Breast Reconstruction in New York City

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.

For immediate tissue expander-implant reconstructions, Dr. Kolker uses a soft tissue support matrix.

Known as acellular dermal matrix, or AlloDerm, this serves as a “sling” to both cover the lower pole of the breast implant, maintain the location of the pectoralis major muscle, and to fortify and maintain the position of the implant. The use of AlloDerm has dramatically improved the aesthetics of breast 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 third stage, following the mastectomy and tissue expander insertion stage and the implant exchange stage. 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, the third stage is generally performed as an ambulatory procedure under sedation.

The technique that Dr. Kolker 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.

Most mastectomies for breast cancer are called a modified radical mastectomy, also known as a total mastectomy combined with an axillary node procedure (sentinel lymph node biopsy or lymph node dissection).

While most of these are largely “skin sparing”, the nipple areolar complex is removed with this type of mastectomy. 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. Kolker and your breast surgeon, who will together consider the oncologic requirements, anatomic parameters, and individual desires.

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.

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 BRCA gene mutation, the breast reconstruction process is begun immediately during the mastectomy procedure.

In some situations, there are:

At the first stage of an immediate, implant-based breast reconstruction, a tissue expander is 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 14 to 30 days. Three to six 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. 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 breast reconstruction after mastectomy and tissue expansion. Saline implants are no longer used as a permanent implant for breast reconstruction.

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 an IV catheter and 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. While there is some breast enlargement with fat grafts, it is diminutive, and not 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 (third stage), and occasionally at the time of breast implant exchange (second stage).