Consultation - When a patient comes to Dr. Dabb as much time as necessary is given for complete understanding of the alternative procedures. Digital photography and computer imaging are utilized to help clarify the alternatives of reconstruction and to emphasize the advantages and disadvantages of each approach. Dr. Dabb will discuss alternative with the patient and determine which one will best fit the need of the patient and at the end of the consultation, the patient and surgeon should be comfortable in making a decision.

We work closely with the oncologic surgeon, radiation oncologist and medical oncologist to insure the best result possible. Factors such as severity of the cancer, need for pre-operative chemotherapy, need for post-operative radiation therapy, and medical status of the patient will all be taken into consideration.

Types of Reconstruction Procedures

Implant Reconstruction - top

Concept - Implant reconstruction is similar to a submuscular augmentation mammoplasty. Implant reconstruction may be especially desirable when bilateral mastectomy is contemplated, when it easy to mimic the shape and size of both breasts.

Surgery - An implant reconstruction consists of placing either a saline or gel silicone implant beneath the pectoralis major muscle. This is usually performed endoscopically. In some situations, a temporary implant called a tissue expander may be placed first, stretching out the pectoralis muscle to create the desired pocket size.

Implant Reconstruction
Example I	Example II

Recovery - The procedure is usually performed on an out-patient basis with the mastectomy. To manage post surgery pain we utilize the pain pump.

Back to Work - 2 week

Full Activity - 6 weeks

Complications/Disadvantages - Implant-related reconstructions do not do well with radiation therapy. The reconstruction is frequently deformed with excessive scar tissue following radiation. In addition, there are potential complications of infection with loss of implant, palpability of the implant, seeing the edge of the implant, probable eventual leakage requiring replacement (most commonly after 10 years), and traumatic rupture.

There has been many allegations against silicone gel implants and their possible side effects such as causing lupus, scleroderma, arthritis, etc. The FDA is currently investigated these allegations. To date, there is no studies to substantiate these concerns.

Latissimus Flap Reconstruction - top

Concept - A popular form of reconstruction at the Center utilizes the latissimus dorsi muscle with its overlying skin and fat. The latissimus muscle arises from the back and hip region and inserts onto the humerus. The unique anatomy of this muscle is that the entire muscle, along with its overlying skin, may be based and obtain predictable blood supply on the singular artery and vein (thoracodorsal) from underneath the arm.

Dr. Dabb has developed a unique pattern to maximize shape and volume. In most situations, there is adequate tissue to re-create an aesthetically pleasing breast. This procedure is highly predictable, with a very low incidence of postoperative complication. Frequently, the reduction mammoplasty will be done on the contralateral side to give symmetry to the reconstruction.

Latissimus Flap Reconstruction
Example I	Example II

Surgery - After the mastectomy, the patient is placed on her side. The flap is dissected and placed in the breast pocket. The back is closed and the flap is the tailored to match the contralateral side.

Latissimus Flap Reconstruction
Example I	Example II

Recovery - This procedure requires minimal hospitalization or may be done as an outpatient with the help of the pain pump. It has the advantage that radiation therapy may be utilized directly to the region of the flap necessary.

Patient snorkeling at 3 weeks after reconstruction surgery.

Complications/Disadvantages - The major disadvantage of this procedure is the tightness of the back following closure. This takes several months to resolve. The most common complication is a seroma(fluid collection) in the back. This is treated with aspiration.

TRAM Flap Reconstruction - top

Concept - A TRAM flap is a procedure that takes the lower abdominal wall skin and fat that would normally be discarded during an abdominoplasty and transfers it to the breast. This procedure is based on the anatomy of the rectus abdominis muscle(abs.). Like latissimus flap, the overlying skin and fat obtains its blood supply from perforating blood vessels that come from beneath the muscle.

Surgery - After a skin sparing mastectomy is performed, the skin and fat of the lower abdomen is tunneled up to the mastectomy site. The upper portion of the rectus abdominis muscle is a left intact, maintaining its blood supply. The abdomen is then closed as though the patient had undergone an abdominoplasty. This procedure has the advantage of both being able to reconstruct a breast and flatten the abdomen simultaneously.

Recovery - This procedure requires hospitalization for several days and has the advantage that radiation therapy may be utilized directly to the region of the flap necessary.

Complications/Disadvantages - A disadvantage of this procedure is that there is a longer recuperation time and some increased incidence of complication including flap loss and weakness of the abdominal wall.

TRAM Flap Reconstruction

Free TRAM/Free Perforator Flap Reconstruction - top

Concept - This operation is based on the same anatomic principles as the TRAM flap. The difference between this operation and the conventional TRAM flap is that the lower abdominal skin and fat is totally removed from its attachment to the abdominal wall. In addition, the rectus abdominis muscle, which would normally be sacrificed, is left intact and only the blood vessels feeding the skin and fat are taken.

Surgery - This procedure requires microvascular expertise, in that the blood vessels of the skin and fat of the abdomen must be reapproximated to the blood vessels of the chest with micro-vascular technique to provide adequate blood supply.This procedure requires additional time for surgery, up to 4 to 6 hours.

Bilateral Free Perforator Flap Reconstruction
Pre-operative Photo	Post-operative Photo

Recovery - Hospitalization is necessary for several days to observe the flap. There is no high reaching or lifting for 6 weeks.

Complications/Disadvantages - It is an ideal procedure in those patients who had previous upper abdominal surgery and who are dependent on the function of the abdominal muscles. Like the TRAM flap, this procedure has the potential for complications including thrombosis (clotting) of the blood vessels of the flap requiring re-operation and flap loss.

Nipple Reconstruction - top

Nipple reconstruction is an important component of an aesthetically pleasing breast reconstruction.

Concept - This procedure may performed at the time of reconstruction or approximately at six months.

Nipple Reconstruction

Surgery - A small flap is elevated on the breast to obtain the nipple mound. This is an office procedure done under local anesthesia. Six weeks after this is completed the nipple and areola are tattooed by our aesthetician. This usually takes two applications and is painless.

Nipple Reconstruction
Preolar Pigmentation I	Areolar Pigmentation II

Recovery - There is no down-time

Complications/Disadvantages - Loss of pigment