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March 2012 Plastic & Reconstructive Newsletter >>
Clinical Scenario: Autologous Breast Reconstruction After Bilateral Mastectomy
A woman with a history of breast cancer underwent genetics risk assessment and prophylactic bilateral mastectomy with immediate autologous reconstruction.
A 47-year-old woman with a history of Stage IIIB cancer of the right breast underwent initial treatment inclusive of chemotherapy and radiation therapy—at the UW Carbone Cancer Center.
Because multiple members of her immediate and extended family have had breast cancer, she underwent cancer genetics risk assessment. She was found to be positive for the BRCA1 gene.
The patient decided to have bilateral prophylactic mastectomies, plus a hysterectomy and bilateral salpingo-oophorectomy. She was evaluated at the multidisciplinary UW Health Breast Center and found to be an excellent candidate for immediate autologous reconstruction using deep inferior epigastric perforator (DIEP) flaps.
She was a suitable candidate because she had a significant amount of abdominal skin and fat to provide donor tissue for reconstructing adequate-sized breasts. Also, she had not had any large open abdominal operations (e.g., laparotomy).
The procedures were performed in one operation by a surgical oncologist and two plastic and reconstructive surgeons. (The patient will undergo bilateral nipple reconstruction three months later; waiting for the breasts to heal after surgery results in the best and most symmetrical outcome).
Overall, the patient is very happy with her results and with her experience here. She was in the hospital for four days, discharged home on the fifth day in minimal pain, and began resuming her normal activities at about two weeks postoperatively. She returned to work one month after her surgery.
Allopathic Vs. Autologous Reconstruction
Women who undergo unilateral or bilateral mastectomy for breast cancer (for either prophylactic or therapeutic reasons) have two options for surgical reconstruction: alloplastic or autologous reconstruction.
Alloplastic reconstruction uses tissue expanders and implants to reconstruct the breast. Autologous reconstruction uses a patients own tissue to reconstruct the breast mound. This tissue usually comes from the abdomen, and includes skin, fat, and possibly a small amount of muscle.
Alloplastic reconstruction is the older and still more common technique. It offers excellent cosmetic results with less donor site morbidity and scar formation, but limitations include capsular contraction, aesthetic mismatch (when performed after a unilateral mastectomy), and implant failure.
Over the past two decades, surgeons’ increased expertise in microvascular techniques has made autologous reconstruction a viable option for many women. Autologous reconstruction offers excellent cosmetic results, and because it uses a woman’s own tissues, it can contribute to an increased sense of “wholeness” after surgery and has fewer long-term complications than alloplastic reconstruction. Risks, however, include diminished sensation at the donor and reconstruction sites, and in very rare cases, partial or complete flap loss.
Flap choice depends on many factors, including the patient’s anatomy and whether she has had prior abdominal surgery. Our preferred method of autologous reconstruction is the Deep Inferior Epigastric Perforator (DIEP) flap. This approach uses fat and skin from the lower abdomen, which closely mimics breast tissue, but preserves the abdominal muscles. The result is less pain, a faster recovery, little to no loss of abdominal strength, and the added benefit of an abdominoplasty.
Other types of abdominal flaps include the Transverse Rectus Abdominus Myocutaneous (TRAM) flap, and the Superficial Inferior Epigastric Artery (SIEA) flap. Flaps from the back, upper thigh, and buttocks may also be used for patients who do not have sufficient abdominal tissue, or in combination with alloplastic reconstruction.
Timing of Reconstruction
Breast reconstruction can be safely performed during the same operation as the mastectomy. Advantages of immediate reconstruction include the need for only one operation and one recovery period, and a faster return to emotional well-being.
Delayed reconstruction, however, is often preferred for patients who undergo post-mastectomy radiation and chemotherapy, because of cellular changes in the skin caused by adjuvant therapy.
Nipple Areola Reconstruction
Nipple areola reconstruction usually takes place several months after reconstruction. In this outpatient procedure, surgeons elevate and arrange a flap of tissue on the breast to create the appearance of the nipple bud.
Tattooing creates the look and color of the areola, and can also be used by itself to restore the look of the nipple in women who do not wish to undergo surgical reconstruction.
Consultation and More Information
For more information about breast reconstruction options, or to contact us, click here.
Serletti JM, Fosnot J, Nelson JA, Disa JJ, Bucky LP. Breast reconstruction after breast cancer. Plast Reconstr Surg. 2011 Jun;127(6):124e-35e. Review. PMID: 21617423.