Today, breast reconstruction utilizes reconstructive techniques as well as cosmetic breast enhancement. The reconstruction method is based on each woman’s anatomy and oncologic and surgical requirements. Achieving a result that is natural, proportional, aesthetically pleasing is aimed in breast reconstruction. Dr Cigdem Unal has a fellowship in breast reconstruction. She completed her fellowship at Gent University, Plastic, Reconstructive & Aesthetic Surgery Department. She has a European Plastic Surgery Board certification as well as The Turkish Plastic Surgery Board.

Breast reconstruction is an option for the majority of women undergoing unilateral mastectomy (one side), bilateral mastectomy (both sides), and breast conserving surgery.

The breast surgeon and your plastic surgeon collaborate in the decision making process of your reconstruction. The type of breast reconstruction and whether your reconstruction procedure can be performed as an immediate or late reconstruction, will be discussed with you and your breast surgeon. Immediate breast reconstruction is usually possible in most patients and the surgical process begins during the mastectomy procedure.

After a mastectomy, there are two primary paths for breast reconstruction:

• Prosthetic or implant-based reconstruction, which involves the use of tissue expanders and/or breast implants
• Autologous reconstruction, utilizing tissue from elsewhere on your own body

When women chose breast conservation therapy that includes:

• Lumpectomy
• Sentinel lymph node biopsy
• Radiation therapy

The role of plastic surgery in breast conserving surgery is shaping of the breast after a lumpectomy (also known as oncoplastic surgery).

Almost all breast reconstructions after mastectomy require several “stages” to achieve the final desired result, although other than the first inpatient surgery (mastectomy and first stage reconstruction), subsequent procedures are outpatient and associated with short recovery periods and minimal downtime.

When bilateral mastectomy is performed, the breast reconstruction process is most often identical on each side, and is associated with greater short term and long term symmetry. With unilateral (one side) mastectomy and breast reconstruction, surgery on the opposite breast (contralateral breast lift, breast augmentation, or breast reduction) is frequently required to achieve the most balanced results.

Timing of Breast Reconstruction: Immediate or Delayed?

Breast reconstruction can be performed at the time of mastectomy (immediate), or during a subsequent operation (delayed). Today, care centers that provide comprehensive breast care, immediate breast reconstruction is an option for most women.

Immediate Reconstruction

The advantages of immediate reconstruction are:

• Breast cancer removal and first stage reconstruction during one operation,
• Avoiding the visual impact of mastectomy only on body image, and
• Preservation of the anatomic landmarks which can lead to a more natural appearing breast.

DELAYED RECONSTRUCTION

In some situations, there are:

• Advanced disease (Stage III)
• Active smoking
• Obesity
• Cardiac disease
• Lung disease
• Poorly controlled diabetes
• Other comorbidities

In these circumstances, delayed breast reconstruction may be recommended.

The advantages of delayed reconstruction are primarily related to blood supply, as poorly perfused mastectomy skin flaps are of little concern during a delayed breast reconstruction. For the vast majority of women in good health with lower stage breast cancer (0, I, II) or in praflactic mastectomy patients with BRCA gene mutation, the breast reconstruction process is begun immediately during the mastectomy procedure.

Choosing the Best Breast Reconstruction Type:

Breast reconstruction after mastectomy can be performed with implants, with ones own tissue, or with a combination of these procedures.

There are a wide variety of options that include:

• Tissue expander-implant reconstruction
• Direct-to-implant reconstruction
• TRAM flap
• DIEP flap
• Latissimus dorsi flap with implant
• And many others

The choices may seem overwhelming. For a plastic surgeon specialized in this area, there may be a clearly better surgical approach based on an individual’s breast size and shape, body habitus, choice of unilateral or bilateral mastectomy, previous breast surgery, history of or need for radiation, lifestyle, and personal preference. Women with a body mass index smaller than 30 who desire shorter recovery time and no distant donor site are ideal candidates for implant reconstruction.

Those with ample abdominal tissue excess and/or a history of breast radiation would be considered for autologous tissue reconstruction. A top breast reconstruction surgeon in Istanbul, Dr Cigdem Unal, will advise you on the best breast reconstruction options for your unique needs and desires.

Implant-Based Breast Reconstruction

Breast reconstruction with breast implants can be performed in one or two primary surgical procedures.

Dr. Cigdem Unal most often recommends a two-stage reconstruction in selected cases, beginning with a tissue expander at the first stage that is gradually filled to desired volume followed by a second procedure wherein the expander is removed and a permanent breast implant is inserted.

In contrast to the one stage implant approach, known as direct-to-implant reconstruction (DTI), the two stage process affords advantages that include: a higher safety profile especially in those where the nipple areola complex need removal, as the amount of tension on the mastectomy skin flaps can be controlled with easy adjustments in perioperative expander volume and a more predictable aesthetic outcome, with fine-tuning at a second stage inherent in the process.

The two main surgeries of the tissue expander implant reconstruction are as follows: first stage, performed most commonly as an immediate breast reconstruction at the time of mastectomy, and the breast implant exchange, most often approximately three months after the first stage procedure. If needed adjuvant therapy (chemotherapy) may impact the timing of the exchange procedure only, as the second stage procedure is generally performed 4 weeks after the last treatment.

Autologous Breast Reconstruction

Autologous breast reconstruction utilizes tissue from ones own body. When there is enough tissue, the reconstruction can be performed without the use of an implant.

The most common “donor site” (the location from which the tissue is moved) is the abdomen, but it can also be transferred from:

• Back
• Hips
• Gluteal region
• Thighs

A TRAM (transverse rectus abdominis musculocutaneous) flap has been the most common abdomen-based reconstruction, joined by the DIEP (deep inferior epigastric perforator) flap which is performed with microsurgery and preserves the abdominal musculature.

Other pedicled flap and free flap donor sites can bring tissue to the chest wall when necessary, but often need to be augmented with the placement of an implant (this is known as a hybrid breast reconstruction, employing autologous tissue and breast implants).

The autologous breast reconstruction procedures involve much more surgical time and a longer recovery. Dr. Unal generally considers these procedures when there is a relative or absolute contraindication to his breast reconstruction in Istanbul, using implants.

Type of Mastectomy – Total Mastectomy or Nipple Sparing?

Most mastectomies for breast cancer are modified radical mastectomies, where a total mastectomy combined with an axillary node procedure (sentinel lymph node biopsy or lymph node dissection) is peformed.

While most of these are largely “skin sparing”, the nipple areolar complex is removed when there is indication in this surgery. With the increasing frequency of genetic testing and diagnosis, and treatment of women with familial genetic predisposition to breast cancer (BRCA), prophylactic mastectomy has become increasingly common.

In the absence of a cancer diagnosis, prophylactic mastectomy can often be performed as a nipple sparing mastectomy. When there is early stage breast cancer (generally Stage 0 or I), treatment with nipple sparing mastectomy can be considered in select cases.

The type of mastectomy that is ultimately selected is primarily informed by the individual’s oncologic requirements. When a single site of breast cancer is present in close proximity to the nipple areolar complex (generally within 2 cm), or in those with multifocal lesions (present in several locations) most breast surgeons recommend total mastectomy, advising against nipple sparing mastectomy.

For prophylactic treatment, and when the breast cancer is solitary, well localized, early stage, and distant from the nipple areolar complex, nipple sparing mastectomy can be considered.

Once it has been established that a woman is a candidate for nipple sparing mastectomy from an oncologic care perspective, there are a number of factors that must be considered to determine candidacy. Breast size, skin elasticity, areolar size, and breast symmetry can have an effect on the anticipated cosmetic outcome and safety profile of breast reconstruction after nipple sparing mastectomy.

Anatomically, women without significant breast ptosis (droop), with symmetric nipples, small to moderate breast size (A, B, or small C cup), and adequate skin thickness and elasticity may be considered candidates. The final determination of a woman’s candidacy for nipple sparing mastectomy is a team approach by Dr. Unal and your breast surgeon, who will together consider the oncologic requirements, anatomic parameters, and individual desires.

Unilateral Mastectomy or Bilateral Mastectomy?

When the breast cancer diagnosis is on one side only, the decision to choose a unilateral mastectomy or a bilateral mastectomy can be daunting. Data suggests that there is no oncologic advantage to performing a mastectomy on the unaffected side. Nevertheless, unilateral mastectomy rates have been decreasing by approximately 2% per year, and contralateral prophylactic mastectomies (a mastectomy performed on the opposite, non-affected side) are increasing by 15% per year. The primary reasons women have been making the choice to undergo bilateral surgery are aesthetic, as symmetry, both short and long term, is improved when the same or similar procedures are performed on both breasts at the same time. Women that chose bilateral (contralateral prophylactic) mastectomy have also cited the advantage of no longer needing radiographic breast surveillance in the future. Women that choose unilateral mastectomy will likely need to undergo what is known as contralateral balancing surgery. Generally at the time of the expander-to-implant exchange procedure, either a breast lift (mastopexy), breast enlargement (breast augmentation with breast implant), or breast reduction may be required to improve symmetry.

Types of Breast Implants

At the first stage of an immediate, implant-based breast reconstruction, a tissue expander or directly an implant may used. A tissue expander is a temporary breast implant that is volume-adjustable, and is filled with saline, the type of salt water solution used as intravenous fluid. By starting with low or moderate volume fill during the first stage, the advantages of this volume-adjustable implant are safety, comfort, and the ability to choose the ideal size in real time during the expansion process. Fills are quickly and easily performed in minutes during outpatient visits, at intervals of 7 to 10 days. Five to ten fill sessions are usually required to attain the desired result.Once the inflation has been completed, the tissue expander is removed and replaced with a permanent implant.

If a direct to implnt reconstruction is planned, the choice of breast implant size, shape, and composition is based on a variety of factors including body habitus, skin thickness, unilateral vs. bilateral reconstruction, and personal preference. Silicone gel breast implants are used for this purpose. There are two breast implant styles that Dr. Cigdem Unal uses: cohesive gel implants, and highly cohesive gel, form-stable anatomical breast implants. Both implants are outstanding options, and have unique advantages in different individuals.

Acellular Dermal Matrix (AlloDerm)

For immediate tissue expander or direct to implant reconstructions, Dr. Unal uses a soft tissue support matrix that serves as a “sling” to both cover the lower pole of the breast implant, maintain the location of the pectoralis major muscle, and to maintain the position of the implant. Known as acellular dermal matrix, or “AlloDerm”, has dramatically improved the aesthetics of breast reconstruction.

Autologous Fat Transfer

Following implant reconstruction, many women benefit from fat transfer. Fat is harvested from areas of the body where there is excess, including flanks, hips, thighs, and abdomen. Using liposuction techniques with tiny access incisions made with fine cannulas, fat cells are gently removed from the donor site, prepared for transfer, and then grafted with fine cannulas into areas of deficiency around the breast. These areas are usualy the cleavage, the axillary tail region, and sometimes the area around the implant. While there is some breast enlargement with fat grafts, it is performed for that purpose. The fat transfer softens the transition zones at the periphery of the implant, and provides more natural “cover” for the breast reconstruction, and improves the aesthetic outcome. Fat transfer is most often performed at the same time as nipple reconstruction (second or third stage depending whether an expander or direct to implant reconstruction was used).

The Steps of Breast Reconstruction

Breast reconstruction is a process, as several steps are required. With immediate breast reconstruction, the first operation is the most involved, and the majority of the work is performed at this first stage. At the conclusion of the mastectomy portion of the procedure, with implant-based reconstruction, a tissue expander is inserted beneath the muscle (pectoralis major and serratus anterior), a layer of allograft is placed, and the tissue expander is filled to a safe and comfortable volume, predicated on the mastectomy flap blood supply. To determine the ideal fill volume at the initial surgery, intraoperative angiography is performed using a specialized laser device (SPY indocyanine green laser angiography). This first surgery is always done in the hospital, with a one or two night postoperative stay.

The second stage of the breast reconstruction process is the removal of the expander and placement of a permanent breast implant. Generally this step is performed approximately three months after the mastectomy and first stage breast reconstruction. If adjuvant chemotherapy is required after the mastectomy, this second stage is usually performed 4 weeks after completion of therapy. After a total mastectomy or modified radical mastectomy, the nipple stage remains; following a nipple sparing mastectomy, the second stage may be the final stage in the breast reconstruction process. This procedure is always ambulatory surgery.

The third stage is typically the final stage of the breast reconstruction. This is usually performed between 6 and 12 weeks after the second stage, and relates to the nipple and any small contour adjustments that may be required. The nipple construction is performed using a modified C-V flap design, commonly using skin including the mastectomy scar, and rarely requiring additional incisions on the reconstructed breast. When performed alone, the nipple reconstruction may be under local anesthesia only. When combined with autologous fat transfer, intravenous sedation is used, and the procedure is ambulatory. Micropigmentation (tattoo) of the areola completes the process approximately 4 –6 weeks later.

If a direct to implant reconstruction was perfomed, a second session for fat injection is planned 4 weeks after completion of chemotherapy, or 3 months after the DTI reconstruction if no chemotherapy was done.

Nipple Reconstruction

After the nipple is removed during a total mastectomy, or modified radical mastectomy, a nipple reconstruction will be required to complete the breast reconstruction process. The nipple reconstruction is most often performed at the second or third stage, following the reoncstruction. If performed as an isolated procedure, the nipple construction can be performed under local anesthesia only. When combined with autologous fat grafts to the breast, this stage is generally performed as an ambulatory procedure under sedation. The technique that Dr. Cigdem Unal favors is a modification of a C-V flap, which uses skin locally on the reconstructed breast only. In the majority of cases, the nipple flap creation utilizes the pre-existing mastectomy scar line. Following this procedure, nipple areolar micropigmentation (tattoo) is performed to complete the nipple and the breast reconstruction.

BRCA and Prophylactic Mastectomy (Risk-Reducing Mastectomy)

Most women with breast cancer have what is considered to be a “sporadic” type, which is unrelated to inherited cancer. Approximately 10 to 20 percent of women with a diagnosis of breast cancer have a first degree relative with breast cancer, and of those with a family history of breast cancer, up to 20 percent have a mutation in the breast cancer susceptibility gene, known as BRCA 1 or BRCA 2. Candidates for testing are women with breast cancer diagnosed before age 50, triple-negative breast cancer, two or more primary breast cancers, ovarian cancer, or have Ashkenazi Jewish ancestry. Women with first or second degree relatives who have had breast cancer diagnosed before age 50, in two or more relatives, or ovarian, pancreatic, or prostate cancers are also candidates for testing. The final determination of your candidacy or need for testing should be made by a breast surgeon and/or a breast oncologist, and genetic counseling is recommended. For women that carry the BRCA gene mutation, without a diagnosis of breast cancer, current recommendations are clinical examinations beginning at age 25, annual breast MR scans (MRI) from age 25 – 29, annual mammogram and breast MRI after age 30, risk reducing oophorectomy after child bearing (and/or by age 40), and consideration of risk reducing mastectomy. Also known as a prophylactic mastectomy, the decision to undergo surgery must be carefully considered, and is based on personal preference and in depth discussion with your breast surgical oncologist. In retrospective and prospective studies, risk-reducing or prophylactic mastectomy decreases the incidence of breast cancer by 90 percent or more in women who carry the BRCA gene mutation. A bilateral total mastectomy that is skin-sparing, and often nipple sparing, with immediate breast reconstruction can be considered.

ONCOPLASTIC SURGERY

Oncoplastic surgery is a process that falls within the category of breast conservation therapy (BCT), in which the breast tissue that contains the tumor is resected with adequate surgical margins. Women who are candidates for this procedure generally have a breast size that is fuller (D cup or greater) who desire a breast reduction as well. During an oncoplastic “reduction”, the most common form of oncoplastic surgery, the lumpectomy region is removed as would be the portion of excess breast tissue that is removed with a breast reduction. The remaining breast tissue can be mobilized and transposed into the region of resection, and the breast is reshaped and lifted. For most women who undergo oncoplastic breast surgery, postoperative radiation is required. While appealing for many women, particularly those with larger breasts, one’s candidacy for oncoplastic surgery is determined by both a breast surgeon and plastic surgeon.

RECOVERY

Dr. Unal recommends returning to work 4 weeks following the first stage, although with less physically demanding occupations, some are able to return as early as 3 weeks postop. Drain tubes are usually maintained for 10 – 14 days. Light exercise (cardio without impact) may be resumed at approximately two- three weeks, and more vigorous physical activity may commence four weeks after breast reconstruction surgery. Strength training that excludes pectoralis muscle contraction (including lower body, core, and biceps/triceps toning with arms held below 45 degrees) may resume after 4 weeks days. The recovery time after the lesser ambulatory stages of the breast reconstruction process is generally 7 to 10 days.

AFTERCARE

After your Istanbul breast reconstruction, follow up visits involve drain and incision line care, drain removal, and tissue expander fills if an expander was placed as a first stage procedure. The fills take a matter of minutes, and while usually performed at two week intervals, they can be spaced at intervals up to 10-15 days. Dr. Unal is available to you at any time during recovery.

The information on this website is meant to provide a broad overview and some of the nuances of breast reconstruction, and of Dr. Unal’s preferred approaches to the spectrum of procedures after breast conservation therapy and mastectomy. To learn more about post-mastectomy breast reconstruction in Istanbul, we recommend a consultation with Dr. Cigdem Unal at her office where she can more thoroughly discuss your options for breast reconstruction with you.