Nipple reconstruction

How long does the breast reconstruction process take?

The entire process of breast reconstruction can take from 6 months up to 1 year. There are several reasons why the process can take so long. After the first stage of breast mound reconstruction, you have to wait for at least 3 months afterwards before performing the next step, the equalization stage, followed a few months later by a nipple reconstruction. For the tattoo pigments to be uniform in appearance, an additional month or two of waiting is required after the nipple reconstruction to allow the scars to heal. Waiting between each stage allows for optimal healing to occur and swelling to settle down. Rushing through this process will likely lead to asymmetry or a poor aesthetic result. Patience will pay off in the long run.

Is there any problem if I had my mastectomy months or years ago?
It does not matter how long ago your mastectomy was, you can still have breast reconstruction. Either a tissue expander and implant method or using your own tissues such as a TRAM flap can be done months to years after a mastectomy.

How is a nipple reconstruction done?
There are many ways that a nipple can be created. The most common methods used include a C-V flap, which only uses the tissues already on your breast mound, or skate flaps, which often require a small skin graft from elsewhere (usually lower belly) to be used. Either method can result in a nipple reconstruction that is adequate in size to match your other nipple.

Do I have to complete all 3 steps for breast reconstruction or can I stop after the first step?
Many patients complete all 3 steps involved in breast reconstruction. However, some patients choose not to complete the nipple reconstruction or have anything done for equalization on their other natural breast, such as a breast lift. In most cases, this comes down to your personal decision.

How long should I wait after chemotherapy or radiation before starting reconstruction?
At least 2 months after chemotherapy is finished so that you can regain full healing capability and minimize infection risk. As for radiation, you need to wait at least 5 - 6 months after finishing radiation therapy before proceeding with breast reconstruction. Performing breast reconstruction too soon after radiation will put you at higher risk of wound healing complications.

Questions on Breast Implants for Breast Augmentation or Breast Reconstruction 

Are breast implants safe?
There have been numerous scientific studies done on patients that had saline filled or silicone filled breast implants. The largest and best performed studies to date have not shown that either saline or silicone filled breast implants are associated with any harm to your health. In addition, the current silicone breast implants are different from the original silicone implants that were removed in 1992. Many patients prefer the natural breast-like feel of a silicone implant. However, the decision to use saline or silicone breast implants is up to you.

Are breast implants permanent?
Breast implants can be permanent. If they do not get infected, deflate or have other mechanical complications, than they do not need to be replaced periodically.

What is capsular contracture?
Anytime a foreign material is inserted in the body, a scar lining forms around the foreign material, in this case the breast implant. In a minority of cases, the lining can get firm and start to contract. This can happen over the course of months and years after the implant is put in. In severe cases, the implant can look distorted and feel much harder, sometimes causing pain. Treatment for capsular contracture is an operation to remove the scar lining around the implant (capsule) and possibly replace the implant. This is an outpatient same-day surgery. Patients who have had radiation for the treatment of breast cancer are very susceptible to this complication.

What happens if I should develop capsular contraction?
Most times capsular contraction is mild and not a problem. The implant will feel more firm than it was when initially placed months to years ago. If however, the implant begins to feel hard or has moved from the initial location, an outpatient surgery may be required. Often times, the surgery involves removing the scar tissue from within (capsulectomy or capsulotomy) and usually, replacing the implant. Recurrence is uncommon.

What happens when breast implants deflate or leak?
Saline implant deflation is usually gradual and not related to a traumatic event like an accident or falling. Rather, most patients notice a gradual deflation and softening of the implant. Since saline is salt water, no bodily harm is inflicted on you. But, you do need an outpatient surgery to replace the defective implant. Most manufacturers cover their product for 10 years.

With silicone implants, the rupture is often unnoticed and therefore, it is recommended that you have an MRI scan every 2-3 years to screen for a ruptured implant. This is for your safety. The new silicone implants have a very low rupture rate (~ 3%).

What happens if I get an implant infection?
In the rare event that your implant or tissue expander gets infected, antibiotics will be necessary. In rare cases, if the infection does not respond to the antibiotics, the only way to cure the infection is to remove the implant. Once the infection has resolved, then the operation can be performed again, usually two or three months after removal. This is a rare complication.

Will my lymphedema (arm swelling) get worse after implant reconstruction?
Tissue expanders or implants will not worsen your arm swelling. Although some swelling may occur in the chest skin and remain for several weeks after the operation, the arm swelling is almost always transient and not permanent.

Should I have saline or silicone breast implants?
This really comes down to a matter of personal preference. There is no scientific evidence that silicone implants are harmful, but this is a subject of continued scrutiny.

How much time off from work will I need after having breast implant surgery?
For most people, 1-2 weeks off from work are more than plenty. Especially if your job or home situation does not require heavy lifting, you can go back to work in a week. Starting to drive depends on when you stop taking the pain medicines.

Can I have breast implants for reconstruction if I had radiation?
Generally the answer is no. Although it can be attempted and sometimes a satisfactory result obtained, the complications are high and end result is often aesthetically unpleasing and not durable. One of the two flap methods is preferable.

Questions on Latissimus dorsi Flap for Breast Reconstruction

What happens to my back and arm strength after the muscle is transferred?
The latissimus is a large muscle, but there are other muscles that can help compensate for the loss. Unless you do an athletic activity that requires full arm strength like energetic cross-country skiing, competitive tennis or competitive swimming, most patients are able to return to their normal activities after full recovery. Studies have shown minimal loss of range of motion or arm strength after one year.

Why do I need an implant as well as the flap?
Your back does not have enough fat to create a breast mound with and in most cases, the latissimus is being used to provide some skin and muscle coverage over damaged, irradiated chest skin. Therefore, there is no bulk to create the breast mound with. The implant is required to provide projection to simulate a natural appearing breast mound.

Will my lymphedema (arm swelling) get worse after the latissimus flap?
There is little risk that your arm swelling could get worse and remain worse after a latissimus dorsi flap for breast reconstruction. Most patients do not notice any significant worsening. A minority of patients have a mild degree of worsening that can be controlled with a compressive garment and this is an important point to discuss with your physician if you are contemplating a latissimus flap for breast reconstruction - especially if you had axillary lymph node dissection and radiation.

Will I have drains and for how long?
Drains will be placed for a short time in the back and the drains are usually left in for 2 weeks or until the volume of each drain has dropped to less than 30cc per 24 hour period.

How much time off from work will I need after a latissimus flap?
The latissimus flap requires around 2-3 weeks off before returning to work, provided that heavy lifting is not involved. You will be in the hospital for 1 night. For selected patients, the Latissimus flap operation can be done as outpatient surgery. For work that involves exertional activity, 6 weeks without heavy lifting is recommended.

Questions on TRAM Flap for Breast Reconstruction

How much pain is there after a TRAM flap?
Most of the pain from a TRAM flap is from the belly and not from the chest. You will be given narcotics afterwards to make you feel comfortable. Most patients are off their narcotic medicines within 1 to at most 2 weeks after the surgery, but this varies from patient to patient.

What happens if I get a hernia after the operation?
This is an unusual complication but can occur. If you should develop a bulge in the abdomen, usually noted around 6-12 weeks after the surgery, then the only treatment of this condition is additional surgery. A hernia operation is done as an outpatient surgery by a general surgeon and may require additional time off from work.

Will my lymphedema (arm swelling) get worse after a TRAM flap?
The arm swelling is transiently and mildly increased due to the fluids given during your surgery and resolves to the same pre-operative level after a few weeks.

Will I have drains and for how long?
You will have drains in your chest and in your abdomen. The drains stay in for around 1-2 weeks after the surgery. You will need to wear an abdominal binder or similar compressive garment for at least three weeks after the surgery.

How much time off from work will I need after a TRAM flap?
That depends on the activity level of your work. If you have a desk job, patients can return as early as 4-6 weeks. Because of the risk of hernia (2-3%), it is recommended that no lifting be done for at least 6 weeks after the surgery. Most patients take 6 weeks off so that they are completely able to perform their duties without restrictions