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Breast Reconstruction

Introduction

Cleveland_Clinic_Host: For women who must face mastectomy, breast reconstruction can offer significant physical and psychological benefits and maintenance of body image. For more than 40 years, Cleveland Clinic plastic surgeons have performed successful breast reconstruction procedures to restore anatomy and symmetry, and have pioneered improvements in plastic surgery techniques that offer patients enhanced results and increased options.

In addition, Cleveland Clinic is one of the few medical facilities in the United States to perform the state-of-the-art DIEP flap technique, a surgical option using the patient’s own tissue, and requiring significant expertise in sophisticated microsurgical techniques. Surgeons from around the world travel to Cleveland Clinic to be trained in this procedure.

Cleveland Clinic specialists treat more than 1,000 patients each year throughout the multidisciplinary subspecialties involved in the care of breast cancer. By collaborating closely with breast cancer surgeons and oncologists in the Breast Center, Cleveland Clinic’s plastic surgeons offer options to compliment the screening, diagnosis and treatment of breast cancers.

Risal Djohan, MD, is a board certified plastic surgeon who specializes in breast reconstruction surgery, aesthetic surgery and microvascular surgery. Dr. Djohan, who has extensive expertise in the DIEP procedure, received his medical degree from Finch University of Health Sciences-Chicago Medical School in Illinois and completed a fellowship in Plastic Surgery at University of Chicago Hospitals in Illinois and an additional fellowship in Aesthetic Surgery at Cleveland Clinic.


Breast Reconstruction Options

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Risal Djohan. We are thrilled to have Dr. Djohan here today for this chat. Let’s begin with some general questions.

put2work: What types of breast reconstruction options are possible for postmastectomy patients?

Speaker-_Dr__Risal_Djohan: Breast reconstruction options are a personal and individual decision. The decision should take into account your body type, overall health status, the type of breast cancer treatment you will pursue and your personal preference.

Options involve both the type and timing of the reconstruction. Reconstruction can involve permanent implants (nonautologous) or autologous (patient’s own tissue). Timing of the reconstruction may be immediately following the mastectomy or delayed breast reconstruction.

Other factors that contribute to the option choice are tumor location, size of defect created by tumor resection and preoperative breast size.

sheltie: How does one decide between immediate breast reconstruction and delayed breast reconstruction?

Speaker-_Dr__Risal_Djohan: Immediate reconstruction can be done at the time of the mastectomy, often in one surgical procedure. A benefit of immediate reconstruction is the improved aesthetics in face of the loss from a breast mastectomy. Delayed breast reconstruction allows the patient additional time for decision making and focusing on cancer treatment, the ability to have radiation therapy if indicated and may be necessary for patients with multiple comorbidities that would not benefit from a lengthy surgical procedure.

conston: What needs to be considered when deciding between choosing an implant for breast reconstruction or using one’s own tissue from the abdomen?

Speaker-_Dr__Risal_Djohan: Nonautologous (implant) breast reconstruction usually involves a two step procedure. First a tissue expander is placed to stretch the skin and create a cavity for the permanent implant. Placement of the permanent implant is the second procedure. Possible complications of implant-based reconstruction include extrusion of tissue expander or implant, capsular contraction or postoperative radiation therapy. Advantages of implant reconstruction include good aesthetic results, shorter procedure time and recovery period.

Autologous reconstruction involves using abdominal fat, skin and fatty tissue from the patient’s lower abdomen or sometime other areas. Autologous reconstruction is contraindicated if there were previous abdominal surgeries, obesity, smoking, a history of blood clots or other major comorbidities.

annieb: Is it better to have breast reconstruction before or after my radiation therapy?

Speaker-_Dr__Risal_Djohan: Delayed breast reconstruction is preferred if postmastectomy radiation probability is high. Delayed reconstruction can optimize both radiation delivery and aesthetic outcome.

pseudoscar: I am 2 years s/p bilateral mastectomies secondary to multifocal DCIS of the right breast. I opted for implant reconstruction, but acquired a pseudomonas infection under the tissue expander within 2 weeks post mastectomy. After 3 months of wound packing the infection was gone, but I was left with scarring and "puckering" of that area. I was recently told that tissue expansion is probably not an option at this point. Pedicle TRAM flap was given as my other option, but I am petrified. Any suggestions?

Speaker-_Dr__Risal_Djohan: Yes - usually once you develop complications with a tissue expander or implant, then your next option would be reconstruction of the breast using your own tissue. This could be done by using a pedicle TRAM flap as you were suggested, or you could use a DIEP free flap. The DIEP free flap has the advantage of not using your muscle like the pedicle TRAM.

pseudoscar: I have stress incontinence post childbirth. Would that be a problem for the tram flap?

Speaker-_Dr__Risal_Djohan: Regarding your stress incontinence, we would have it evaluated by our urology specialist as to what is the cause or etiology.

pseudoscar: Would a current rotator cuff injury rule out lat flap reconstruction?

Speaker-_Dr__Risal_Djohan: Since the procedure in this case would be considered a delayed breast reconstruction, we would not have to access the site through your axilla, We would position your arm directly by your side during the procedure.


Breast Reconstruction tissue flaps

mary_b3: What are the different types of abdominal tissue flaps used for breast reconstruction?

Speaker-_Dr__Risal_Djohan: Breast reconstruction using the patient’s own tissue is referred to as autologous reconstruction. This often involves using abdominal fat, skin and fatty tissue from the lower abdomen. There are a couple of different types of flap techniques.

  • TRAM flap (transverse rectus abdominis muscle) uses the blood supply of the rectus  abdominis muscle along with the skin and fatty tissue.
  • DIEP (deep inferior epigastric perforator) free flap technique is a variation of the TRAM  flap technique that preserves the rectus abdominis muscle. The main advantage of the  DIEP free flap technique is the ability to use the patient’s own tissue while minimizing  complications.

mom3: What are the pros and cons of autologous reconstruction?

Speaker-_Dr__Risal_Djohan: Yes, there are pros and cons to autologous reconstruction:

PROS
  • No need for future implant replacement
  • Result is a natural feeling, looking breast
  • Autologous tissue will grow or decrease in size with weight fluctuations, just like a  normal breast.
  • The autologous tissue harvested essentially is similar to a “tummy tuck” procedure.
CONS
  • Additional incision and scarring at harvest site (abdomen)
  • Radiation therapy may affect final outcome of reconstruction

Nipple-Sparing Mastectomy

holdingon: What are the circumstances that are ideal for having a nipple-sparing mastectomy? If I have a nipple-sparing mastectomy will I retain normal nipple sensations?

Speaker-_Dr__Risal_Djohan: The main driving force behind this technique is the aesthetic outcome. Nipple-sparing mastectomy has improved with DIEP or TRAM flap reconstruction techniques. It is often performed at a later time than the immediate reconstruction in order for healing and the shape of the reconstructed breast to return to a more definite shape. Current literature indicates that the procedure may be considered oncologically safe if the tumor is remote and does not have intraductal components.

newtonm: Could you explain what is involved with nipple and areola reconstruction?

Speaker-_Dr__Risal_Djohan: Most of the nipple reconstruction will use your own breast tissue or reconstructed flap tissue by folding them into the formation of a nipple. The areola is formed by either skin grafting or a tattoo process. Nipple sensation will not be the same as before. You will regain some sensation though as you recover.


Breast Reconstruction Aesthetic Considerations

wifeandmother: Will my breast(s) look natural after breast reconstruction surgery? Will you be able to tell the difference between my reconstructed breast and my remaining breast when wearing revealing clothing?

Speaker-_Dr__Risal_Djohan: You are correct. Reconstruction using your own tissue (autologous) will give you a more natural look and feel, however sometimes we have to perform a matching procedure to the other side of the breast in order to make them appear similar.

The appearance under clothing is dependent on the location of the mastectomy incision and reconstruction. Most of the time it is usually hidden.

sweptup: Is it often necessary to do an implant in the other breast in relation to symmetry?

Speaker-_Dr__Risal_Djohan: Modifying the contralateral breast is often necessary to preserve symmetry. This may require a mastopexy (breast lift), reduction or augmentation procedure.

katinthehat: Will my reconstructed breast be able to feel normal breast sensations?

Speaker-_Dr__Risal_Djohan: No, unfortunately your reconstructed breast will not feel like a normal breast, with normal sensation. This is because during the mastectomy, the breast tissue is removed along with the nerve. You will regain some sensation in the future. However, it will not have the same feeling like the normal breast.


Breast Reconstruction Complications

twitter: What is capsular contracture?<

Speaker-_Dr__Risal_Djohan: Capsular contracture is one of the possible adverse outcomes in implant reconstruction. All of the people will develop this complication depending on the degree of the capsular contracture. The implant reconstruction might need to be revised with another implant or switched to a tissue reconstruction.

ptop355: Does having diabetes cause any problems with having a breast reconstruction?

Speaker-_Dr__Risal_Djohan: NO, as long as your diabetes is well controlled. We suggest that you have a thorough medical check-up and release prior to surgery.

newtonm: Could you explain what is involved with nipple and areola reconstruction?

Speaker-_Dr__Risal_Djohan: Most of the nipple reconstruction will use your own breast tissue or reconstructed flap tissue by folding them into the formation of a nipple. The areola is formed by either skin grafting or a tattoo process. Nipple sensation will not be the same as before. You will regain some sensation though as you recover.

newtonm: How often does reconstruction fail? How long does it last? Will I have to have another procedure later in life (I am now 54)?

Speaker-_Dr__Risal_Djohan: The success rate of DIEP breast reconstructions is 98-99%. If you do have a failure we have to investigate the cause of the failure and certainly you would be a candidate for another reconstruction of another kind - either using tissue from another place such as back, thigh or buttock muscle or an implant.

nevermore: What happens if my cancer reoccurs?

Speaker-_Dr__Risal_Djohan: If the cancer reoccurs, it depends on the type of reconstruction you had. We have to concentrate on treating the cancer as the primary goal. If it is isolated to a small area, then the remainder of your tissue reconstruction might be able to supplement the defect. If it is an implant, we would most like have to replace the implant.


Breast Reconstruction & Insurance Coverage

patter_jo: Does insurance cover breast reconstruction?

Speaker-_Dr__Risal_Djohan: The Women’s Health and Cancer Act of 1998 is a federal law that requires that if the medical insurer covers for mastectomy, they must cover for reconstructions of the affected breast and reconstruction of the other breast to provide symmetrical appearance. This law applies to delayed, delayed-immediate and immediate reconstruction options.


Choosing a Program for Breast Reconstruction

sillyme: How do I find a good plastic surgeon for my breast reconstruction?

Speaker-_Dr__Risal_Djohan: You can go to the ASPS web site (American Society of Plastic Surgery) and look for a dedicated plastic surgeon that does breast reconstruction in their practice.

If you look at the Cleveland Clinic website, our Plastic Surgery Department has several surgeons who specialize in breast reconstruction which include myself, Dr. Bernard, Dr, Isakov, Dr. Lucas and Dr. Goodman.

Cleveland Clinic’s experience in breast reconstruction is impressive. Cleveland Clinic performs 100 DIEP procedures a year and implant reconstruction procedures are approximately 250 procedures a year.

The Cleveland Clinic Department of Plastic Surgery is composed of 12 full-time plastic surgeons, making it one of the largest plastic surgery departments in the nation. While U.S. News & World Report does not rank plastic surgery departments, we believe our efforts make us one of the best plastic surgery programs in the country.

All our full time staff surgeons are board certified in their specialty, as is required of all Cleveland Clinic full time staff. Our staff is "verticalized," meaning that each plastic surgeon has a specific area of clinical focus, giving us expertise and breadth in virtually all areas of aesthetic and reconstructive plastic surgery. The senior status of five of our 11 plastic surgeons represents a cumulative 100 years of plastic surgery experience. Additionally, three of the surgeons on staff are listed in America's Top Doctors.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Risal Djohan is now over. Thank you again Dr. Risal Djohan for taking the time to answer our questions about breast reconstruction.

Speaker-_Dr__Risal_Djohan: Thank you participation in this web chat. Should there be any further questions, please feel free to contact our office and we will facilitate an appointment for you.


More Information

  • To make an appointment with Dr. Risal Djohan, or any of the other specialists in the Dermatology and Plastic Surgery Institute at Cleveland Clinic, please call 216-444-4646 or call toll free at 800.223.2273 ext. 44646. You can also visit us online at: my.clevelandclinic.org/dermatology/dermatology_and_plastic_institute.aspx
  • A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult
  • If you need more information, contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
  • Some participants have asked about upcoming web chat topics. If you would like to suggest topics for 2009, please use our contact link clevelandclinic.org/webcontact.

This health chat occurred on October 16, 2009.

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.