Lewis Plastic Surgery: Gordon Lewis, MD
2331-A Robious Station Circle
Midlothian, VA 23113
Breast Reconstruction After Cancer
We understand that with diagnosis of breast cancer, our patients have begun a roller coaster of emotions and physician visits. In many cases, prior to coming to us, our patients will have already seen a few other physicians and are overloaded with information. Our goal is to guide you through the decision making process, give you clear and concise information that gives clear foresight on your breast reconstruction procedure.
Breast reconstruction is a complex process that when skillfully applied using the most advanced techniques available can create a breast very close in shape and feel to your natural breast.
In many cases, your general surgeon will refer you Lewis Plastic Surgery. This often allows for an immediate reconstruction at the same time as your operation to treat the primary breast cancer. Some patients also come to Dr. Lewis after a mastectomy (or lumpectomy) wishing to have an improvement in the shape or symmetry of their breasts.
Breast reconstruction is a very complex topic, and the information on this webpage should only be a start to your knowledge base. We welcome you to Lewis Plastic Surgery for a consultation where we will have questions for you and you will undoubtedly have questions us. This discussion will help us formulate a plan together, to create the best possible result with truly personalized care.
We wish each person well as they go through this difficult time.
What is breast reconstruction?
Breast cancer is frequently treated with a surgical treatment to remove the entire breast called a mastectomy. This involves removal of the entire breast and in more advanced cases, also the lymph nodes from the armpit. Without reconstruction, the result from this operation gives a completely flat contour to the chest wall and a horizontal incision across the front of the breast.
Breast reconstruction involves surgical procedures performed at the time of a mastectomy, or later after a mastectomy. This allows the creation of a breast with either your own natural tissue or more commonly with an implant.
In the United States and around the world, implants are used for about 80-90% of breast reconstructions. The implants are usually silicone implants and these can give a very good look and a natural feel to a reconstructed breast.
There are a variety of options for using your own tissue for breast reconstruction, and in some cases, this is a better option than implant based reconstruction. The two common locations for tissue for breast reconstruction is the skin and fat from the lower abdomen (TRAM flap) and less commonly the latisimus dorsi muscle and overlying skin from the back. When the latisimus is used, there is less natural tissue and an implant may be needed as well.
These are discussed further on the procedure page.
How long does breast reconstruction surgery take?
The surgery for breast reconstruciotn is individualized and the length of the procedure varies greatly. Most breast reconstruction involves tissue expanders and implants and takes about one hour to reconstruct one side. If autologous tissue (your own tissue) is used, these operations are longer and can take 4-16 hours depending on the type of surgery performed.
How long does the process take to complete?
Breast reconstruction is unfortunately not a one operation procedure. We try to keep care to the minimum number of surgical cases, but it is rare that one operation can achieve a good end result. In most cases it takes six months to a year to complete breast reconstruction from start to finish.
The first operation is usually the placement of tissue expanders. It usually takes about 6-8 weeks to inflate them to the required volume. Once there, they will be left in place for 3 months. At that time, you will need to return to the operating room for a quick outpatient procedure to place permanent implants. Once this is healed, a nipple can be created in the office and then tattooing can complete the care. If radiation is used, this will delay the process by several months. Chemotherapy usually has less effect on the length of the reconstructive process, but can have some effect on the timing of the operations.
How does radiation or chemotherapy fit in to this process?
Radiation is commonly used if the tumor is larger than 5 cm, or if it has spread to the lymph nodes. Radiation can cause a thickening and tightening of the skin that makes reconstruction more difficult. The skin loses some of its elasticity, has increased pigmentation and is at increased risk of infection. In short, radiation is not good for breast reconstruction, but is used because the primary goal is to keep the cancer from recurring. We will have an in depth discussion about the options when radiation is planned.
Chemotherapy does not frequently have any effect on breast reconstruction, and your procedure rarely has any effect on starting chemotherapy. Because healing is compromised while patients are on chemo, we will wait until chemotherapy is completed prior to any second stage procedure.
The most common type of breast reconstruction is performed with breast implants. These typically are silicone-based breast implants, that in many cases can look and feel very natural. This type of operation typically involves two major steps, the placement of a tissue expander and then the replacement of this tissue expander with a permanent breast implant. The end result in most women is a breast that has a natural shape and feel.
What is the process involved with this?
The start of breast reconstruction is usually at the time of the mastectomy or bilateral mastectomies. After a general surgeon has removed the breast, we are able to preform our portion of the operation. We begin by creating a pocket underneath the pectoralis muscle in order to insert an appropriately sized tissue expander.
A tissue expander is a specialized, temporary, implant that is designed to allow a needle to be placed through the skin, into the tissue expander to inject a saline solution. This will stretch the skin of the breast back to its original shape and volume.
After the tissue expander is placed underneath the pectoralis muscle, a acellular dermal matrix product is used to cover the lower portion of the tissue expander and attach this to the chest wall. This allows complete coverage of the tissue expander that will give the greatest, most natural shape after the operation. At this point, a surgical drain is placed and then the remaining skin on the breast is closed over top of the muscle and tissue expander. The tissue expander is filled to the maximal volume possible without compromising the blood supply to the overlying skin.
After a short stay in the hospital, usually one night for single-sided breast reconstruction, and two nights for bilateral breast reconstruction, the patient will go home with pain medications and antibiotics. The surgical drains usually are removed around two weeks after the initial operation.
Starting approximately 3 weeks after the operation, tissue expansion begins. This involves injecting fluid into the tissue expander and stretching the overlying skin. Once we’ve achieved the desired size (at this point the shape is less importance), we will start planning for exchange to a permanent breast implant. This is usually performed 3 months after the final tissue expansion. This delay allows the skin to relax and soften.
Another return to the operating room for a short and quick operation allows the tissue expander to be removed, and a permanent breast implant to be placed. This is a great improvement to the breasts as they immediately become much softer, and the shape improves greatly.
Nipple reconstruction and subsequent tattooing can be performed as short outpatient procedures once all incisions are healed.
What are the types of implants that can be used?
Both tissue expanders and permanent breast implants have silicone shells. The interior of tissue expanders and saline implants contained a saltwater solution.
Saline breast implants have a silicone gel and are filled during the operation to the desired volume with a saltwater solution. As with silicone breast implants, great care is taken to prevent infection of the implants including washing them with a triple antibiotic solution, minimal contact with the skin and meticulous care of the overlying tissues that will be closed on top of the implant.
“Silicone” breast implants not only have a silicone shell, but also contain a silicone polymer gel. Both permanent saline breast implants and silicone implants can offer a patient a soft breast with a natural appearing contour but there are pluses and minuses to both.
Although silicone breast implants have a controversial history, recent studies have concluded that these are very safe. These implants have been used for breast reconstruction continuously since the 1970s. There was a 15 year period until 2006 when they were not allowed to be used for breast augmentation due to concerns of a correlation between the placement of silicone breast implants and autoimmune disorders. During this period, there are some large Scandinavian studies, which demonstrated that there was no increased risk of autoimmune disorders from silicone breast implants. In 2006, the FDA re authorized use of silicone breast implants for breast augmentation surgery as well.
A recent advancement of the silicone gel implant is the “gummy bear” implant. This is a cohesive gel implant that is anatomically shaped similar to a breast. This implant can offer a more natural contour and transition from the upper portion of the breast to the lower portion of the breast.
During your consultation we will have a lengthy discussion about the risks and benefits of the different types of implants. In general we prefer the use of silicone breast implants for breast reconstruction. With the loss of the overlying breast tissue, there is less “natural “breast tissue overlying the implant. Saline breast implants have a higher likelihood of being palpable as well as the possibility of seeing ripples in the implant.
For some women, autologous tissue, may either be preferred or may offer a better option for breast reconstruction. There are a few options for this type of reconstruction. In each of these types, volume from the breast is replaced with skin and fat from another location in the body.
TRAM flap reconstruction
This surgery involves using the skin and fatty tissue form the lower abdomen to reconstruct the breast. After the mastectomy is performed, this tissue is separated from the surrounding tissue in the lower abdomen, but remains connected to the underlying blood supply though connections to one of the two rectus abdominus muscles. This connection is maintained as the TRAM flap is brought up into the pocket where the breast used to be. This gives an immediate reconstruction to the side involved.
The belly is closed by bringing the skin back together with a horizontal incicion. This gives the added benefit of getting an improvement in the shape and contour of your belly similar to a tummy tuck.
This operation is a longer operation (about 4 hours) than implant based reconstruction and usually requires a 3-4 night stay in the hospital after the surgery. Despite the removal of one of the two rectus abdominus muscles, studies have shown that there is no increased weakness in the abdominal wall. There is a small chance of a hernia after this operation.
The pedicled TRAM flap is a common operation to perform for breast reconstruction and has been used for over three decades. This is a safe and reliable operation that can achieve remarkable results when properly performed.
Latissumus Dorsi Flap reconstruction
The Latissimus Dorsi muscle is a large muscle in the back that supports a large amount of skin overlying it. This can be brought around to the front of the chest to reconstruct the breast. The volume of tissue from this skin and muscle is usually less than the breast tissue that has been removed and therefore often requires that additional use of an implant. With the combination of this tissue and an implant, the reconstructed breast can look and feel very natural.
This surgery also requires a stay in the hospital for 3-4 days after the operation.
How long will complete recovery take?
After the surgery you will be seeing Dr. Lewis fairly frequently. We are available at all hours by phone, and are open five days a week at the office. If you have any concerns, we are there to help.
The physical recovery from these operations varies by procedures performed. Return to work is very hard to predict as every patient has a different level of interest or desire to return to work.
Tissue expander/ implant reconstruction: This has the fastest recovery and return to normal activities. This usually only requires one night in the hospital after the operation and then some women are able to return to work within 7-10 days if they are highly motivated. Most can enjoy walks around the neighborhood within a few days of the operation and activities are gradually increased over time.
Muscle flap: this usually requires a longer hospitalization of up to 3-7 days after surgery depending on the type of procedure. Most women take 4-6 weeks off work after these operations. It takes a bit longer to return to full activities due to the loss/ damage of the native muscular tissue.
Over the several weeks following an operation for breast reconstruction, you will notice that you are feeling better. There are good days and bad days. Dr. Lewis will be available to assist in your care at any time after surgery. He is on call 24 hours a day, 7 days a week and will respond any hour of the day. You will be well cared for after the operation.
Dr. Lewis and his staff will give you detailed instructions for your postoperative care and activities prior to and after the surgery, but if at any time you have questions that are not answered by the instruction forms, or are unclear, please call. We are here to help.
Am I a good candidate for breast reconstruction surgery?
Most people undergoing treatment (mastectomy) for breast cancer are candidates for immediate breast reconstruction. We will evaluate your overall health status and make the final determination, but in most cases the additional health risk is minimal.
There are a variety of factors that go into the consideration when deciding the appropriate surgery:
- Size of cancer
- Hormone receptor status
- Location of cancer
- Likelihood of needing radiation
- Overall health
- Body habitus
We will evaluate each of these and discuss with you to determine the best option for breast reconstruction.
What are the risks of breast reduction surgery?
With any surgical procedure there are risks that you must be aware of. To minimize the risks, ensure your surgery is conducted in a safe and secure environment using the latest surgical techniques by checking the certifications and accreditation of your surgeon. Accreditation boards and bodies are there to protect you. Dr. Gordon Lewis has 9 years surgical experience and is affiliated to several important professional organizations.
- He is board certified by the American Society of Plastic Surgeons www.plasticsurgery.org
- Affiliated to the Richmond Academy of Medicine www.ramdocs.org and the Medical Society of Virginia www.msv.org
- He is also an associate member of the American Society for Aesthetic Plastic Surgery www.surgery.org and the American College of Surgeons www.facs.org
- A candidate member of the American Society for Surgery of the Hand www.assh.org
What are the complications of breast implants?
With any implant there is a possibility rupture. If a saline breast implant ruptures, the saline solution that is within the implant will become absorbed by the body. This results in the rapid loss of volume in the breast and a “flat “breast. In the event of this occurrence, a new implant can be placed during a quick outpatient procedure.
As silicone is not absorbed by the body, implant rupture is not always apparent. The FDA recommends that patients with silicone breast implants get MRIs to evaluate for rupture. The recommended schedule to get a MRI to evaluate for implant rupture starts 3 years after surgery, and then every 2 years. As this is part of the screening and care of the reconstruction for breast cancer, this is covered through insurance policies. When an implant rupture is determined, this will require removal of the implant and replacement with a new implant. This is typically a fast outpatient procedure.
Any time an implant is placed in the body, there is a possibility of infection of this implant. We are meticulous in our care to avoid infection. You will be given antibiotics prior to the operation, after the operation and the implants and the pocket for the implants are washed with a triple antibiotic solution. Even still, there is a small chance of an infection after the placement of an implant. If this does occur, this will require removal of the implant for several months to allow the infection to clear. Once clear, a new implant can be later inserted.
During your initial consultation we will review the notes from your general surgeon and / or oncologist. We’ll ask you about your overall health and goals for the surgery, discuss the options for breast reconstruction and the steps needed to complete the process. Together we will formulate a plan for the surgery.
After you leave, we will coordinate with your referring surgeon (if needed) and plan a date for the operation. This is usually in one to three weeks after the first visit.
We understand that this is a time of tremendous stress. There is an enormous amount of information that takes time for each patient to process, so a second visit prior to surgery is recommended. This allows you to ask further questions and for you the have a better understanding of the surgical plan and steps involved.
Surgical procedures are performed at an accredited outpatient surgical center or a local hospital. Dr. Gordon Lewis is affiliated with several local medical centers where his patients undergo surgery. He primarily operates at these locations:
Stony Point Surgery Center
Parham Surgery Center
He also has privileges at St. Mary’s Hospital and Henrico Doctors Hospital, but he operates there less frequently.
Initial consultations, follow-up appointments, and all non-surgical treatments and minor surgical procedures are performed at Lewis Plastic Surgery practice, which is located on the grounds of Johnson-Willis Hospital in Richmond, Virginia.
Will breast reconstruction surgery be covered by insurance?
Yes, the vast majority are covered under health insurance policies.
Every patient is required to attend an initial consultation before a procedure can be booked. Once you decide to proceed with surgery, we will assist you in finalizing a date and getting everything ready for surgery. We try to be as flexible as possible and will make arrangements to see you at Lewis Plastic Surgery on the grounds of Johnston-Willis Hospital within a few days after you contact us.
Gordon Lewis, M.D.
Dr. Lewis, a native of Richmond, prioritizes building honest, trusting relationships and providing personalized care for his patients.Meet Dr. Lewis