staged breast reconstruction

Significant advancements in reconstruction of the breast after mastectomy have allowed women historically unable to undergo these procedures to have a variety of options with reliable, reproducible and cosmetically pleasing results. Most women benefit from approaching them in a staged manner, which involves more than one procedure to attain a patient's desired goals. 

The first surgery is usually performed at the time of mastectomy in coordination with the breast cancer surgeon and involves the placement of a tissue expander, a temporary device similar to a water balloon that can be placed either above or below the pectoralis muscle. Since a patient’s radiation requirements are often unknown until after the mastectomy, the tissue expander maintains the breast space open while the need for radiation is being evaluated. As long as the expander is in place prior to radiation, all options are still open for patients. If an expander had not been placed prior to radiation, reconstruction is still possible but becomes limited to some form of tissue-based reconstruction.   

When the tissue expander is placed, it is only partially inflated. Over the next three to five weeks, the expander is gradually inflated during visits to the surgeons office. It is inflated by placing a needle through the skin and into the device. Most patients are numb in the breast skin so this is not typically uncomfortable. Once the desired size or limit of possible inflation is reached, the patient’s radiation status will define the next steps. If radiation is necessary, the expander will be radiated while still inflated. Once radiation is complete, patients can proceed with either implant-based or tissue-based reconstruction depending on their preference. 

If implant-based reconstruction is chosen, patients are advised to undergo an intermediary surgery before their final exchange procedure. This is known as fat grafting, a technique that has emerged as a powerful means of repairing tissues damaged by radiation due to the content of stem cells and growth factors within it. Fat grafting is able to be performed three months after the completion of radiation with the exchange procedure three months after that for a total of six months from the date of radiation completion.

If tissue-based reconstruction is selected, this is typically done through the transfer of abdominal skin and fat. It can be performed one year after completion of radiation to provide patients with the greatest chance of success based on available research.