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Breast reconstruction plastic surgery
To get answers to the most frequent questions about breast reconstruction
plastic surgery, health insurance, and flaps, please select one
of the links below:
Will my reconstruction match the opposite breast?
One of the goals of breast reconstruction is to provide a good
match to the opposite, or contralateral, breast.
Most women who undergo reconstruction are at an age where the
breast normally has a degree of droop or "ptosis." A
natural ptosis is difficult to reconstruct, and is one of the
greatest shortcomings with non-autologous techniques. Because
of this, in approximately 50% of cases, the opposite breast is
lifted, enlarged or made smaller in order to provide a better
match with the reconstructed side.
The actual number of women needing contralateral symmetrizing
procedures may be significantly higher but the statistics may
be influenced by patient preference or the managed care plan's
refusal to provide coverage.
Will my health insurance cover surgery on the
opposite breast?
Insurance coverage for reconstruction of the diseased breast
is now the rule more than the exception throughout the country.
Unfortunately in an effort to control costs, many managed care
plans and HMO's have denied coverage for procedures upon the opposite
breast arguing that because it is not diseased it does not require
treatment.
Legislation has progressed on a state-by-state basis to require
coverage of the contralateral breast based on the concept that
the breast is a paired organ. Prior to beginning reconstruction,
it would be wise to check with your health plan or State Insurance
Department to determine what policies apply to your particular
case.
If I have a lift, will there be scars?
All techniques that lift or
reduce the breast produce some type of scar.
The most common location for the scars is around the areola in
combination with an upside down "T" although numerous
variations are possible. In some cases, the breast can be lifted
with scarring limited to the area around the areola. Recently
liposuction, particularly ultrasonic
assisted liposuction, has been utilized for small size changes
in breast reduction although the advisability of this method as
a symmetrizing procedure in breast reconstruction is questionable
because of concerns about changes in future mammograms.
The impact of a traditional breast lift upon future mammograms
is usually minimal and the scars are well accepted by most women.
What is a circumareolar mastopexy?
A circumareolar mastopexy is one of the newer techniques of lifting
the breast where the scarring is limited to the area around the
areola. Variations of the technique also utilize a vertical scar
from the base of the areola. The breast can be made smaller utilizing
these techniques as well.
Left breast reconstruction
with saline implant and
right periareolar mastopexy
Does surgery on the opposite breast increase
the risk of cancer in that breast?
A recent Canadian study involving approximately 173,000 woman-years
follow-up revealed that there is no increased risk of breast cancer
following bilateral breast reduction surgery and approximately
a 40% reduction in risk existed in women followed for an average
of 6.5 years. (Reference: Brown, et. al. A Cohort Study of Breast
Cancer Risk in Breast Reduction Patients Plast. Reconstr. Surg.
103:6 1674 1999.).
In a follow-up study, the five-year calculated survival rate
from breast cancer was not significantly different following breast
reduction suggesting that breast reduction does not hinder diagnosis
or treatment of breast cancer. (Reference: Tang, et. al. A Follow-Up
Study of 105 Women with Breast Cancer following Reduction Mammaplasty
Plast. Reconstr. Surg. 103:6 1687 1999.)
Because of concerns with follow-up examinations and mammography,
we recommend that all women considering modification of the contralateral
breast discuss this procedure with both their oncologic surgeon
and their plastic surgeon prior to surgery.
Breast reduction surgery causes changes in postoperative mammography
that an experienced radiologist can distinguish from architectural
changes of other origins. In some cases, early cancerous changes
or pre-cancerous changes in the opposite breast are detected during
symmetrizing procedures, facilitating early treatment.
What are the "autologous" techniques
of breast reconstruction?
Autologous techniques use the body's own tissues
to reconstruct the breast without the use of implants or expanders.
The most well-known and popular technique is the TRAM
flap (see below).
Other autologous techniques transfer tissue from the buttock
or thigh with microsurgery and are not as commonly used. The "latissimus
dorsi flap" is actually a combination technique because while
a flap is utilized an implant is still needed in most cases.
What is a "flap"?
A flap is a basic technique of plastic surgery
where tissue is moved from one position on the body to another.
Flaps can contain skin, muscle and even bone and must be nourished
by blood flow in order to stay alive.
Usually the flap is designed to include the blood flow through
its base or "pedicle", and the flap is rotated or moved
without detaching it completely from the body. In many flaps,
the blood flow accompanies an adjacent muscle that is incorporated
into the flap design.
In a type of flap known as a "free flap", the flap
is completely detached from the body and reconnected to blood
vessels in the recipient area using microsurgery.
What is a TRAM flap?
A TRAM flap is a flap in which the blood supply
is based upon the rectus abdominis muscle. Actually, the TRAM
acronym stands for transverse rectus abdominis myocutaneous because
the flap consists of muscle, skin and subcutaneous tissue harvested
in a transverse orientation from the lower abdomen.
In a TRAM flap, the breast is fashioned from the skin and subcutaneous
fat of the lower abdomen, and the blood flow needed to nourish
the flap accompanies the underlying rectus abdominis muscle. An
ellipse of skin and fat is harvested from the abdominal wall (usually
its lower part) and is rotated into the area of tissue loss created
by the mastectomy. The flap remains attached to the body via the
rectus muscle and is nourished by blood vessels that pass through
the muscle.
In most circumstances, the muscle opposite the mastectomy is
chosen for use in the reconstruction, but the other side can be
used. The muscle and soft tissue are tunneled under a skin bridge
in the lower chest and are then placed in the mastectomy defect
and surgically sculpted into a breast mound.
A type of TRAM flap known as a "free TRAM" utilizes
microsurgery to re-attach the blood vessels of the flap after
completely separating the flap from the body. TRAM flaps have
achieved great popularity since their description in the mid 1980s
but they still account for less than half of all breast reconstructions.
Patient who had TRAM flap
technique for reconstruction
(J. O'Connell, M.D.)
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454-0044.
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