Modern Breast Reconstruction in San Antonio Texas

Performing an immediate breast reconstruction after mastectomy allows the most natural breast reconstruction, as we will be able to keep most, if not all, of the breast skin and nipple.  Patients will discuss using her own tissue to reconstruct the breast (flap reconstruction) versus an implant or a tissue expander.  Dr. Albright performs the most up-to-date techniques in breast reconstruction including above-the-muscle (prepectoral) reconstruction and direct to permanent implant reconstruction.  

A delayed breast reconstruction surgery differs from performing the reconstruction at the time of the mastectomy because the skin of the breast has been removed. Therefore with a delayed reconstruction, we must replace the missing volume of the breast, but also address the lack of available skin. This is achieved by either stretching the remaining skin on the chest (with a tissue expander below the pectoralis muscle), or by moving new skin from another part of the body to the chest (a flap). Dr. Albright will discuss the pros and cons of both approaches and help you pick the best path moving forward.

Prepectoral implant based reconstruction is the most modern type of breast reconstruction and has many benefits over traditional below-the-muscle techniques. When the saline or silicone gel implant is below the pectoralis muscle, the muscle has to stretch across the implant. Not only will this produce more pain, it will also limit how much volume of implant can be placed to reconstruct the breast, and is the main rationale for using an expander (a temporary adjustable but not permanent implant). Since an expander is not a good permanent implant device, it will eventually need to be removed and replaced with a permanent breast implant in a second surgery which may be several months after the first surgery.

Another drawback is the movement the muscle makes when it contracts.  This will typically distort the shape of the breast and is called animation deformity. Furthermore, muscle contraction will also apply a pressure to the implant, and may accelerate implant displacement over time (typically out toward the armpit).  When the implant is placed above the muscle, these issues do not occur.

Dr. Albright is a board certified plastic surgeons with extensive knowledge and experience with this modern breast reconstruction technique. He will examine you to see if you are a good candidate for this new breast reconstruction technique.

For patients, a breast reconstruction is a significant commitment of time, money, recovery and emotion. Dr. Albright takes this very seriously.  Because complications from breast reconstruction can be so traumatizing (potentially delaying breast cancer treatments!), Dr. Albright utilizes every available resource and up-to-date technique to help avoid these pitfalls. It is also why Dr. Albright puts so much emphasis on postoperative recovery.  

Most patients who undergo above-the-muscle implant-based reconstruction will be limited from exercise for about 5-6 weeks.  In the first two weeks after surgery, you will be unable to reach and pull with the arms, or sleep on your sides. You will also have postoperative drains during this period.  Concurrently, you will be wearing some form of breast support continuously for four weeks.  In weeks 3-4, you will be able to perform range of motion stretches to the shoulders, but will still be somewhat limited on reaching/pulling.  Weeks 4-6, you will be unrestricted with arm movements and able to sleep on your sides.

Most patients will return to work at 2 weeks after surgery (all the rest of patients by 4 weeks) depending on how much reaching/pulling they must perform.  The reconstructed breast volume is relatively stable by 2 months, when patients can purchase new bras.  Final shape and look of the breasts out-of-clothing (assuming no radiation), will be achieved by 4-6 months after surgery for most patients.

There are several reasons why this approach can ultimately save you money, time, and unnecessary pain. Obviously, the financial savings will depend on the details of your contract with your insurance company, as well as current arrangements between your insurance carrier and Alamo Plastic Surgery. Whether Dr. Albright is an in-network or an out-of-network provider, you could still see substantial savings using this technique.
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In Dr. Albright's experience, prepectoral direct to implant breast reconstruction is often a single reconstructive surgery at the time of mastectomy, with a very low rate of revision surgery. About 25% of his patients will undergo a second reconstructive revision surgery, with the majority of these surgeries being simply fat transfer to improve implant rippling (a visual and more cosmetic concern rather than a functional problem). With fewer surgeries, there is often less cost seen by the patient because traditional expander reconstruction has a 100% revision rate (expander needs to be exchanged for the permanent implant. Commonly, since this exchange is often delayed by several months after your initial surgery, it commonly occurs in a different calendar year when your deductible has been reset.

There is also a potential cost savings with less postoperative recovery time compared to other types of breast reconstruction, whether implants below the muscle (traditional technique) or flap reconstruction. With prepectoral breast reconstruction, Dr. Albright's patients are getting back to work sooner than his previous under-the-muscle reconstructions and flap reconstructions.

Radiation is often used in breast cancer treatment to try to limit growth of any remaining cancer cells in the breast. It achieves this by causing damage to rapidly dividing cells.  However, it is not selective, and damages all the cells in the area. When the cells lining the blood vessels become injured, scarring may develop and ultimately limit blood flow to the skin.  Without normal blood flow, oxygen and micronutrient delivery may be compromised reducing your ability to heal wounds. Additionally, delivery of infection-fighting white blood cells may be decreased which increases your risk of infection with surgery.  Putting these issues together, we see why operating on radiated tissues has a high complication rate.  This is true for both implant-based and flap-based reconstruction.

However, implant reconstruction in the setting of radiation gets a bad reputation when compared to using your own tissue, as implants have a higher overall failure rate. But implant based reconstruction can still be performed in patients facing possible or even planned postmastectomy radiation.  These select patients will need to be otherwise ideal candidates for implant-based reconstruction to limit other risk factors for reconstruction failure. Dr. Albright will discuss these risks with you and your family so you can make an informed decision.

Even in Dr. Albright’s hands, these patients have a very high complication rate. The most important reason why this happens is because the radiation has already caused permanent damage to the tissues by restricting blood flow. Attempting to reconstruct these tissues when they have already been damaged is less predictable for wound healing and infection.  Even if patients get through the initial healing from surgery, most patients will develop capsular contracture around an implant within 5 years. Dr. Albright is rightfully cautious and highly selective when offering (or not offering) implant-based breast reconstruction to patients who had previous breast radiation.

The plan for the nipple and areola (pigmented skin around the nipple) depends on both oncologic needs (treating the cancer), and cosmetic issues. Your breast surgeons may need to remove the nipple and areola if your cancer is close to or could be close to the undersurface of these structures. It is not a good idea to leave cancer in the breast just to save the native nipple or areola. Typically Dr. Albright will discuss the cancer issues with your breast surgeons but will always defer to your breast surgeons when it comes to treating your cancer.

There are also cosmetic considerations when trying to keep the nipples. If the breasts are very large, there may be too much skin of the breast to be able to adequately fill with an implant. Additionally, as the nipple will be the furthest skin from intact blood vessels (all the vessels that were traveling through the breast tissue itself are now gone), there can be issues with wound healing at the nipple. Occasionally, the blood supply to the nipple is not adequate even if the patient was an ideal nipple-sparing mastectomy patient, and, unfortunately, this will only be apparent during the surgery (when you are asleep on the table). Therefore, Dr. Albright always discusses the possibility of losing a nipple during the procedure even if the plan is to save the nipple. If you have any questions or concerns, give us a call and we will be happy to schedule a visit to discuss.