Reconstruction

Breast reconstruction is one of Dr Fortin’s special interests. She obtained sub-specialty training at the MD Anderson Cancer Center in Houston Texas. This institution houses the largest Department of Plastic Surgery in North America and is completely focused on cancer reconstruction. Breast reconstruction is completely covered by OHIP, including corrective surgery on the other breast. There is no time limit on when to undergo breast reconstruction so you should take the time to make sure it is right for you. Breast reconstruction is not felt to interfere with ongoing breast cancer surveillance and does not increase the chance of recurrence of breast cancer.

There are 3 basic techniques of breast reconstruction: Implant only; Implant plus Tissue; and Tissue only (Autologous). Each technique has pros and cons which are unique and should be discussed specifically on a patient by patient basis. We also provide nipple reconstruction. A thorough website dedicated to breast reconstruction and developed by Canadian Plastic Surgeons is found at www.breastreconstructioncanada.ca (it is also available in French at this location).

The North East Cancer Centre at Health Sciences North has a Supportive Care Program with a website at www.breastnorth.info They can also be contacted directly at 705 522-6237.

For assistance with bra fitting we recommend the Pink Ribbon Room at the Southridge Mall (Four Corners). Call 705 522-2013 to arrange a fitting with June.

Breast Reconstruction Awareness Days

Breat Reconstruction Awareness Days is an initiative designed to promote education, awareness and access for women who may wish to consider post-mastectomy breast reconstruction. “BRA Day” is the 3rd Wednesday of October each year. Check the website www.bra-day.com for more details.

Nipple

The nipple reconstruction is the final stage, although not all women proceed with this option. Generally it is done as 2 steps, the first to create the nipple with projection (bump). This is done as a small procedure under local anaesthetic with a large dressing afterwards for 1 week to prevent the new nipple from being squished. After a 3 months wait to allow for scars to settle, the 2nd step is done to create the areolar pigment (colour). This is generally done by tattooing, again with local anaesthetic if required. Dr Fortin performs this in the hospital. Some fading may occur and may need to be revised in the future. It really does give a focal point which completes the reconstruction.

Implant Only – Tissue Expander

Implant based breast reconstruction is undergoing evolution constantly but the basic technique involves the use of a tissue expander which is essentially a deflated implant which is able to be inflated once inside of you; usually by injections at weekly visits. This allows the pocket for the implant to be created and modified before placement of the permanent implant. The tissue expander phase may take 3-10 injections depending on size and tolerance for the injections. After achieving the full volume desired you are left with the expander in place for a minimum of 3 months to allow for scar settling. We recommend massaging your breast and scars daily. After this the expander will be exchanged for a permanent implant of your choice.

Risks include wound healing problems, scars, capsular contracture, infection, and failure of the implant. Patients who have had prior radiation or are expecting radiation are not good candidates for this option because of increased risks of healing problems and contracture.

Healing time is 1-2 months for the initial surgery and 2 weeks for the second phase. In some cases we are able to place a special prosthesis or immediate implant which will avoid the need for the 2nd surgery.

Patient – 47 yr old woman

pre-op for delayed breast reconstruction, during expansion with contoured expander (560cc) , and 9 months post reconstruction with a contralateral breast augmentation (210cc) for balancing.

Patient – 50 yr old woman

With prior 425cc gel implants that were ‘bottoming out’. Post op photo after change to 300 cc gel implants and correction of infra mammary fold. (click to enlarge).

Implant Plus Tissue – Latissimus Dorsi

Most commonly referred to as the latissimus dorsi breast reconstruction, this technique uses the muscle and skin tissue from your back to provide extra coverage of an implant reconstruction. There is a resulting scar on the back and the muscle function of the latissimus dorsi (pull down) is lost following this procedure, however, most women note that their arm and shoulder function returns to ‘ normal’ after approximately 2-3 months. The additional tissue coverage of the implant allows for a more cosmetic/natural appearance of the breast reconstruction, particularly in an ‘immediate’ setting (ie at the same time as your mastectomy). It is a good option for patients who have had prior radiation.

Recovery includes usually 1-2 days in hospital and 2 months off of work. There will be drains in the back area for the first few days.

Patient – 46 yr old woman

Pre-op immediate bilateral breast reconstruction, note lumpectomy scar on right side. 4 year post-op views of front, side and back scars after reconstruction with latissimus dorsi flaps bilaterally and contoured 410 gel style (400cc implants).

Patient – 38 yr old woman

Pre-op photo for immediate breast reconstruction on right using latissimus dorsi and implant. 2 month post-op view of reconstruction, including contralateral breast augmentation with 275cc round saline implant for balancing.

AUTOLOGOUS TISSUE – TRAM FLAP

This technique is most commonly referred to as the TRAM flap. The term ‘flap’ refers to any piece of tissue that can be safely moved around on the body with its own blood supply. TRAM stands for Transverse Rectus Abdominus Musculocutaneous (muscle and skin). This essentially means that we are able to move the tissue from the lower abdomen (the tissue often discarded in a tummy tuck) and use it to reconstruct the breast. Several variations on this technique exist.

The traditional technique is the pedicled TRAM flap where the tissue moved using the entire rectus muscle and the blood supply is left intact. This technique has the highest likelihood of weakening the abdominal wall.

The evolution of this technique then involved microsurgery, changing the technique to a ‘free flap’; this means that the tissue or flap is detached completely from the body as in a transplant type of operation. This technique may be referred to as a Free TRAM flap, a muscle-sparing TRAM flap, a DIEP flap or SIEA flap. The names refer to the technical details of the operation. The aim of the surgery is to successfully move the same lower abdominal tissue with the least-possible damage to the abdominal musculature. During surgery the specific blood vessel supplying the tissue is identified and is then divided and re-anastomosed to a new feeder vessel in the chest area. Most often the internal mammary vessel (this is the same vessel used in cardiac bypass surgery). The technical details of this surgery make it longer in duration (5-10 hours) and it also requires an in-hospital stay of 3-5 days; during which time the nursing staff will be watching you and the tissue carefully for signs of blood flow.

For the Free TRAM flap technique you will stay in the ICU for the first 2 nights for close observation of the flap. There is a 5% risk of needing an urgent return to the operating room for problems with blood flow in the blood vessels that have been sewn together. If that happens there is a chance that the whole flap reconstruction will have to be discarded. This is a small but real risk, and a huge disappointment when it happens. Once you have healed from this episode other options can be discussed to complete the reconstruction.

Both TRAM and Free TRAM techniques require a full 3 months for recovery. You will wear an abdominal binder to support the abdomen during the first 6 weeks of healing. No heavy lifting (>10lbs) for the first month. The abdomen will have drainage tubes in place which will be removed when they drain less than 30mls in 24 hours. That may be while you are still in hospital or may happen at home with the help of home care.

There are less frequently used autologous tissue sources for breast reconstruction including the TUG (transverse upper gracilis) from the upper inner thigh area, and the SGAP (superior gluteal artery perforator) from the buttock. These are generally reserved for cases not candidates for the more standard reconstructions.

Patient – 38 yr old woman

pre-op for bilateral breast reconstruction using free TRAM flap. 18 month post op view, right side was delayed and left was immediate reconstruction. Nipple reconstruction also completed.

Patient – 30 yr old woman with BRCA gene and family history of breast cancer

Pre-op for immediate prophylactic mastectomy and bilateral breast reconstruction with Free TRAM Flap. 18 month post op view with nipple reconstruction as well.

Patient – 46 yr old woman

Pre-op for bilateral immediate breast reconstruction with free TRAM flap. Post op view at 2 years.

Patient – 38 year old woman

Pre op immediate breast reconstruction with free SIEA flaps and bilateral implants (150cc round gel). Post op view at 2 years.

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