos

 

BREAST RECONSTRUCTION

 

 

CONTACT US

Call the office at (573) 443-5500.  Our experienced patient support representatives are happy to answer your telephone questions, 8AM to 5PM, Monday through Friday.

 

PREOPERATIVE CONSULTATIONS

Preoperative consultations are available by appointment on Mondays, Wednesdays and Fridays 8AM to 5PM.  The consultations usually last 45-90 minutes.  Dr. Seaberg will do a detailed medical history and physical examination.  You will have a chance to review before and after photos of other breast reconstruction patients.

 

THE TISSUE EXPANSION METHOD OF IMMEDIATE BREAST RECONSTRUCTION

At the conclusion of a mastectomy, there is usually not enough skin to cover a breast implant the size of the breast that was removed.  We must therefore gradually stretch the surrounding skin to make a skin envelope large enough to cover the new breast mound without being abnormally tight.  The device used to accomplish this is called a tissue expander.  It is an inflatable temporary breast implant which has a self-sealing inflation port.  The inflation port allows the addition of fluid to the expander, and keeps the fluid that was added from leaking back out.  The tissue expander is positioned beneath the pectoral muscles after the mastectomy.  The muscles and skin are then closed over the top of it.  After the mastectomy, the patient visits her plastic surgeon in the office once or twice a week for gradual inflation of the tissue expander. At the time of each visit, a needle is passed though the skin into the inflation port and additional fluid is added to the expander.  By two weeks after the mastectomy, the tissue expander has usually been inflated to a volume equaling the opposite breast.  The patient is now ready to start chemotherapy, with her usual bra evenly filled out on both sides, just as before the mastectomy.  Most patients then receive chemotherapy for six months to a year.  

 

Six weeks after the completion of the chemotherapy, the patient returns to the plastic surgeon to start a series of inflations to overexpand the tissue expander to a size somewhat larger than the opposite breast.  The visits are again done twice a week, for two or three weeks.  The reason for this step is to prevent abnormal firmness in the final result.

 

WHY RECONSTRUCTED BREASTS USED TO BECOME ABNORMALLY FIRM, AND HOW WE CAN NOW PREVENT IT IN MOST CASES

In the days of immediate placement of permanent implants, the plastic surgeon had to separate the tissue layers beneath the skin to create the space into which he placed the implant.  Since the tissues lining this space had been operated upon, they healed by forming a scar.  This scar on the inner surface of the tissue pocket around the implant contracted over time, as all scars do.  As it contracted, it squeezed on the implant. 

 

The implant came manufactured in the shape of a disc, or lozenge.  As the contracting scar squeezed it, the implant tried to take up less space.  It gradually assumed the shape in which it had the smallest possible surface area in contact with the scar.  This shape was a sphere.  As the scar contracted further, the pressure inside the now spherical implant built up until it equaled the contracting force in the scar lining of the implant pocket.  The implant was then spherical, abnormally firm, and fixed in position on the chest wall, so it could not move in response to gravity. 

Normal breasts are teardrop-shaped, not spherical.  They are soft, and they move in response to gravity.  To create a new breast with these characteristics, we have found that we need to make the implant pocket larger than the implant we intend to place inside it.  When we place the implant in this large pocket, the implant has room to move about in response to gravity.  It stretches the overlying skin downward when the patient is upright and out toward the side when the patient is reclining.  This gives a very realistic simulation of the movements of normal breast tissue. 

 

The over expansion to make the large pocket usually takes two weeks to achieve.  The tissues are then allowed to rest in their stretched state for at least four weeks.  The patient then undergoes an outpatient operation taking about half an hour to remove the tissue expander and place a permanent breast implant.  The reconstructed breast produced by this method is soft, teardrop-shaped, and has no droop, yet moves in response to gravity.  If the opposite breast has significant droop, or is significantly smaller or larger than the reconstructed breast, many patients elect to have a breast augmentation or breast reduction or nipple lift on that breast at the time the permanent implant is placed in the reconstructed breast.  If a breast reduction is required on the opposite breast,  that will make an overnight stay in the hospital necessary in most instances. 

 

NIPPLE RECONSTRUCTION

The nipple itself is made by folding some of the skin of the reconstructed breast into a nipple shape, the areola ( the brown area around the nipple) is then reconstructed using a medical tattoo. 

 

About one week after the permanent implant is placed, the patient returns to the plastic surgeon's office for instruction in breast softness exercises.  These exercises consist of moving the implant to the edge of the tissue expanded pocket and holding it there for 15 second.  This process is repeated in each of the four directions of the compass for 15 seconds each.  This is done to keep the scar lining of the implant pocket stretched out to the size it was originally made at the time of surgery.  This keeps the scar from contracting around the implant, which would make the implant less mobile, less soft and less natural.

 

WHY IS THE BREAST RECONSTRUCTION SEPARATED INTO TWO STAGES

The first breast reconstructions were done in one stage, by placing the permanent implant in a pocket beneath the pectoral muscle at the conclusion of the mastectomy.  This resulted in tightly stretched skin.  The combination of tight skin and post-operative immobility while recovering from the mastectomy made it difficult for the patient to start the breast softness exercises in the early post-operative period.  The patients consequently developed scar capsules around the implants and ended up with abnormally spherical, abnormally firm, immobile breasts.

 

The two step strategy of using the tissue expander to first make a pocket larger than the implant, and following up with daily softness exercises to keep the pocket large, prevents this complication in 95% of the cases.  Although adding the tissue expansion step makes an extra small operation necessary, the eventual natural softness and mobility that result more than justify the extra effort.

 

WHAT ARE THE POSSIBLE COMPLICATIONS OF BREAST RECONSTRUCTION

Like all surgical procedures, breast reconstruction with tissue expansion has possible complications.  The early complications which can jeopardize the breast reconstruction process are skin loss over the expander or infections around the expander.  In order to assure complete removal of breast tissue, the skin flaps remaining at the end of the mastectomy are by necessity quite thin.  Their blood supply is fragile.  The skin at the edges along the incision sometimes loses blood supply.  It then has to be removed and replaced with a skin graft.  If the muscle beneath the lost skin is healthy, a skin graft can be placed and the reconstruction continued. If the muscle is also compromised, then the expander will become exposed and will have to be removed.  The wound must then be allowed to heal before the reconstruction process can be started over.  This problem is most likely to occur in cigarette smokers.  The risk can be minimized if the patient stops smoking for thee days before her mastectomy, and does not resume afterward. 

 

Infections around the expander occur in about 1% of patients.  Since the expander is a foreign body with no circulation, it provides places where bacteria can hide and the body cannot deliver white blood cells and antibiotics to eliminate them.  The expander must therefore be removed in order to clear the infection.  After a healing period of about three months, a new tissue expander can be placed and the reconstruction process resumed. 

 

CAPSULE CONTRACTURE: As the body heals following breast implant surgery, a smooth layer of scar tissue forms over the entire inner surface of the implant pocket. This scar tissue has genetic programming to contract a little bit more every day, until the implant pocket completely disappears. Since the implant is there, the pocket does not completely disappear, but it does shrink until it begins to squeeze the implant. The implant becomes spherical as the scar tissue tightens around it. The end result of this process is an abnormally firm and spherical breast, fixed in position on the chest wall and unable to change shape or position in response to gravity. To prevent this unnatural result, we surgically create an implant pocket significantly larger than the size of the implant. The implant thus is given room to move around in response to gravity. When one is upright, the implant fills out the bottom one-half of the breast. When one lies down, it is moved by gravity to the outside of the pocket, pulling the breast skin outward in a natural way.

 

BREAST IMPLANT SOFTNESS EXERCISES
To prevent scar contraction(capsule contracture), one needs to do implant softness exercises daily. The idea is to push the implant to the edge of the pocket, and hold it there under pressure for 10 to 15 seconds, to stretch out the scar tissue by however much it has contracted since the day before. Doing this in each of the four directions of the compass every day keeps the implant pocket the original size it was made at the time of the surgery. The implant is then able to move naturally in response to gravity and the breast stays soft. If patients do not do the softness exercises, 40% of them will develop abnormal breast firmness within three months of the surgery. Faithfully performing the softness exercise routine reduces the capsule contracture rate to 5% at 1 year after surgery, and 9% at 3 years after surgery.

  

WHAT ARE THE BENEFITS OF BREAST RECONSTRUCTION

The greatest benefit that comes from doing the immediate breast reconstruction as outlined above is that the healing period following the mastectomy is utilized for the construction of the new breast.  By the time the patient would ordinarily be fully healed from her mastectomy, she is fully healed from her first stage reconstruction.  She is able to continue to wear the same clothing, including swimsuits and low cut gowns, that she was able to wear before the mastectomy.  The subsequent stages of reconstruction can be done on an outpatient basis, and disruption of normal life routines is minimal. 

 

BREAST IMPLANT OPTIONS


FDA APPROVAL OF SALINE-FILLED BREAST IMPLANTS
Silicone gel-filled breast implants were invented in 1963. Saline-filled breast implants were invented in 1969. At that time, the FDA was only responsible for regulating drugs, and the number of medical devices available was so limited that no one felt federal regulation of them was necessary. In 1976, Congress passed the Medical Device Amendments to the Food and Drug Act, expanding the FDA's authority and responsibility to include regulation of medical devices, such as breast implants, which were already on the market. Congress did not provide the FDA with any additional funding to support this new set of responsibilities, however. The agency therefore placed most devices (including breast implants) in class II, requiring general controls and performance standards, but no detailed studies. This situation continued until 1981, when a clever attorney in San Francisco successfully sued Dow Corning on behalf of a patient with rheumatoid arthritis. The attorney had read the part of the Medical Device Amendments that states that devices must be proved safe and effective before being released for use. This wording places the burden of proof entirely on the manufacturer, if a patient develops a problem and alleges that the device created that problem. Since no one knows what causes rheumatoid arthritis, the manufacturer couldn't prove that the breast implant DIDN'T cause it. The patient won the case--for 3 million dollars. The six men and women on that San Francisco civil federal jury didn't have any medical training, and didn't base their decision on any scientific studies. They just decided that, in this particular case, the manufacturer couldn't prove that the implants DIDN'T cause the woman's rheumatoid arthritis. Since this was the first case addressing the issue, however, it became the law of the land that breast implants cause rheumatoid arthritis. On January 19, 1982, the FDA responded by proposing to place breast implants in class III, requiring stringent testing. In 1988, after Dow Corning had lost several more lawsuits, the FDA finally did reclassify breast implants into class III. In 1992, the FDA placed silicone gel-filled implants under restriction, for research use only, and left saline-filled implants on the market in the same "not approved but also not restricted" status that had been the case ever since 1976. In 1994, the FDA met with manufacturers to set the ground rules for pre-market approval testing of saline-filled breast implants. In March 2000, the implant manufacturers completed their 5 year pre-market approval studies and submitted the data to the FDA. On May 10, 2000, the FDA approved saline-filled breast implants for general use. 

FDA APPROVAL OF SILICONE GEL-FILLED BREAST IMPLANTS
In 1992, the FDA placed silicone gel-filled breast implants under restriction, for research use only. Research studies were initiated for women who had had a mastectomy for cancer, for women who already had silicone gel-filled implants from a previous procedure, for women who needed a breast lift, and for women who had previously had problems with saline-filled implants. In 1997, Congress approved funding for the Institute of Medicine of The National Academy of Sciences to conduct an independent, unbiased review of all past and ongoing scientific research regarding the safety of silicone breast implants. After reviewing literally every scientific study ever published regarding silicone gel-filled breast implants, the Institute identified 17 studies that were of sufficient quality that they could be trusted. These high quality studies had age-matched control groups of women without implants, so the occurrence of diseases in women with implants could be compared to the incidence of those same diseases in women their same age, who did not have implants. They had a large enough study population that a statistically valid conclusion could be drawn, and they had been conducted in a careful scientific manner. On June 15, 1999, the Institute of Medicine published their findings: "A review of 17 epidemiologic reports of connective tissue disease in women with breast implants was remarkable for the consistency in finding no elevated risks or odds ratio for an association of implants with disease." Although women with implants do sometimes develop connective tissue diseases, it has turned out that those diseases do not occur more frequently in women with implants than in women without implants. I am a clinical investigator for both McGhan and Mentor silicone gel-filled breast implants. Those studies are no longer enrolling new patients, but I continue to follow patients for their 3yr, 5yr and 10yr checkups. In November, 2006, the FDA eased the restrictions on silicone gel implants, and made them once again available for general use in breast augmentation, with conditions: the patient has to be at least 22 years old, and agree to participate in a post - approval study with followup exams at 1 year, 3 years, 5 years and 10 years. MRI examinations to check for silent rupture are recommended at three years, and every two years after that. The advantages of the silicone gel-filled implants are that they feel more natural to touch than saline-filled implants, and don't show visible rippling at the edge of the implants. This is particularly advantageous if the implants are placed above muscle, in the "sub glandular" position. The disadvantages of the silicone gel-filled implants are that they add $1000 to the cost of your procedure, and require you to participate in the post-approval study protocol for 10 years after the implants are placed.

IMPLANT MANUFACTURERS
In May 2000, the FDA approved two American companies, McGhan Medical and Mentor Corporation, to produce saline-filled breast implants for cosmetic breast enhancement. Both companies manufacture implants in several styles, offering round and contoured shapes, and smooth and textured surfaces. Following a series of corporate mergers, McGhan Medical is now part of Allergan.

IMPLANT MANUFACTURERS' GUARANTEE

ALLERGAN IMPLANT WARRANTY: Standard warranty (Included with all implants, no extra charges or paperwork) 1. Lifetime free replacement implant, if original implant fails. 2. The replacement implant can be any size or style. It can be different from the implant it is replacing, if you like. 3. If rupture occurs in the first ten years after the implant was placed, Allergan will pay up to $1200.00 to help cover the cost of the surgery to replace the implant. Extended warranty (Requires submission of a registration form and payment of $100 to Allergan within 1 month of breast augmentation surgery.) 1. Lifetime free replacement implant, if original implant fails. 2. The replacement implant can be any size or style. It can be different from the implant it is replacing, if you like. If you would like to replace both implants at the time one of them fails, Allergan will provide 2 free implants. If the style you select costs more than the style you are replacing, you will be liable for the difference in price between the two styles of implant 3. If rupture occurs in the first ten years after the implant was placed, Allergan will pay up to $2400.00 to help cover the cost of the surgery to replace the implant.

MENTOR IMPLANT WARRANTY: Standard warranty (Included with all implants, no extra charges or paperwork) 1. Lifetime free replacement implant, if original implant fails. 2. The replacement implant will be the same or similar type as the original implant. 3. If rupture occurs in the first five years after the implant was placed, Mentor will pay up to $1200.00 to help cover the cost of the surgery to replace the implant. This warranty covers implant deflation due to crease fold failure, patient trauma, or unknown cause. It specifically does NOT cover removal of intact implants due to capsular contracture, wrinkling or rippling. It further does NOT cover implant damage during reoperative procedures, open capsulotomy, or closed compression capsulotomy. Extended warranty (Requires submission of a registration form and payment of $125 to Mentor within 1 month of breast augmentation surgery.) 1. Lifetime free replacement implant, if original implant fails. 2. The replacement implant will be the same or similar type as the original implant. 3. If rupture occurs in the first ten years after the implant was placed, Mentor will pay up to $1200.00 to help cover the cost of hospital and anesthesia charges, and up to $1000 to help cover surgeon's fees for the surgery to replace the implant. This warranty covers implant deflation due to valve failure, crease fold failure, patient trauma, or unknown cause. It specifically does NOT cover removal of intact implants due to capsular contracture, wrinkling or rippling. It further does NOT cover implant damage during reoperative procedures, open capsulotomy, or closed compression capsulotomy.

IMPLANT FILLING MATERIAL
Normal saline solution is distilled water with 0.9% salt added, to exactly match the salt concentration of your natural body fluids. Everyone's natural body composition is 71% normal saline. If a saline-filled implant should wear out someday and begin to leak, the normal saline solution that leaks out will be immediately absorbed into the circulation and cleared by the kidneys, with no harm to your body.

Silicone is a polymer made by hooking together several individual silicone molecules to form a chain. The physical characteristics of the polymer change, depending on the length of the chain. Short-chain silicone polymers are oils, slightly longer chain silicone polymers are gels, still longer chain silicone polymers are rubbery in consistency, and longest chain silicone polymers are solid plastics. Silicone, the core atom in the silicone molecule, has many chemical characteristics similar to carbon, which is the core atom for all biological molecules. This chemical similarity is believed to be the reason for silicone's biological compatibility. Silicone is the benchmark substance for biologic nonreactivity in the US Pharmacopeia. Stainless steel, polyethylene, polycarbonate and all the other substances used in implantable devices (heart valves, artificial joints, etc.) are all rated in comparison to silicone.

IMPLANT SHELL
The implant filling material is contained within an envelope, or "shell," made of silicone rubber. Another word for silicone rubber is "elastomer." The room-temperature vulcanizing process for creating a smooth-surface, silicone-rubber elastomer for saline-filled implants was developed in 1969. In 1979, the manufacturer changed the design of the filling valve to its present form. In 1986, surface texturing became an available option. The theory behind surface texturing was that the textured surface would prevent capsule contracture. This has proven to be partly true if implants are placed in the subglandular position, but has been shown to not make any difference if implants are placed in the submuscular position. The two advantages smooth implants have over textured implants are that they are thinner-walled and more flexible (therefore less likely to be detectable by touch,) and they cost less. The elastomer shell of the Mentor implants is somewhat thinner and more flexible than the elastomer shell of the McGhan implants. At 3 years follow-up, 79% of patients with each kind of implant had good cosmetic results, natural in both appearance and feel. Among the 21% for whom the implants had a cosmetic imperfection, Mentor implants had a higher incidence of visible wrinkling, and Allergan implants had a higher incidence of being detectable by touch. (This is for saline implants. Gel implants are much less likely to cause visible rippling or feel abnormal to touch.)

IMPLANT SHAPE: ROUND VS CONTOURED
Contoured implants are wider than they are tall, and project forward in front of the chest wall farther than similar-sized round implants. Since they are not round, they look strange if they get tilted or rotated. To help keep them fixed in place, they have textured surfaces. Since they don't move, we don't do softness exercises on them. I use them frequently for breast reconstruction after a mastectomy, and occasionally for above-muscle breast augmentation in female body builders. I use round implants for most breast augmentation. I almost always use smooth-surfaced implants for augmentation, because they feel more natural to touch than textured-surface implants.

IMPLANT SIZE
Information is available from several sources to help you select your implant size. Photos: Internet photos from breast augmentation websites can be helpful, especially if information is included about the ribcage size of the person in the photo. (Try www.implantinfo.com). Photos from men's magazines can be helpful as a demonstration of a desired postoperative look, but selecting the implant that will take you from your starting ribcage size and starting breast shape to the postoperative appearance of the model in the photo requires long experience, good judgment and a certain amount of luck on the part of your surgeon. Trying on bras and implants: If you will wear a knit top to your office consultation, we can fit you with a bra in your desired postoperative size, then try different sizes of implants to see which size fills out the bra. You can then put your knit top on to see how you look in the mirror with that size bra and implants.

ANESTHESIA
Local anesthetic is always injected into the operative site before the operation. It helps separate the tissue, making the surgery easier to perform. It also causes the constriction of blood vessels, which reduces the amount of bleeding during surgery. To minimize your awareness of the surgery, your local anesthetic will be supplemented, either with sedative medications given through your IV, or general anesthesia.