How Long Does Mastectomy and Immediate Breast Reconstruction Surgery Take?

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The length of the surgery can vary depending on many things, especially the type of surgery being performed and if it involves one breast or both breasts. In general, expander/implant reconstruction is somewhat faster than abdominal tissue transfer, and usually takes 2-3 hours for one side mastectomy with reconstruction, and 3-4 for two sides.

Many women think that abdominal tissue transfer means a 12-14 hour surgery with possible blood transfusions, intensive care units stays, and an extended recovery. Because of the system that we work with, we are able to perform these surgeries much quicker. Rarely do women require any blood transfusions and all of our women go to the regular surgical floor after surgery.

We coordinate our surgery with the Surgical Oncologist so that we can begin working on the abdomen while they perform the mastectomy, which can save time. Also, by working as a team with two experienced Microsurgeons, we can perform these surgeries much faster than if we worked alone or with unskilled assistants. For a one-sided mastectomy with immediate abdominal tissue reconstruction, we expect to be finished within 4 hours of the start of the mastectomy. For a two-sided mastectomy and reconstruction, we expect to be finished within 6-7 hours.

What Is the Recovery like after Reconstruction with an Implant or DIEP Flap?

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For women who undergo mastectomy with expander or implant reconstruction, it is common to spend one or two nights in the hospital. Women are usually prescribed narcotic pain medicines and muscle relaxants which are usually weaned off in a couple weeks. Weekly visits are required to the plastic surgeon’s office to get the drains removed (usually within two weeks) and to undergo tissue expansion.
The number of clinic visits required for tissue expansion is variable, depending on the starting size of the breast, amount tolerated with each expansion, and final goal breast size. Driving is OK once narcotics are stopped, usually 2-3 weeks. For women with light duty jobs (no heavy lifting), work can frequently be resumed 3-4 weeks after surgery and most activities can be resumed by 6 weeks.

For women who undergo mastectomy with DIEP flap reconstruction, 3 nights in the hospital is common. One or two visits are required in the first couple weeks to have drains removed. Some women go home without any narcotic medications, and most women are weaned off of narcotics within one week. Women are usually able to drive within two weeks of surgery and return to light duty work within 3-4 weeks. Light activities are encouraged, and most activities can be resumed by 6 weeks and full activities by 12 weeks.

When comparing implant vs DIEP flap reconstructions in regard to recovery, there are several general considerations, although they might vary depending on the individual. In general, implant patients spend less time in the hospital (1-2 nights vs 3 nights). Pain tends to be very similar, and DIEP flap patients tend to wean off of narcotics a little faster. Implant patients tend to have more soreness and tenderness during the expansion phase which is not usually resolved until the expander is exchanged for a long term implant. Time to driving and time to work is usually comparable, but can

The Long Term Cosmetic Differences between a Lumpectomy with Radiation Therapy & a Mastectomy with Reconstruction

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Choosing between breast conservation therapy (BCT) and mastectomy can be very difficult decision for a woman to make. Most women like the idea of preserving the majority of their breast and nipple with the hope of minimal cosmetic deformity in the long run. They might view a mastectomy with reconstruction to be more surgery than they would like to consider. Unfortunately, it is not a clear cut situation and sometimes a mastectomy with reconstruction can provide a better long term cosmetic outcome.

There are two major issues that Plastic Surgeons will consider when assessing the likely cosmetic outcomes of BCT. The first major issue is understanding the size of the tumor relative to the size of the breast. If the tumor is small and the breast is large, then only a small percentage of the breast would need to be removed, leaving a majority behind. For women with small or moderate sized breasts, however, even a small tumor could require removal of a significant amount of their total breast volume.  Taking a large portion of a breast can lead to deformity. The second issue to consider is the location of the tumor, as some tumors will be positioned better in order to conceal any resulting deformity. In general, tumors that are behind or below the nipple, or within the inner portion of the breast can result in significant deformity, especially if the tumor is on the larger size. In general, tumors that are on the outside of the breast tend to be the best for a reasonable cosmetic outcome.

The cosmetic rationale for mastectomy, especially with abdominal tissue reconstruction, is the ability for a woman to have a skin-sparing mastectomy which can limit the scars of the mastectomy. This allows for the Plastic Surgeon to “lift” the breast and fix the breast sagging that is common for women as they age. A balancing breast lift of the other breast can usually be performed at the same time as the breast reconstruction. This allows a women to go into surgery, have their mastectomy, undergo reconstruction with a lift on the other side, and wake up with two lifted or perky breasts. This frequently gives an optimal cosmetic result. And since radiation therapy is usually not indicated after a mastectomy, the reconstruction will remain stable and likely not change over time.

I’ve Had a Lumpectomy and Radiation Previously but Now I Need a Mastectomy. What Should I Know?

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Lumpectomy and radiation, also known as Breast Conservation Therapy (BCT), is an increasingly common way to treat breast cancer, especially in women with larger breasts and smaller tumors. Although BCT has similar survival rates compared to women who undergo mastectomy and reconstruction (usually without radiation), there is a higher local recurrence rate for breast cancer in the same breast after BCT.

For women who have had BCT previously but now have a new breast cancer in the same breast, another lumpectomy with radiation is not possible. For this reason, women are best counseled to treat their new cancer with mastectomy. Although hormornal or chemotherapy may be indicated, radiation is usually not able to be given a second time.

For women undergoing mastectomy in this scenario, reconstruction with an expander or implant has a much higher rate of infection and reconstruction failure compared to women who undergo microsurgical breast reconstruction using their own tissues. For this reason, we strongly counsel women to consider free flap breast reconstruction. Depending on the previous scars present and the tissue quality, skin sparing mastectomy might still be possible.

I’ve Had (or Need) Post-Mastectomy Radiation, What Are My Reconstructive Options?

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Patients with stage III breast cancer, and now some patients with stage II breast cancer, are recommended to have ‘post-mastectomy radiation’. This will often be referred to as ‘chest wall radiation’. Contrast this to ‘whole breast radiation’, which is offered to all patients undergoing breast conservation (lumpectomy + radiation), regardless of stage.

To clarify, ‘post-mastectomy radiation’ typically involves treating the remaining chest wall skin, underlying pectoralis major muscle, and regional lymph nodes (in the arm pit or axilla). Whereas ‘whole breast radiation’ treats the remaining breast tissue, and only on occasion includes the regional lymph nodes in the axilla as part of the treatment.

Patients who have had post-mastectomy radiation present a reconstructive challenge because the radiated chest wall skin can’t be expanded, so addition of skin is required. Our preferred donor site for reconstruction is the lower abdominal skin and fat (DIEP flap) as enough skin and fat can be harvested to reconstruct a breast without the need for an implant. The abdominal skin provides a close match to breast skin.  If the abdomen isn’t an option other donor sites exist for total breast reconstruction without an implant. A flap from the back (latissimus flap) is an option but, because of limited amount of tissue from this area, addition of an implant is typically required to complete the reconstruction.

In some scenarios a tissue expander is placed at the time of mastectomy and then chest wall radiation is required. In this scenario the second stage of reconstruction can occur with an implant, but with higher risk of healing problems and infection, either of which can lead to loss of the implant. Alternatively, the reconstruction can be converted to tissue-based reconstruction, which is generally considered a safer approach.

Oncoplastics Breast Surgery, What Is It?…Am I a Candidate?

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Breast conservation therapy (lumpectomy + radiation) has demonstrated equivalent overall survival to mastectomy. The early experience with breast conservation was focused on treating the cancer far more than consideration of the aesthetic outcome of the breast. The field of Oncoplastics breast surgery integrates plastic surgery principles and techniques with breast cancer surgery. The goal is to preserve aesthetic outcomes without compromising principles of resecting the cancer.  In fact, recent studies have shown that surgical margins (how much ‘normal’ tissue is taken around the tumor) are better with Oncoplastics procedures.

In general, ideal candidates for breast conservation are those who have a small tumor relative to total breast size.  Location of the tumor matters, and patients with medial tumors (inner part of the breast) or those with tumors immediately below the nipple should be considered for mastectomy. Oncoplastics surgery can be integrated with any lumpectomy procedure, but patients with very large breasts or breasts with a lot of sag are the ideal candidates. In these cases the tumor can be removed with standard breast reduction or breast lift techniques and improve the appearance of the breast.

Why Do I Need to Have a CT-Angiogram before My DIEP Flap Reconstruction?

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DIEP flap reconstruction has come a long way since the early description of the procedure in the early 1990s. Our understanding of the perforating vessels that supply circulation to the lower abdominal skin and fat has evolved. Everyone’s anatomy is unique, and a CT-angiogram provides a clear road map of a patient’s anatomy. The benefits of these studies are very significant for patient outcomes, and include:  shorter operative times, lower complication rates, planning of the lowest possible scar, and maximal preservation of abdominal wall function.

Notably, in some circumstances the necessary information can be obtained from cancer staging studies or routine CT scans done for other reasons. At the time of consultation it’s useful to notify your surgeon if you’ve had a prior CT scan of the abdomen and/or pelvis.

How Do You Make a Nipple?

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Nipple reconstruction is usually a part of the final stage of reconstruction. A nipple reconstruction can be done as an office procedure, but sometimes is incorporated with revision of the reconstruction in the operating room. In our practice we perform the nipple reconstruction, and then tattooing of the areola as a separate procedure.

In simple terms, the nipple is made from elevating skin and folding it in a way that leaves a ‘nub’ of skin that looks like a nipple. In medical terms we refer to the skin elevation as “elevating a flap”, and the flaps described for nipple reconstruction are numerous. We may use a different flap design based on the needed size, width, or projection – either to match the other side (for one-sided reconstruction) or based on the patient’s goals (for two-sided reconstruction). Importantly, though the final product may strongly resemble an actual nipple, the reconstructed nipple does not have sensation or ability to change with temperature changes, and lacks erogenous sensation.