Specializing in breast reconstruction, we hope to provide our patients with an option that both restores the beauty of their form while minimizing the fear of breast cancer recurrence and the need for radiation. We have put this web site together to provide you our perspective on breast cancer and breast reconstruction. If you or someone you know has breast cancer, we hope this web site will provide some insight as they go through the difficult decisions before them.

For women, initially hearing that they have the diagnosis of breast cancer can be overwhelming. In this state of shock, sorting through the multiple treatment options can be extremely difficult. Remember first that there is no immediate rush. Take the time to educate yourself. Bring someone with you to your physician appointments and have them write down the important points and list your options. It is also often helpful to obtain a second opinion, especially if you do not feel entirely comfortable and need some reassurance. Realize, however, that there is no one correct answer when it comes to breast cancer treatment. The treatment of breast cancer is controversial and what is best for you should be tailored to your individual needs. Breast surgery, primarily breast reconstruction, represents the majority of our practice. We offer the hope of a normal appearing breast for the woman who either is required to have a mastectomy or has chosen a mastectomy over lumpectomy and radiation due to the concern over the long term effects of radiation or the risk of breast cancer recurrence. In these patients, it is our desire to restore a breast shape that looks better than the shape she started with. In the included photo library of cases, one can see that this is often possible.

The following is an outline of the three basic surgical options for breast reconstruction. The results for all three techniques are generally better if performed at the same time as the mastectomy (immediate reconstruction). It is for this reason that if you feel that you might ever consider mastectomy and reconstruction, it is a good idea to consult with a reconstructive plastic surgeon from the very beginning.

 

There are three commonly used procedures for breast reconstruction: breast tissue expander followed by permanent implant, latissimus dorsi with or without tissue expander and permanent implant, and a transverse rectus abdominus myocutaneous flap. An additional variable to these three procedures which must be factored in is whether or not the reconstruction will be done at the time of the mastectomy (primary reconstruction) or at a later date (delayed reconstruction). Even if performed at the time of the initial mastectomy, most plastic surgeons will require two procedures to complete the reconstruction.

The use of a tissue expander followed by a permanent gel or saline implant is a common procedure used today for breast reconstruction. It can be used when performing a primary or delayed reconstruction. In either case, the tissue expander is placed beneath the chest (pectoralis major) muscle. The muscle and breast skin are closed over it and allowed to heal. Most tissue expanders have a port built into them that can be accessed through a needle inserted in the skin. Saline or salt water is injected through the port usually at 2-3 week intervals. Just as an abdomen stretches during pregnancy, the addition of fluid slowly stretches the skin and recreates a breast mound. Following the completion of chemotherapy or (if chemotherapy is not required), the patient and the surgeon return to the operating room where a small incision is made, the expander is removed, and a permanent saline or gel implant is placed in the cavity.

At the second procedure, a nipple areola reconstruction is usually performed completing the reconstruction. The advantage of a tissue expander/implant reconstruction is that it takes little time to place the expander at the time of surgery and there is not a secondary operative site to deal with.

The disadvantages are that it is often difficult to match a mature woman's breast with just the use of a tissue expander followed by an implant. Most women's breasts have a degree of ptosis or sag, and this is difficult to reproduce with an expander followed by an implant alone. A secondary concern is that without bringing in additional tissue, the skin covering an expander/implant reconstruction can at times become quite thin resulting in visible wrinkles and/or an unnatural feel. In short, the advantages of an expander/implant reconstruction are the relative short duration of surgery and the lack of a secondary operative site. The disadvantages of this procedure are that the surgeon has little flexibility to deal with adverse conditions, and it is difficult to reproduce the appearance and feel of a mature woman's breast with this procedure alone.


 

The second procedure commonly used for breast reconstruction is the use of a latissimus dorsi flap from the back, with or without a tissue expander or implant. Over the years, this technique has become my primary method for reconstruction. It usually utilizes an expander in a similar manner as previously described but in addition brings additional tissue, skin, muscle and fat from the side or back. This additional tissue allows the surgeon the opportunity to fill in any defects from the mastectomy and allows the surgeon something to mold into a more natural breast shape.

The disadvantage of this procedure is that it requires an additional hour of surgery and requires a secondary incision on the side or back of the patient. While not resulting in an ideal result, the use of the latissimus muscle allows for postoperative radiation if indeed this is required. The postoperative recovery period is similar to that of an expander/implant reconstruction, with 1-2 nights in the hospital and 2-3 weeks off work.


 

The third option for reconstruction is the transverse rectus abdominus myocutaneous flap or TRAM flap. There are several variations of this flap: the pedicle tram, free tram, and DEIP flap. All three utilize the lower abdomen to create a breast mound. The advantages of this procedure are that a permanent implant is usually not required and postoperative radiation treatment, while again not ideal, is possible. The disadvantages of this procedure are that it results in a large abdominal scar, portions of the flap can become hard and may result in lower abdominal weakness and possible hernia formation. In addition, the procedure takes approximately 3-4 additional hours of surgery. Most commonly a patient stays 2-3 days in the hospital and is off work 3-4 weeks post surgery.

 


When tailored to the right patient, all three of the above described methods give reasonable results in the reconstruction of the post mastectomy breast. It is beneficial that the patient have a discussion of the appropriateness of each of these three options with respect to her case.

Over the years, I have used each of the three methods described as my primary technique for breast reconstruction. In the last 5-6 years,however, I have become increasingly biased towards the latissimus dorsi flap as my primary means for reconstruction. For most patients, it provides the best aesthetic result, minimal postoperative recovery time, and the lowest postoperative complication rate. Included are some representative cases to compare results with. It is hoped that this discussion will help you in your decision. If you have questions concerning your treatment plan, please do not hesitate to contact Rosemary Murphree, R. N., our reconstructive team leader, and if we cannot help you, we will do our best to find someone in your area that can.

Stephen F. Davidson, MD

A tissue expander is inserted following the mastectomy to prepare for reconstruction.
After surgery, the breast mound is restored. Scars are permanent, but will fade with time. The nipple and areola are reconstructed later.
The transported tissue is used to cover the implant and replace skin deficit.
The Flap is being placed over the breast implant.
The transported tissue forms a flap for a breast implant or it may provide enough bulk to form the breast mound without an implant.
Tissue may be taken from the abdomen and tunneled to the breast or surgically transplanted to form a new breast mound.
After surgery, the breast mound, nipple and areola are restored.

 

These photos represent post operative results. These women have undergone either unilateral or bilateral mastectomy's with reconstruction.

Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi
Right Tram
Left Latissimus Dorsi
Right Tram
Left Latissimus Dorsi
Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi
Bilateral Tram

Bilateral Tram
Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi

Right Latissimus Dorsi
Left No Surgery

Right Latissimus Dorsi
Left No Surgery
Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi
Right Latissimus Dorsi
Left No Surgery
Right Latissimus Dorsi
Left No Surgery
Right Latissimus Dorsi
Left No Surgery
Right Latissimus Dorsi
Left No Surgery
Right Breast Augmentation
Left Latissimus Dorsi
Right Breast Augmentation
Left Latissimus Dorsi
Right Latissimus Dorsi
Left No Surgery
Right Latissimus Dorsi
Left No Surgery
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi

Right Latissimus Dorsi
Left No Surgery
Right Latissimus Dorsi
Left No Surgery
Bilateral Latissimus Dorsi
Left Latissimus Dorsi
Right Reduction
Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi
Right Latissimus Dorsi

Right Latissimus Dorsi
Before Left Latissimus Dorsi
And Right Augmentation
After Left Latissimus Dorsi
And Right Augmentation
Right Latissimus Dorsi
Left Breast Augmentation
Right Latissimus Dorsi
Left Breast Augmentation
Left Latissimus Dorsi
Right Breast Reduction
Left Latissimus Dorsi
Right Breast Reduction
Left Augmentation
Bilateral Latissimus Dorsi
Left Augmentation
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi

Bilateral Latissimus Dorsi
Left Latissimus Dorsi
Right Breast Augmentation
Left Latissimus Dorsi
Right Breast Augmentation
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi
Left Latissumus Flap
Right Mastopexy
Left Latissumus Flap
Right Mastopexy
Right Tran
Left Breast Reduction
Right Tran
Left Breast Reduction
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi
Left Latissimus Dorsi
Right Mastopexy Implant
Left Latissimus Dorsi
Right Mastopexy Implant
Bilateral Latissimus Dorsi
Bilateral Latissimus Dorsi

 

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rmurphree@phsa-ms.com or (601)936-0903

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