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Reconstructive Breast Surgery Options

Name of OptionBrief DescriptionAdvantagesDisadvantagesWhy Choose Johns Hopkins Medicine?

Simultaneous Reconstruction

(Refers to timeline of reconstruction)

Reconstruction of the breasts done at the same time as surgery to remove the cancer

The patient wakes up with a breast mound already in place, having been spared the experience of seeing herself with no breast at all.

The process is done in the shortest time possible and is not a series of complex surgeries over a length of time.

If there is a recurrence of the cancer, the reconstruction may need to be modified.

If there are complications, post-surgery, women may need to have more surgeries.

Small revision surgeries or matching procedures on the opposing breast may be required.

Rarely, it is determined that a patient will need radiation, which can compromise reconstructed breast tissue.

Ours is one of the few breast centers in the region to offer this number of reconstructive surgery options to women.

Our surgeons perform skin sparing, nipple sparing and scar sparing mastectomy whenever possible, leading to better cosmetic and reconstructive results.

Our specialists are experienced in creative techniques, such as fat grafting, that can use fat from your body as a way to naturally shape the breast. Though revisions to your original procedure may need to be done over time, the end result is improved.

Staged  Reconstruction

(Refers to timeline of reconstruction)

This reconstruction involves placement of a temporary tissue expander at time of mastectomy. The expander gradually stretches the muscle and skin in preparation for either an implant or flap reconstruction.

The surgeon creates a natural pocket in which a permanent implant or a tissue flap may be placed.

The overall result is more symmetric, natural, and aesthetically pleasing.

It allows a woman to complete radiation treatment while having a “placeholder” implanted.

It allows enough time to make sure all of the cancer has been treated.

It takes longer to “complete” the breast cancer treatment process.

During the time of temporary tissue expansion, the breasts do not look natural.

Small revision surgeries or matching procedures on the opposing breast may be required.

Our surgeons have refined this technique and are able to deliver consistent, state-of-the-art outcomes.

Our specialists are experienced in creative techniques, such as fat grafting, that can use fat from your body as a way to naturally shape the breast. Though revisions to your original procedure may need to be done over time, the end result is improved.

Delayed Reconstruction

(Refers to timeline of reconstruction)

This reconstruction happens after all of the recommended treatment to treat the cancer is completed.

Some women aren’t comfortable weighing all the options at once when they are struggling with a diagnosis of cancer.

Some women need time to come to terms with losing their breast(s).

Some women who are overweight, smokers or have high blood pressure may be advised to wait.

It allows enough time to make sure all of the cancer has been treated.

Longer time to “complete” the breast cancer treatment process.

Women may not feel whole without their breast(s).

We specialize in complex breast reconstruction, including revisions to other surgeries where complications have developed.

Our specialists are experienced in creative techniques, such as fat grafting, that can use fat from your body as a way to naturally shape the breast. Though revisions to your original procedure may need to be done over time, the end result is improved.

Prosthetic Options

Breast Implants

A breast implant is a silicone shell filled with either silicone gel or a salt water solution known as saline.

The recovery from the initial expander placement surgery and from the permanent implant placement surgery is usually quicker than flap surgery.

It may be easier to control the final size of the reconstructed breast with implant reconstruction.

There are no additional scars on the patient’s body other than those on the breasts.

For patients without excess fatty tissue and who do not require radiation treatment, implants are a good choice and yield good final results.

With this implant most patients require placement of an expander first, followed by replacement of the expander with an implant. This type of reconstruction almost always requires at least two surgical stages and multiple visits to the plastic surgeon’s office between these stages for tissue expansion.

It is important to realize that for patients who are having a unilateral (one-sided) mastectomy, matching the other natural breast with an implant can be difficult. The shape and “feel” of an implant is not exactly like that of a natural breast.

In the short term, implants can become infected or mal-positioned and require surgery to correct these problems.

Implant-based reconstruction is not generally recommended if patients require radiation, due to the risk of complications. In the longer term, implants can develop capsular contracture (tightening of the soft tissues around the implant), implant mal-position, and implant rupture.

If there are complications, secondary procedures may be required.

As with any reconstructive breast procedure, patients having implant surgery at Johns Hopkins have the advantage of a highly trained breast reconstructive surgeon performing the procedure.

Autologous Microvascular Free Flap Options

DIEP Flap
SIEA Flap
SGAP Flaps

The DIEP flap is the technique where skin and tissue (no muscle) is taken from the abdomen in order to recreate the breast. Other flap techniques, called the SIEA flap, the LSGAP flap and the SGAP flap, take tissue from the lower abdomen or lateral buttock regions.

Since the reconstruction involves using the patient’s own tissues, the risks of implant reconstruction are avoided, particularly in the case of radiation.

Most patients have less postoperative pain than after a TRAM flap and are therefore able to leave the hospital sooner, and return to normal activities quicker than after a TRAM flap.

Because the abdominal muscle is not removed as in the TRAM flap, patients have much less risk of developing hernias, bulges and core weakness at the site where the flap is removed than patients who have had a TRAM flap. This advantage is much greater in bilateral (both sides) reconstruction.

It is typically easier to match the contralateral natural breast with the patient’s own tissue when compared to implant reconstruction.

Patients essentially end up with a “tummy tuck,” “bottom lift” or other cosmetic benefits at the same time as the breast reconstruction.

DIEP/SIEA/SGAP flap reconstruction generally requires a longer and more challenging surgery at the first stage when compared with implants or TRAM flaps.

Patients will have a scar across the lower abdomen or the upper part of the buttock where the flap is obtained. However, this does not differ from the TRAM flap as the abdominal scars are equivalent.

Small revision surgeries or matching procedures on the opposing breast or donor site may be required.

Patients who smoke, are obese or have diabetes are not ideal candidates for this type of surgery.

Our Breast Center surgeons perform more types of flap procedures than other breast centers in the area. Common procedures include bi-lateral SGAP flaps, LSGAP "cushion" flaps, and transverse upper gracilis (TUG) flaps. Our specialists pay particular attention to blood vessel mapping and nerve preservation, which improves results and minimizes anesthesia time for patients.

Many patients who are good candidates for surgery can have excellent results with these procedures. At our Breast Center the success rate is 97 to 99 percent.

Our specialists are experienced at creative techniques, such as fat grafting which can use fat from your body as a way to naturally shape the breast. Though revisions to your original procedure may need to be done over time, the end result is improved.

TRAM flap

In a pedicle TRAM flap, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat, and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself, without need for an implant. The free TRAM flap involves less muscle.

Shorter and less complex surgery than the other flap procdedures.

This was state-of–the-art decades ago and has since been replaced by other, more advanced procedures.

The patient may have more postoperative pain and longer hospital stays.

There is a risk of abdominal bulge or hernias, and as a result, there might be a limit to how much weight you can lift.

Other newer procedures may offer more natural results.

Surgeons at Johns Hopkins Medicine no longer perform or recommend the TRAM flap.

We offer many newer and more advanced options for reconstruction, including free tissue transfer procedures. Not all plastic surgeons can perform these newer procedures.

Patients who had complications from TRAM flap procedures come to our Breast Center for revision procedures.

Oncoplastic Surgery (Bilateral Breast Reduction or Lift Combined with Lumpectomy

This surgery combines the latest plastic surgery techniques with a lumpectomy. When a large lumpectomy is required (which will leave the breast distorted), the remaining tissue can be sculpted to restore natural appearance to the breast. The opposing breast will also be reduced to create symmetry.

Only involves one surgery.

Surgery is completed prior to radiation and does not pose the risks associated with wound healing.

Tissue surrounding the tumor is carefully analyzed for the presence of cancer—once when the surgical oncologist removes the tumor, and again when the plastic surgeon operates.

Breasts are symmetrical.

In the case of a breast reduction, if symptoms of large breasts were a problem before, these symptoms can be alleviated.

There is a risk of losing nipple sensation on the breast where the cancer is removed and the possibility for a free nipple graft.

Our plastic surgeons are well trained in this and other related procedures

 Reconstructive breast surgery options.
Reconstructive breast surgery options.
 
 
 
 
 
 
 

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