Breast Reconstruction

by arnoldangeles 3. October 2010 19:26

With breast reconstruction, I have no idea how it feels to be "unbreasted,” nor will I assume that I can understand completely what they are going through. This is one journey in life that nobody wants to begin…
On weighing every thought, most clients believe it’s the best offer…having a breast removed because of a new and unwanted growth. I believe it's not a matter of choice, but of convenience and of instinct. Its even harder to think about breast reconstruction at this stage?
I say convenience because some women really have big and smelly tumor that seeps in sticky odor that can be smelled yards away. This has caused their withdrawal from society, family and even self. I say instinct because nobody wants to die too soon, even if they say it, they are lieing. Everybody wants to live long…a painless and infallible life.
You not only have to deal with a deforming surgery, you deal with the anxiety of what lies ahead. I am inclined to believe that there is always something good that comes out of everything….except for this and may be Stephen Hawkin, and you know that he has other reasons beside faith…if there is such a thing.
But I guess, there is…only if you look at it in the right way.
Some clients really succeed; they have achieved a tumor free life…cured!?#* Would you really believe that this "new life" event was the result of competent doctors and the right medicines? But how about those who are still burdened by their cancers? Were they forgotten? What do we have to say to them? Let us pray? Believe me, it's not enough…and there are still no answers “why.”
Then we move on…
Breast reconstruction always means fixing the breast defect. Fixing needs parts. What makes it more difficult is those spare parts cannot be bought or ordered in a supply store; well, except for some bone, blood and bioengineered skin and dermis. Other than that, we rely on what we have. We get one part and transfer it to another, as simple as that. This has always been the deal and there is nothing you can do about it, no matter how good or rich you are. We get "part A" and bring it to "defect B." Sounds easy right? But what happens to that part where "part A" came from? That part becomes an acceptable defect…an acceptable loss of function. We go back to weighing things again and what weighs more is the correction of what is more visibly defective…and that is your breast/s.
Somehow, the results of these reconstructions are sometimes amazing, barring complications and miss judgments…and because of such results, breast reconstruction has been acceptable option for those who don't want to endure their defect…go girl!
Next question.
Is breast reconstruction dependent on the defect or the price? Is it like buying a car? Would it largely depend on your budget and monthly income? It's either a Vios or a Camry, right? Although the defect really dictates the kind of reconstruction that would be recommended, the added expense will define the "detailing" of the procedure….such things like using implants vs no implants, isofluorane vs sevofluorane, bovie monopolar vs harmonic or bipolar. Again, these are just tools and I still firmly believe that the final result is dependent on the carpenter and not on the tools. Bad thing is, there is no financing and using post dated cheques or PNs (promissory notes) has always been a “bad” form…and yes, due to circumstances, “it can do, pig, it can do.”
What are the options for reconstruction?
You can always reconstruct using a skin graft. A split thickness skin graft (STSG) is always recommended because it can cover large defects compared to the full thickness skin graft (FTSG)…although the latter heals more aesthetically appealing later on. Choosing this option will just maintain the defect. It would still appear as a crater, a remembrance of something that was once there. It’s just like a cover, which is all it is, no more, no less. Sometimes, it may develop small ulcers and scabs that heal by themselves. It is easily bruised and abraded because of its “thinness.” The good thing is, any new local recurrence can be detected easily and early. No more ideas of cleavages and wearing clothing can cover the scar (as it always does), but you have to wear a breast explants, or just put something underneath the bra just to give it bulk. At least, you don’t feel awkward going out to church?
The next option is creating a local randomized flap or a distal flap. Don’t be confused, these are all semantics. A local randomized flap is using something near the defect. Meaning, the redundant skin nearby is used…free it, pull it, and rotate it until it covers the defect. Of course, this doesn’t only contain skin, but needs the other structures underneath it to survive the transfer…and will likely include your fats, fascia and sometimes even muscles. There is no identifiable blood supply here to nourish the flap, but they’re there alright, you just cannot see them. It’s in the angiosomes…you can bing it if you want.
These following flaps are more complex because it includes muscles, nerves and sometimes bone. Some muscles near the defect can be used like the external oblique muscles…but this can only cover the defect and not provide the bulk we want to look like a breast. The 2nd muscle that we can use is the Lat dorsi which is normally at the back (below the wing bone). We harvest the muscle from the back and “swing” it towards the front into the defect. Although all layers from the skin up to the muscle are carried over one single flap, this does not really provide bulk. Sometimes, we still have to place together a tissue expander just to make space for an implant which will provide the added bulk later on, making it look “breasty.” We want that breasty look, except of course, if the other normal breast is small and pea-like, there will be no need for added features or implants. The 3rd muscle that we can really use for bulking up the breast is the rectus muscle. This is the six-pack muscle you usually appreciate in male models. Don’t worry, women have this muscle too, it’s just there, hiding underneath all the layers. This muscle would look like a banner that we detach the “far-side,” carefully releasing the underside up to the other end, gently folding it on itself covering the defect. I believe that this 3rd type of muscle flap has another advantage. The defect left behind is closed like a tummy tuck procedure and the result is a more “sexy” lower abdomen…this is something to look forward to?
There are other forms of breast reconstruction which gives good results, but you have to think about it very carefully. Sometimes this is the last option in any reconstruction ladder and I believe this is the most expensive and tasking. Guarantees of success are not that high, but if indeed successful, this can really provide the new breast form you’d imagine to have. There are some plastic surgeons that are good at this and their success rates are considerably high. Here, I must admit, you need good instruments and machines that pumps up the cost a little higher compared to the rest. This free graft transfer involves cutting off a piece of tissue together with the vessels and bringing it over to the defect. You have to re-connect (or anastomose) these vessels for the graft to survive in its new location. These vessels are probable 2 – 4mm in diameter, so stitching them up needs skill, reliable instruments and a good microscope. Sometimes, the vessels will clog or will develop into spasms and if these things happen, the graft might start to be compromise and die. Monitoring is toxic and the duration of operation and hospital stay may be longer than usual.
The last breast reconstruction option…and definitely not the least…nor it is the last option…is the use of tissue expansion devices. These devices are used once the wound is stable and will no longer break. They are placed underneath the tissue surgically. You slowly inflate it with sterile saline every day until you reach a larger size than desired. It usually takes at least 3 to 4 weeks to do this and at the end, the tissue expander is replaced by a permanent breast implant. This does not create any defect in any other part of the body, which is a good deal. But, sometimes, the implant can be appreciated underneath the skin, looking a little unnatural. But hey, you can’t have everything, can you?

One form of tissue expander device is the BRAVA (Breast Enhancement and Shaping System). It is an explant (opposite of implant) where you put the device over the defect (and not inside like the usual implant….which requires anesthesia and surgery). This BRAVA is usually done over an office visit which means, no anesthesia and surgery. The BRAVA applies gentle, sustained tension on your breasts, which causes cells to replicate and produce new breast tissue ( This idea has been started for reconstruction purposes some 30 years ago, but is now generally used to cosmetically enhance breast tissue without using an implant. Now, it’s getting back into reconstruction again. Once the desired breast size has been achieved, the final and only surgery that follows is liposuction. You get the curves you’ve always wanted. The fat harvested from the liposuction is the fat that is grafted into the new breast. The amount of fat depends on the size of breast mound developed. The more fat grafts needed, the more liposuction done…the more liposuction done, the better. I have reviewed some studies regarding the viability of the fat and how long will it stay after grafting. Survival rate of fats is very satisfying (about >90%) since we do understand that some fats indeed melt or gets resorbed after a few months. Surprisingly, not much fat are resorbed and due to the fantastic blood supply of the newly expanded breast tissue, most of the fats survive permanently.
These things are just my quick thoughts about breast reconstruction. I am sure there is more¸ but I don’t intend to write a book yet.

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