Numerous breast reconstruction patients visit Dr. Rosenberg due to his innovative approaches and surgical ability. Many women need significant breast reconstruction due to breast cancer or the removal of implants. Breast reconstructive procedures are designed to restore the shape of the breasts in the most natural and aesthetic manner possible. Our Beverly Hills and Newport Beach practice sites offers breast implants and flap reconstruction procedures to enhance our patients’ figures and renew their self-esteem. With an extensive selection of breast reconstructive procedures, Dr. David Rosenberg works closely with each patient to determine the appropriate procedure for her.
Our breast reconstruction treatments include:
- Implant Reconstruction
- TRAM Flap Reconstruction
- Latissimus Dorsi Reconstruction
- Breast Implant Removal
- Lumpectomy Reconstruction
Broadly speaking, breast reconstruction can be divided into “implant-based” reconstruction or “autologous” (your own tissue) reconstruction. However, there are reconstructions, such as the latissimus dorsi flap from your back, which incorporates both your own tissue with an implant to create a breast of appropriate volume based on your preferences or to match the other remaining breast. Back to top
A breast implant is a round or teardrop-shaped shell, filled with saline (salt-water) or silicone gel. The implant is placed behind the pectoralis major chest muscle in a manner similar to what occurs during breast augmentation surgery. Back to top
In a select group of women, implants may be placed as a one-stage process, where a permanent implant is used at the time of the mastectomy. However, most women require a two-stage process, using a tissue expander before the permanent implant is placed.
A tissue expander is an implant with a valve/port that can be filled with saline to stretch the remaining chest skin and soft tissues to make room for the breast implant. The tissue expander is placed under the pectoralis major muscle at the time of your mastectomy. After the incisions have healed, a small valve/port is accessed and saline is injected into the expander during several office visits, usually over a 6-8 week period of time. This gradual stretching creates more skin and soft tissue, not unlike how the skin of the abdomen stretches during a pregnancy. The tissue expander is filled until it is slightly larger than the desired size to assure that the skin and soft tissue can accommodate the permanent implant. At a second surgery, the tissue expander is replaced with a permanent saline or silicone implant.
The advantage of this type of reconstruction is that the initial surgery is shorter, on average adding only 1-2 hours to the mastectomy surgery and typically requiring only a single day of hospitalization. Since this technique does not involve removal of tissue from another site of your body, it does not create any additional scars or potential donor-site morbidity (see below for more details).
The disadvantage of this approach is that it typically involves a tissue expander, which requires at least 2 surgical stages and multiple visits to our office during the expansion process. There are instances where this may be more challenging for the patient than a recovery from a latissimus dorsi flap reconstruction (see below). In addition, an implant does not have the same shape and feel of a natural breast, so that it may make matching the opposite breast more difficult (for patients only having a unilateral [one-sided] mastectomy). As opposed to other types of reconstruction this type of surgery may produce a higher risk of early complications when performed as immediate breast reconstruction. In the short-term, the implant can become infected or malpositioned, which may require surgery to correct these problems. In the longer-term, implants may eventually require subsequent procedures to replace them due to hardening around the implant (capsular contracture), rupture, or malposition.
Breast reconstruction can be performed without implants, using a flap of your own tissue. A flap entails a combination of skin, fat, and/or muscle that is taken from one portion of your body and moved to your chest to create a breast. The advantages of using your own tissues are that it typically has a more natural shape and feel of a normal breast, and that it typically avoids the use of an implant. It also offers immediate reconstruction of the breast shape that usually requires only minor adjustments during secondary procedures. The disadvantages of this approach are that it requires a longer surgery and recovery time, and creates an additional scar on your body, with the potential for donor-site issues. The main autologous reconstructions use tissues from the back or abdomen and are described below. Back to top
Latissimus Dorsi Flap
A latissimus dorsi flap involves taking the skin, fat, and the latissimus dorsi muscle from your back, in the area below your scapula (shoulder blade) and tunneling it through the axilla (armpit) to create a breast. Sometimes it is possible to use this flap without implants in order to achieve the desired size. However, this technique often is used in conjunction with a tissue expander or implant to reconstruct the breast.
Why use a latissimus flap if you are going to use an implant anyway? There are several reasons. Using a latissimus flap with an implant typically has a more natural shape and feel than an implant alone. One way to describe this effect is for you to imagine putting an implant under a bed sheet. With only a thin sheet over the implant, all of the contours of the implant are visible and the implant can be readily felt. On the other hand, if the implant is placed under a thick comforter, the implant is there only to provide volume, and is not as visible or palpable. The former analogy describes an implant-only based reconstruction, while the latter analogy describes the latissimus flap with implant reconstruction. In addition, placing the skin, fat, and muscle over an implant may reduce complications relating to infection and radiation therapy.
Therefore, the advantages of the latissimus flap are that it decreases some of the risks of using an implant, it typically is easier to match the opposite breast with this approach, and it replaces deficient skin and soft tissue which may be missing or damaged after the mastectomy and/or radiation treatments. In cases of immediate breast reconstruction, the patient emerges from the mastectomy and reconstructive surgery almost completely restored to a natural (or sometimes better) size and shape as compared to having a mound of tissue present if an expander is utilized. After the initial surgery, there often is no additional expansion necessary. Therefore the recovery period is usually surprisingly easier than for an expander/implant reconstruction, because there is no need for the sometimes-painful injections and stretching associated with the expansion process. We utilize this technique in all age groups (young and old) with tremendous success. We believe it is optimal for women looking for a relatively quick recovery and very satisfactory results without the disadvantages of prolonged expansion and problems of implant exposure.
The disadvantages of this approach are that it requires a longer surgery, and it results in an additional scar on your back where the flap is obtained (although this scar is usually well hidden by your bra). The loss of muscle function is usually well compensated by the other muscles of the shoulder and back.
The TRAM flap stands for a Transverse Rectus Abdominus Myocutaneous Flap. Put simply, it uses your abdominal skin and fat based on blood vessels that travel through the rectus abdominus muscle (AKA your six-pack muscle). There are many variations of this type of flap which indicates the method by which Dr Rosenberg moves the abdominal tissue up to the chest to create the breast. In a pedicled TRAM, the tissue is moved to the chest by a subcutaneous tunnel in the lower portion of your breast. In a free TRAM, the abdominal tissue is transferred to the chest by using microsurgical techniques to reconnect the blood vessels that provide nourishment to the tissues.
The advantages of the TRAM are that it removes abdominal tissue to reconstruct the breast, which improves your abdominal contour after surgery similar to an abdominoplasty (tummy tuck). In addition, it avoids the use of an implant, has a more natural look and feel, and is durable.
The disadvantages of this approach are that it requires a longer surgery with a longer recovery time than for both an implant-based or latissimus flap reconstruction, it creates a scar across your lower abdomen (similar to the scar after a tummy tuck), it may result in some abdominal muscle weakness, and it is possible to develop bulging or a hernia at the site where the flap is taken from.
The DIEP flap stands for the Deep Inferior Epigastric Perforator flap. This flap falls under the category of a perforator flap, which are advanced microsurgical procedures that attempt to spare the abdominal muscles. The advantage of using these flaps is that it spares the abdominal wall fascia and muscles, and may reduce the incidence of weakness, hernia/bulging, and post-operative pain. The disadvantages of the DIEP flap is that is a significantly longer operative procedure, and has the risk of problems with the microsurgical connections of the blood vessels.
In some patients who are receiving a unilateral mastectomy, to achieve optimal results we may recommend surgery on the contralateral (opposite) breast in order to make the breasts more symmetric. This may involve a breast reduction, breast lift, or breast augmentation. Fortunately, these procedures are covered under insurance under the Women’s Health and Cancer Rights Act of 1998. Back to top
After the breast mound is created with a flap and/or implant, Dr Rosenberg reconstructs the nipple and areola in a subsequent outpatient or office procedure. The nipple is made by surgically rearranging a small portion of the skin and fat of your reconstructed breast, and the areola is tattooed in a separate procedure.
Bilateral Breast Reconstruction
In some circumstances, bilateral breast removal or mastectomy may be recommended by your oncologist or breast surgeon. This may either be for treatment of a bilateral breast cancer or as a prophylactic measure in high-risk patients. Breast reconstruction in this circumstance often allows Dr Rosenberg more control over the reconstruction and to achieve outstanding and symmetrical results. We have utilized bilateral implant reconstructions, bilateral TRAM flaps, and bilateral latissimus dorsi flaps with great success. Back to top
Some patients will undergo a lumpectomy for breast cancer (rather then a mastectomy), with the goal to preserve a portion of their native breast. These procedures, however, can severely distort the appearance of the breast, leaving a woman feeling scarred and unsatisfied with the ultimate appearance of their breast. These cosmetic deficiencies can be treated with a variety of techniques, including local tissue rearrangement, reconstruction with a variety of local flaps, or a small breast implant. Rosenberg Plastic Surgery can help in obtaining authorization from insurance companies and speaking to the patient more about their options.
Contact Rosenberg Plastic Surgery for More Information
To learn more about the reconstructive breast procedures offered at our Los Angeles-area center, including reconstruction with breast implants or implant removal procedures, consult with Dr. David Rosenberg regarding your specific needs. Your medical procedure may be covered by insurance. Contact Rosenberg Plastic Surgery today with any questions you may have. Our kind and professional staff would be happy to help you in any way.
For more, please visit RosenbergBreastReconstruction.com