BREAST RECONSTRUCTION

It is never easy to learn that you have breast cancer or a genetic predisposition to it. This is a challenge that 1 in 8 women will face during their lifetime. Treatment can include surgery, radiation, and medical therapies. Dr. Zelken will empower you to be a part of the decision-making process. If you are interested in learning more, call (949) 432-4730 to discuss your story and options.

At Z Plastic Surgery, we encourage every woman to focus on the positive aspects of the breast cancer journey: beating cancer and living a full life. Dr. Zelken will do his best to restore your femininity and sense of wholeness. Most women we meet are unaware of the options they have. Dr. Zelken has access state-of-the-art tools and a fellowship trained skillset to rebuild your breast using implants or your own tissue. Dr. Zelken fervently believes that aesthetic standards after reconstruction should mirror those for elective procedures. He follows the same principles, uses the same sutures, aims for the same aesthetic standards, and harbors the same perfectionism in reconstruction as he does for cosmetic cases.

Reconstructive options after lumpectomy and mastectomy are different. Timing of surgery, chemotherapy, and radiation must be considered on a case-by-case basis. For now let’s focus on the basics:

AFTER LUMPECTOMY, YOU CAN OPT FOR:

1. No reconstruction at all

Many women choose to do nothing at all. In some cases, the affected breast may be larger than the unaffected side, and in other cases, aesthetic outcome is simply not a priority. Women who choose do nothing at all may change their mind down the road, often after radiation, for revision surgery. In many cases, the lumpectomy defect can be filled in with fat grafting.

2. Oncoplastic breast reduction

Dr. Zelken calls this the silver lining operation, because for every challenge there is a silver lining. In fact, oncoplastic reduction is his favorite breast reconstruction option for women who are appropriate candidates. Cancer is a tremendous burden. According to some women, so is having large or heavy breasts. Women who are candidates for breast reduction or mastopexy may be candidates for oncoplastic procedures that involve excising cancerous tissue and reducing or reshaping the remaining breast. In the majority of cases, a matching reduction and breast lift is performed at the same time to preserve symmetry. Depending on the size and location of the mass, results of this procedure often resemble the results of elective procedures.

3. Fat grafting

Women with small masses resulting in small deformities may opt for a less invasive option. Think of fat grafting as robbing Peter to pay Paul. A small suction cannula is used to take fat from the tummy, thighs or anywhere depots of fat are found. The fat is then cleaned of blood, oil, and other impurities, and injected into areas of the breast that are sunken-in. Because the fat has no blood supply, it relies on the surrounding tissue to keep it alive. For this reason, we are limited by how much we can inject at any given time. Up to 80% of the volume of fat he transfers survives; two or three treatments may be necessary. Dr. Zelken will not promise appreciable cosmetic improvement where the fat is taken from because he only takes 100-200 cc of fat (half a soda can). Autologous fat grafting itself is a nearly scar-less operation.

4. Flap reconstruction

When the defect is too big for fat grafting, local soft tissue rearrangement may be able to replace lost tissue and restore the natural curves of the breast. Sometimes, a shoulder muscle and its overlying skin can be transferred from the back to the breast (latissimus dorsi flap).

AFTER MASTECTOMY:

1. Do nothing at all

As with lumpectomy, there is no rule that you need to be reconstructed after mastectomy. In America the vast majority of women elect for reconstruction, still, many do not. In some cases, patients may not be appropriate candidates for reconstruction if they are sick. In other cases, getting rid of, or preventing cancer is such a priority that reconstruction is a distant afterthought. If you choose not be reconstructed, you can always come back to it later. The soft tissue envelope may be less pliable in delayed cases, making reconstruction a bit more challenging, but it is a feasible and understandable option. Dr. Zelken estimates that he performs two to three immediate reconstructions (on the day of mastectomy) for every delayed reconstruction.

2a. Implant-based breast reconstruction (prostheses are placed under your skin)

Nationally, this is the most common reconstructive option after mastectomy. Whether or not the nipple is present, radiation is planned, or you’ve had prior implants, chances are you’re a candidate. When skin is taken as part of the mastectomy, the skin envelope may be tight. To expand the pocket, an inflatable bag called a tissue expander is placed under the chest wall muscle. To hold it in place, a leather-like sling (acellular dermal matrix) may be placed between the chest wall muscle and the bottom of the breast that acts like an internal brazier. This is beneficial because it allows for earlier expansion of the implant and confers extra protection to the implant. The internal bra is eventually replaced by your own tissue and thickens the breast skin over time. Dr. Zelken’s patent-pending technique is designed to improve lower pole projection and reduce the rate of seroma.

After your expanders are placed, fluid is injected into a magnetic port as soon as two weeks after surgery. This is done in clinic and is typically pain-free. Every week or two, more saline is injected into the expander until you’ve reached your desired breast size. Then, usually 2-3 months after the mastectomy, you undergo a second surgery to remove the inflated tissue expander and replace it with a softer, more natural-looking silicone implant. This second surgery is typically quick and less painful than the mastectomy and tissue expander placement, and you can go home the same day. Dr. Zelken tries to avoid using drains after this second stage, but this may vary on a case-by-case basis.

2b. Direct-to-Implant reconstruction

At Z Plastic Surgery we often get asked why expanders are needed and if we can simply skip the expander step, placing an implant straightaway. Sometimes we can. Nicknamed one-and-done surgery, direct-to-implant reconstruction skips the expander stage altogether. A silicone implant is placed under the same leather-like sling on the day of surgery, and drains are used. Although this might sound ideal, not all women are candidates. Generally, healthy women with small breasts who are okay with staying the same size or going smaller are candidates. Even if you are a candidate, Dr. Zelken may decide to place expanders, or no device at all, in the operating room if he is concerned about blood supply to the overlying skin. Because the breast skin blood supply is compromised after mastectomy, any tension on the incision can lead to breakdown and exposure of the implant, or even worse, loss of the skin altogether. At some facilities Dr. Zelken also may employ a tool called the Spy that allows him to visualize areas of blood flow disturbance in the operating room. This will facilitate intraoperative decision-making and lead to the best aesthetic result.

Dr. Zelken is pleased to offer direct-to-implant reconstruction but will warn you that one-and-done is misleading because most women still opt for revisions down the road for skin tailoring and contour irregularities.

Autologous breast reconstruction recruits your own tissue to rebuild your breasts. A successful autologous reconstruction does not need to be replaced, grows with you, ages with you, gains weight with you; it is you. Autologous is a fancy word for your own. With autologous breast reconstruction, implants are generally not used, although they can be. Instead, tissue is taken from one body part and transferred to your breast. The most common donor body parts used are the shoulder area and the abdomen.

3a. Shoulder

The latissimus dorsi is a large triangular muscle that runs from your rear shoulder to your spine. That muscle is one of several that help extend the shoulder backwards. Although it is large, its absence does not significantly impact the lives of women who choose to use it to reconstruct their breast. With this procedure, the muscle and an overlying ellipse of skin and fat are dissected free, leaving only the blood supply behind. The flap of skin and fat are passed under the skin from the back of the chest to the breast, replacing both skin and volume, and a beautiful result can be achieved. In thin women, there may not be enough skin and fat so an implant is placed underneath. The scar on the back can be big and drains are placed for several weeks, but the scar is generally well tolerated and patient satisfaction is high.

3b. Abdomen

The idea of taking fat from your tummy and transplanting it to your chest may seem ideal for many. Fat grafting, as mentioned above, is best suited for small corrections. At most, after several treatments, fat grafting can add a cup size. After mastectomy, grafting typically provides too little tissue to replace the female breast. The only way to get large amounts of fat from the tummy to the chest is to preserve its blood supply. Fortunately, Dr. Zelken was fellowship trained to do just that.

Underneath your belly you have your six-pack muscles (rectus abdominis). In the core of these muscles is an artery and vein that runs from top-to-bottom, and it sprouts little tiny perforating vessels that bring blood to your tummy skin and fat. If you cut the muscle on bottom, but do not separate the skin from the muscle, you can use the six-pack muscle as a leash that contains the blood supply and rotate the belly skin, fat, and one of your six-pack muscles to replace the breast. This is called a TRAM flap, where the RAM stands for rectus abdominis muscle. This is a time-tested flap that has been offered for decades, but since a big abdominal wall muscle is used, hernias and bulges are potential complications down the road. Also, there may be a bulge near the lower breast where the muscle is. Finally, it is common to lose some skin and fat and possibly to have wound breakdown.

To address the lower breast bulging and partial flap loss, a free TRAM is another option. With this option, the six-pack muscle is divided on top, near the ribcage, and the bottom blood vessels are carefully dissected. As with a TRAM, the skin and muscle are left stuck together to preserve the little tiny blood vessels that keep the skin and fat alive. The whole muscle, skin and fat are isolated, and the bottom artery and vein are clipped in the groin, then transplanted to the chest by attaching the artery and vein of the six-pack muscle to an artery and vein in your chest. This requires very specialized surgical technique (called microsurgery) and there is a risk that the artery or vein could compress or clot off. In these cases, you are taken back to the OR and we try and find and correct the problem. This will occur in 1 out of 10 patients. If you have to go back to the OR, half the time, flaps cannot be salvaged and so we have to resort to implant-based reconstruction.

If you want Dr. Zelken to carefully explain and draw this, or any operation, out for you, call (949) 432-4730 to schedule a consultation.

The free TRAM eliminates the bulge under the breast and reduces the risk of partial loss of the tissue. However, it still means you lose one or both six-pack muscles (if both halves of your tummy are used). Accordingly, long-term hernias and bulges may occur. More recently, a flap called the DIEP flap was described. Remember those tiny vessels that sprouted from the artery and vein to your six-pack muscles? Those are DIEPs (Deep Inferior Epigastric artery Perforators), and when we perform the DIEP flap we choose one, two or three of these little sprouts and dissect them all the way down to the groin, leaving all your muscle behind. Because of this, you get all the benefits of the free TRAM, but without the associated weakness and long-term bulge and hernia risk. Dr. Zelken believes this is a gold standard of autologous reconstruction, but may not work in all women. If you are interested, you will need a CT scan of your belly that helps us determine if you are a candidate.

The free TRAM and DIEP flaps require microsurgery. Not only is this technically demanding, but also the operation can be as long as 8 hours for one side and 12 hours for both sides. You need to be closely monitored after surgery to make sure the reconnected blood vessels are working. You also need at least three days in the hospital to recover. This may be seem daunting to some women, but is generally well tolerated. We are happy to put you in touch with women who have had this surgery to get a better sense for what it’s like. Most women would do it again, and are thrilled to have their breasts replaced with like tissue, an improved abdominal contour, and more natural appearing breasts. The best candidates for a DIEP flap are those with radiated skin who are at increased risk for skin breakdown if expanders or implants are used, women with high BMI, women averse to the idea of having foreign objects placed in their body, and women who simply want it.

4. Nipple and areola reconstruction:

If you have a mastectomy that includes the nipple-areola complex (skin sparing mastectomy), the nipple and areola will need to be replaced. We have a number of ways to do this, but generally hold off until at least 3 months after the implant or flap is placed. This can be done in the Z Plastic Surgery procedure suite or an operating room. After we create a nipple mound and it heals, the areola can be tattooed on by an artist. We will refer you to one unless you’ve got a friend in the business.

OTHER FAQS:

What is lymphedema and how can I treat it?

Lymphedema is the collection of fluid in your soft tissues that cannot drain back to your heart. When you bump your arm and it swells, that fluid normally gets reabsorbed by small vessels called lymphatics and drains back to your heart. The same lymphatic channels often coincide with the lymphatic channels that drain your breast. When the drainage pathway of lymph is obstructed, for example after lymph node removal, lymph collects in the affected arm. Sometimes lymphedema resolves on its own as swelling improves and channels open up. Other times, you may need compression and physical therapy to improve swelling. This may provide temporary or permanent relief. Another strategy in early cases of lymphedema is to connect tiny lymphatic vessels to veins in the affected arm. That way, the lymphatics that pick up stray fluid have a place to drain. This is called lymphovenous anastomosis or lymphovenous bypass.

If lymphedema goes on for a long while without improvement, the fluid filled soft tissues become fibrous and fatty, and the patency of the lymphatics within the arm break down. At this point there are no lymphatic channels to bypass and lymph node transfer may be recommended. By transplanting lymph nodes to the affected extremity, the lymph nodes take up fluid as they would in the arm, and the fluid gets diverted to the tiny veins draining the transplanted lymph nodes into the arm. This is a difficult topic and warrants further discussion. If you or a loved one has lymphedema, call (949) 432-4730 to schedule a thorough discussion with Dr. Zelken.

What is the downtime?

If we do nothing to reconstruct the breast, you can expect to take a week off work to recover. If we place tissue expanders, you can expect to take up to two weeks off after tissue expander placement, and then another week off after expander exchange for implants. If you have a shoulder or tummy flap, you may need three weeks or more to recover. When drains are needed, they may stay in for as long as four weeks, though they’re typically removed after two. Of course, the term downtime is very nonspecific and has different meanings for different people; we will address this topic in greater detail during your interview.

When can I start my chemotherapy?

Breast reconstruction should not delay chemotherapy. Priority #1 is to beat cancer. In some cases, if there is delayed wound healing or infection, chemotherapy may be delayed for a short period of time. We work closely with the medical oncologists and will typically clear you for chemotherapy by the time it is scheduled.

When can I get radiated?

You can choose to delay reconstruction until radiation therapy is complete, or you can radiate the reconstructed breast. There are pros and cons of each. If you delay reconstruction until after radiation, it may be easier to predict the final result of a reconstruction. If you have tissue expanders, there is an increased risk of expander-related complications if the expander is radiated. In women with very thin skin, we may even deflate or partially deflate the expander during radiation treatments, and then expand again a month or so after radiation therapy has completed.

If you use my own body to rebuild my breast, can I get breast cancer again?

Yes and no. Breast cancer is just that: cancer of breast tissue. This includes lobules and ducts. The objective of mastectomy is to remove all breast tissue. If course, it is possible that some breast tissue remains. Although it is unlikely, there is a remote possibility that cancer can recur in a breast remnant. However, you will not develop breast cancer in abdominal tissue, shoulder tissue, or any other tissue that is not the breast.

Can you use skin and fat from my butt or thigh to reconstruct my breast?

Simply put, yes. Skin and fat from the anterior thigh, inner thigh, upper and lower buttocks can be transplanted to your chest. Although these operations are not common, and may offer less tissue, they are options, we offer them, and we would be happy to discuss them further in person.

What are the different implant choices?

Implants come in various shapes and sizes. We will discuss your goals and choose the proper fill material, shape, size, and texture of implant for you. Fill options are silicone or saline (salt water). We prefer to use silicone when possible, and imagine you would prefer it for its natural feel and shape. The term gummy bear implants refers to modern form-stable implants that look like a gummy bear when cut (the fluid doesn’t spill out). Despite the name, gummy bear implants are not as firm as their namesake candy. Dr. Zelken offers both teardrop-shaped (anatomic) and round implants. In reconstructive breast surgery, anatomic implants may look more natural in some women. Implants come in smooth and textured forms. Most round implants we use are smooth and most anatomic implants are textured. Textured implants may hold their position better due to their rough surface, and may reduce the risk of capsular contracture.

Is silicone safe?

Silicone implants are known to be safe, or else Z Plastic Surgery wouldn’t use them. Modern fourth- and fifth-generation implants are made from highly cohesive gel that does not bleed and is unlikely to extend beyond the shell of the implant. If the implant ruptures, you may not even know it.

Is it possible to look better after mastectomy than I did before?

Anything is possible. At Z Plastic Surgery, this is what we aim for. If you or a loved one is concerned about the aesthetic impact of breast cancer and reconstruction, call (949) 432-4730 to schedule an appointment with Dr. Zelken.