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Breast Reconstruction

Reconstruction of the breast following breast removal is performed to create a soft, natural looking breast for a woman who has suffered cancer or other disease. Breast reconstruction can be performed immediately following mastectomy or at a later time. For many women, breast reconstruction offers the chance to look like themselves again and to regain the confidence they may have lost due to breast removal. Breast reconstruction can be performed using the patient's own tissue or using a saline or silicone filled implant. Dr. de Ramon is able to determine with the patient, the general surgeon and the oncologist the best option for reconstruction.


There are many things to consider prior to having breast reconstruction performed by Dr. de Ramon:


Breast reconstruction is covered by all health insurance plans as are procedures to restore and achieve symmetry on the other breast. Dr. de Ramon's specially trained patient care coordinator will work with you to obtain coverage for the procedure.


During a consultation, Dr. de Ramon will review your history and operative notes (please forward these to our office prior to your appointment). A discussion of the reconstructive options and surgical plan will be performed as well as an exam. A second consultation is recommended so final questions can be answered and a surgical plan refined. Dr. de Ramon will also discuss your case with your other surgeons and oncologist to develop the best care plan for you. Only when you are comfortable with the reconstructive plan recommended will you be scheduled for surgery. Although reconstruction can be a lengthy process, it is a great way to look and feel like your old self. Many of our patients are willing to discuss their experience through the process.


Dr. de Ramon also offers a post-operative pain pump which is inserted into the surgical area to reduce pain and reduce the need for post-operative pain medication and utilizes the harmonic scalpel. Dr. de Ramon is one of the first plastic surgeons in the nation to be trained in the plastic surgical uses of the harmonic scalpel. Incorporating this new technology into breast reconstruction has dramatically decreased post op swelling and the use of drains. This also means faster recovery. Advances in suture technique and technology have also allowed Dr. de Ramon to minimize patients' general anesthesia time.


Our other breast plastic surgery options:


More Information:

By Lisa Barclay


Breast cancer. It is the leading cancer diagnosed in women in America. This year, it will affect the lives of more than 180,000 women for the first time - and end the lives of 40,000 more. Thanks to proactive efforts like National Breast Cancer Awareness Month celebrated in October, the disease doesn't automatically mean a death sentence. However, the impact breast cancer has on the lives of its victims is arguably life altering - and not easily erased.


In this article, we will share the experiences of five women who have survived the disease, as well as the expertise of several American Society of Plastic Surgeons (ASPS) members who specialize in breast reconstruction after breast cancer. It is our hope that the information presented in this article will serve as a valuable resource in your journey through breast cancer treatment and recovery.


A Diagnosis of Cancer

Fear. Shock. Denial. These are just a few of the emotions women experience upon learning they have breast cancer. Jayne Siebold, of Hinsdale, Ill., was 49 when she was diagnosed with the disease and explains her initial reaction to the news. "When the doctor confirmed it was cancer, I remember thinking, 'They can't be talking about me, this must be a mistake.' Then the fear kicked in."


Barbara Taylor of Dallas went into physical shock. "Everyone I had ever known or heard of who had the disease died from it. So the fear I experienced initially was completely overwhelming, virtually crippling."


When Sue Kocsis of Omaha, Neb., was diagnosed she was 34 years old and the mother of three little girls. "The entire process was extremely overwhelming. It took visits to five different physicians before the cancer was actually diagnosed, so in the beginning I was relieved to know just what I was dealing with - but felt a tremendous amount of anger toward the doctors who kept telling me it was just fibrocystic disease and nothing to worry about."


The treatment of breast cancer involves a physical change to the body. As a result, it can have a profound psychological impact. "A woman's breasts are deeply rooted in her sense of femininity...her role as mother and nurturer, " says Jack Bruner, M.D., of Sacramento, Calif. "Therefore, facing the loss of one or both breasts can be very traumatic." Dr. Bruner recommends that every women diagnosed with breast cancer request information about reconstructive options from their general surgeon and seek the opinions of several plastic surgeons prior to surgery.


Reconstructive Solutions

Almost any woman who loses her breast to cancer can have it rebuilt through reconstructive surgery. And discussion about reconstruction can start immediately after diagnosis. Ideally, you'll want your breast surgeon and your plastic surgeon to work together to develop a strategy that will put you in the best possible condition for reconstruction.


There are several reconstructive options available after mastectomy. Typically, your plastic surgeon will make a recommendation based upon your age, health, anatomy, tissues and goals. The most common procedures include skin expansion followed by the use of implants or flap reconstruction.


Flap reconstruction is a more complex procedure than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed site, and recovery time is longer than with an implant. However, when the breast is reconstructed with one's own tissue, the results are generally more natural and concerns related to implants are non-existent. Recovery times for both procedures range from six months to one year, or longer, depending on individual circumstances.


Skin Expansion

This common technique combines skin expansion and subsequent insertion of an implant. Following mastectomy, your plastic surgeon will insert a balloon expander beneath the skin and chest muscle. Through a tiny valve mechanism buried beneath the skin, he or she will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has been sufficiently stretched, the expander is removed in a second operation and a more permanent implant - either saline or silicone - will be inserted. Some expanders are designed to be left in place as the final implant. The nipple and dark skin surrounding it - called the areola - are reconstructed in a subsequent procedure.


Flap Reconstruction

An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the abdomen, back or buttocks. In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of skin, fat and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself without need for an implant. Another flap technique uses tissue that is surgically removed from the abdomen, thighs or buttocks and then transplanted to the chest by reconnecting the blood vessels to new ones in that region.


Making the Choice

Breast cancer affects women differently depending on their age, marital status and self-image, as does their attitudes about reconstruction. No matter how they feel about it, Glenn Davis, M.D., of Raleigh, N.C., stresses that "every woman should be afforded the choice of undergoing reconstruction as part of her breast cancer treatment, and provided adequate facts to make an informed decision.


Unfortunately, many women are not given the option or the information they need to make an informed decision about reconstruction. According to Christine Horner-Taylor, M.D., of Edgewook, Ky., the women who don't undergo reconstruction procedures after losing a breast to mastectomy have many reasons for doing so. "Many women have told me the reason they didn't have breast reconstruction was because their general surgeon didn't recommend it or didn't mention that it could be done at the same time as the mastectomy. If the women are older, their surgeon may have decided they don't really need to go through it," she says.


Other reasons women pass on reconstruction include their unwillingness to have any more surgery than is absolutely necessary and an inability to weigh all the options available while they're struggling to cope with a diagnosis of cancer.


When Reconstruction May Not Be an Option

Not all women are good candidates for breast reconstruction. According to Dr. Horner-Taylor, "Women who have had a mastectomy or Lumpectomy with radiation are typically not strong candidates for skin expansion reconstruction. Radiation changes the characteristics of skin tissue, causing a variety of complications ranging from excessive scar tissue development, to blood supply and overall healing problems."


Dr. Davis feels that while radiation does present some difficult challenges, it doesn't automatically rule out the possibility of reconstruction. "While each circumstance is different, I strongly believe that if there is enough good tissue to work with, reconstruction remains a viable option for most women," he says.


Dr. Bruner notes that patients that are emotionally unstable should probably postpone reconstruction. "Coping with the reality of breast cancer is an extremely overwhelming process. If a woman cannot understand the risks and limitations of reconstruction prior to her mastectomy surgery, I would recommend she wait."


Managing Misconceptions

Misconceptions abound regarding breast cancer reconstruction. "Most misconceptions are fueled by a lack of information," says Dr. Bruner.


Common misconceptions include having to wait up to one year to safely undergo reconstruction, reconstruction makes it difficult to identify cancer if it recurs, and reconstruction interferes with cancer treatments, such as chemotherapy.


"Wrong on all counts," says Dr. Horner-Taylor. "Reconstruction can take place immediately following mastectomy with little complication. In the case of implants, reconstruction may take longer if the patient has to undergo chemotherapy, but otherwise doesn't interfere with the process."


Managing Expectations

Managing patient expectations is one of the most important aspects of breast cancer reconstruction. It is important for women to remember that the goal of reconstruction is improvement, not perfection. "Be sure to discuss your expectations candidly with your plastic surgeon, and expect nothing less than total honesty from him or her in return," says Dr. Horner-Taylor. "It's always smart to get the opinions of several plastic surgeons before moving ahead."


To ensure reconstructive surgery has the desired outcome, breast symmetry procedures - surgery to the other breast - is usually also part of the reconstructive process. "Symmetry procedures either reduce, lift or reshape the remaining breast to ensure a better match to the reconstructed breast," says Dr. Bruner. He goes on to note that symmetry procedures can be an ongoing process, with periodic adjustments necessary to correct the affects of the aging process. ASPS is currently pushing for legislation to ensure women have access to symmetry procedures as part of their reconstruction treatment after breast cancer.


Dolores Glover, Siebold and Kocsis all decided to undergo reconstruction procedures - Siebold at the same time as her mastectomy, Glover 10 years later and Kocsis one year later. Glover and Siebold opted for skin expansion with implants. Kocsis decided to go with flap reconstruction.


"Breast reconstruction was the number one motivation that got me through the most difficult times of my treatment," says Siebold. "The breast reconstruction, although excellent, will never look or feel the same as a natural breast. However, not having to stuff my bra with fillers is a great relief, and I truly feel like a complete woman again."


Glover was never given the option of reconstruction at the time her cancer was diagnosed and her mastectomy performed. She was 38. "I was so busy being a mom to my two children and a wife that I didn't think about reconstruction initially. I also didn't want to endure any more pain or surgery, although my oncologist strongly recommended it," she says. However, every time she caught a glimpse of herself in the mirror, she was reminded of her disfigurement. "I felt deformed, and that feeling never went away until I had reconstruction. I eventually did use a prosthesis, but still wasn't happy with the results." Ten years after her mastectomy, Glover finally decided to have breast reconstruction. "I'm glad I had it done. It helped me to find closure and feel normal again."


For Kocsis, breast reconstruction was a completely mind restorative process. "The day I had my reconstructive surgery was the day I took my life back," she says. She first learned about flap reconstruction through a local support group and decided to undergo the procedure one year after her diagnosis. "I liked the idea of using natural tissue for the reconstruction, and once I made the decision to have surgery, I actually looked forward to having it done." The reconstruction was a success and Kocsis is thrilled with her results. "I really feel great about my decision and the end result. In fact, my family and I celebrate the date of my surgery every year as my re-birthday." Kocsis is now active in public education efforts for breast cancer and reconstruction, writing articles, conducting interviews and giving presentations.


Davis decided not to undergo reconstruction, although she was prepared to go through with it until the day before her mastectomy. "I just decided that I didn't want to be under anesthesia or on the operating table that long," she says. And five years later, she's confident she made the right decision. "It was more important to me to focus on treating the cancer. My breasts are not that important to me, they don't define who I am as a person."


Making An Informed Decision

The decision to undergo breast reconstruction is an intensely personal one. All of the ASPS members interviewed for this article agree that the decision should be made by the patient, not by treating physicians. "It really is a quality of life issue," says Dr. Davis. "And it doesn't matter how old the patient is or if they're married or single. All women should have the option, if they want it."


The most important tool available to women coping with breast cancer is information. "Women need to get as much information as they can, from doctors, cancer organizations, support groups and other women," says Dr. Bruner. "And they shouldn't be afraid to ask the tough questions, as many as necessary to increase their comfort level with their treatment and aid in their recovery process."


For more information on breast reconstruction, please contact ASPS at 1-800-635-0635.


For more information about breast cancer, call any of the following toll-free numbers:


American Cancer Society



Cancer Care, Inc.



Cancer Research Foundation of America



National Alliance of Breast Cancer Organizations (NABCO)



National Cancer Institute's Cancer Information Service



Y-ME National Breast Cancer Organization


American Society of Plastic Surgeons
Despite the increase of breast reconstruction procedures performed in 2008, nearly 70 percent of women who are eligible for the procedure are not informed of the reconstructive options available to them, according to a recently published report. Newly released statistics by the American Society of Plastic Surgeons (ASPS) shows there were more than 79,000 breast reconstruction procedures performed in 2008 - a 39 percent increase over 2007. But in spite of this, current research suggests that many breast cancer patients are missing out on a key conversation that should take place at the time of diagnosis. Every woman deserves a conversation, because every woman deserves a choice.

If You're Considering Breast Reconstruction ...
Reconstruction of a breast that has been removed due to cancer or other disease is one of the most rewarding surgical procedures available today. New medical techniques and devices have made it possible for surgeons to create a breast that can come close in form and appearance to matching a natural breast. Frequently, reconstruction is possible immediately following breast removal (mastectomy) so the patient wakes up with a breast mound already in place, having been spared the experience of seeing herself with no breast at all.


But bear in mind, post-mastectomy breast reconstruction is not a simple procedure. There are often many options to consider as you and your doctor explore what's best for you.


This information will give you a basic understanding of the procedure - when it's appropriate, how it's done, and what results you can expect. It can't answer all of your questions, since a lot depends on your individual circumstances. Please be sure to ask your surgeon if there is anything you don't understand about the procedure.


The Best Candidates for Breast Reconstruction
Most mastectomy patients are medically appropriate for reconstruction, many at the same time that the breast is removed. The best candidates, however, are women whose cancer, as far as can be determined, seems to have been eliminated by mastectomy.


Still, there are legitimate reasons to wait. Many women aren't comfortable weighing all the options while they're struggling to cope with a diagnosis of cancer. Others simply don't want to have any more surgery than is absolutely necessary. Some patients may be advised by their surgeons to wait, particularly if the breast is being rebuilt in a more complicated procedure using flaps of skin and underlying tissue. Women with other health conditions such as obesity, high blood pressure or smoking may also be advised to wait.


In any case, being informed of your reconstruction options before surgery can help you prepare for a mastectomy with a more positive outlook for the future.


All Surgery Carries Some Uncertainty and Risk
Virtually any woman who must lose her breast to cancer can have it rebuilt through reconstructive surgery. But there are risks associated with any surgery and specific complications associated with this procedure.


In general, the usual problems of surgery, such as bleeding, fluid collection, excessive scar tissue or difficulties with anesthesia, can occur, although they're relatively uncommon. And, as with any surgery, smokers should be advised that nicotine can delay healing, resulting in conspicuous scars and prolonged recovery. Occasionally, these complications are severe enough to require a second operation.


If an implant is used, there is a remote possibility that an infection will develop, usually within the first two weeks following surgery. In some of these cases, the implant may need to be removed for several months until the infection clears. A new implant can later be inserted.


The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways and sometimes requires either removal or "scoring" of the scar tissue or perhaps removal or replacement of the implant.


Reconstruction has no known effect on the recurrence of disease in the breast, nor does it generally interfere with chemotherapy or radiation treatment, should cancer recur. Your surgeon may recommend continuation of periodic mammograms on both the reconstructed and the remaining normal breast. If your reconstruction involves an implant, be sure to go to a radiology center where technicians are experienced in the special techniques required to get a reliable x-ray of a breast reconstructed with an implant.


Women who postpone reconstruction may go through a period of emotional readjustment. Just as it took time to get used to the loss of a breast, a woman may feel anxious and confused as she begins to think of the reconstructed breast as her own.


Planning Your Surgery
You can begin talking about reconstruction as soon as you're diagnosed with cancer. Ideally, you'll want your breast surgeon and your plastic surgeon to work together to develop a strategy that will put you in the best possible condition for reconstruction.


After evaluating your health, your surgeon will explain which reconstructive options are most appropriate for your age, health, anatomy, tissues and goals. Be sure to discuss your expectations frankly with your surgeon. He or she should be equally frank with you, describing your options and the risks and limitations of each. Post-mastectomy reconstruction can improve your appearance and renew your self-confidence - but keep in mind that the desired result is improvement, not perfection.


Your surgeon should also explain the anesthesia he or she will use, the facility where the surgery will be performed, and the costs. In most cases, health insurance policies will cover most or all of the cost of post-mastectomy reconstruction. Check your policy to make sure you're covered and to see if there are any limitations on what types of reconstruction are covered.


Preparing for your surgery
Your oncologist and your plastic surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain vitamins and medications.


While making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days, if needed.


Where Your Surgery Will Be Performed
Breast reconstruction usually involves more than one operation. The first stage, whether done at the same time as the mastectomy or later on, is usually performed in a hospital.


Follow-up procedures may also be done in the hospital. Or, depending on the extent of surgery required, your surgeon may prefer an outpatient facility.


Types of anesthesia
The first stage of reconstruction, creation of the breast mound, is almost always performed using general anesthesia, so you'll sleep through the entire operation.


Follow-up procedures may require only a local anesthesia combined with a sedative to make you drowsy. You'll be awake but relaxed, and may feel some discomfort.


Types of Implants
If your surgeon recommends the use of an implant, you'll want to discuss what type of implant should be used. A breast implant is a silicone shell filled with either silicone gel or a salt-water solution known as saline.


Because of concerns that there is insufficient information demonstrating the safety of silicone gel-filled breast implants, the Food & Drug Administration (FDA) has determined that new gel-filled implants should be available only to women participating in approved studies. This currently includes women who already have tissue expanders (see below under Skin Expansion), who choose immediate reconstruction after mastectomy, or who already have a gel-filled implant and need it replaced for medical reasons. Eventually, all patients with appropriate medical indications may have similar access to silicone gel-filled implants.


The alternative saline-filled implant, a silicone shell filled with salt water, continues to be available on an unrestricted basis, pending further FDA review.


As more information becomes available, these FDA guidelines may change. Be sure to discuss current options with your surgeon. (Above guidelines are current as of July 1992.)


The Surgery
While there are many options available in post-mastectomy reconstruction, you and your surgeon should discuss the one that's best for you. Skin expansion. The most common technique combines skin expansion and subsequent insertion of an implant.

Following mastectomy, your surgeon will insert a balloon expander beneath your skin and chest muscle. Through a tiny valve mechanism buried beneath the skin, he or she will periodically inject a salt-water solution to gradually fill the expander over several weeks or months. After the skin over the breast area has stretched enough, the expander may be removed in a second operation and a more permanent implant will be inserted. Some expanders are designed to be left in place as the final implant. The nipple and the dark skin surrounding it, called the areola, are reconstructed in a subsequent procedure.

Some patients do not require preliminary tissue expansion before receiving an implant. For these women, the surgeon will proceed with inserting an implant as the first step.

Flap reconstruction. An alternative approach to implant reconstruction involves creation of a skin flap using tissue taken from other parts of the body, such as the back, abdomen or buttocks.


In one type of flap surgery, the tissue remains attached to its original site, retaining its blood supply. The flap, consisting of the skin, fat and muscle with its blood supply, are tunneled beneath the skin to the chest, creating a pocket for an implant or, in some cases, creating the breast mound itself without need for an implant.

Another flap technique uses tissue that is surgically removed from the abdomen, thighs or buttocks, and then transplanted to the chest by reconnecting the blood vessels to new ones in that region. This procedure requires the skills of a plastic surgeon who is experienced in microvascular surgery as well.

Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than skin expansion. Scars will be left at both the tissue donor site and at the reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more natural and there are no concerns about a silicone implant. In some cases, you may have the added benefit of an improved abdominal contour.


Follow-Up Procedures
Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery may be required to replace a tissue expander with an implant or to reconstruct the nipple and the areola. Many surgeons recommend an additional operation to enlarge, reduce or lift the natural breast to match the reconstructed breast. But keep in mind, this procedure may leave scars on an otherwise normal breast and may not be covered by insurance.


After Your Surgery
You are likely to feel tired and sore for a week or two after reconstruction. Most of your discomfort can be controlled by medication prescribed by your doctor.


Depending on the extent of your surgery, you'll probably be released from the hospital in two to five days. Many reconstruction options require a surgical drain to remove excess fluids from surgical sites immediately following the operation, but these are removed within the first week or two after surgery. Most stitches are removed in a week to 10 days.


Getting Back to Normal
It may take you up to six weeks to recover from a combined mastectomy and reconstruction or from a flap reconstruction alone. If implants are used without flaps and reconstruction is done apart from the mastectomy, your recovery time may be less.


Reconstruction cannot restore normal sensation to your breast, but in time, some feeling may return. Most scars will fade substantially over time, though it may take as long as one to two years, but they'll never disappear entirely. The better the quality of your overall reconstruction, the less distracting you'll find those scars.


Follow your surgeon's advice on when to begin stretching exercises and normal activities. As a general rule, you'll want to refrain from any overhead lifting, strenuous sports and sexual activity for three to six weeks following reconstruction.


Your New Look
Chances are your reconstructed breast may feel firmer and look rounder or flatter than your natural breast. It may not have the same contour as your breast before mastectomy, nor will it exactly match your opposite breast. But these differences will be apparent only to you. For most mastectomy patients, breast reconstruction dramatically improves their appearance and quality of life following surgery.

November 5, 2001 — More than 180,000 women in the United States will be diagnosed with breast cancer this year, many of whom will have mastectomies. Nearly 79,000 breast reconstruction procedures following mastectomy were performed last year, a 166 percent increase since 1992, according to the American Society of Plastic Surgeons (ASPS.) At the ASPS 70th Annual Scientific Meeting in Orlando, Fla., four papers exploring various aspects of breast reconstruction were presented.


The first study examined reconstruction in women who have or are at a high-risk for developing cancer in both breasts. These women chose to have both breasts removed. Overall, the women were found to be happy with the result. The study, which looked at 74 women, surveyed patients on their physical, emotional, social and general well-being as well as on body image and breast and scar appearance.


"Women are understandably reluctant to have a healthy breast removed," said Richard Redett, M.D., fellow of plastic surgery at Johns Hopkins Hospital. "But we now can show them that women who do undergo bilateral mastectomies do very well. Along with possibly extending their life, they are happy with their body."


The study concluded that there was no significant difference in quality of life between the different types of reconstruction. But women who had a bilateral pedicle TRAM flap (where the reconstructed breast comes from a portion of skin, fat and muscle taken from the abdomen and is tunneled beneath the skin to the chest while still connected to its original blood supply) scored higher in the areas of general body image, appearance of the reconstructed breast, how the breast feels to the touch and its appearance in a bra, compared to women who had other types of reconstruction.


The second study looked into the possibility of using implants for breast cancer patients who require radiation after reconstruction. It had previously been accepted that the use of skin expanders and implants (where an expandable balloon-like device is inserted beneath the skin, and over several weeks, the expander is gradually filled with salt water causing the overlying skin to stretch) did not work well in women whose treatment included radiation. It had been previously concluded that radiation did not allow the skin to expand, as well as possibly injuring the skin and losing the implant to infection.


In the study of 81 patients who had implant reconstruction followed by radiation, more than 80 percent had a good to excellent result. Eighty-two percent of the patients would choose the same method of reconstruction again. The rate of capsular contracture (when scar tissue forms around the implant, tightening and squeezing it) was 49 percent, but exhibited a very low level of distortion.


"There is a group of patients that traditionally have not been candidates for reconstruction if their treatment includes radiation after mastectomy," said Peter G. Cordeiro, M.D., chief, department of plastic and reconstructive surgery, Memorial Sloan Kettering Hospital. "This study opens the door to them to have reconstruction with a tissue expander and implant. It proves you can have successful reconstruction with implants in patients that require post-mastectomy radiation. Our study had a greater than 90 percent overall success rate."


The third breast reconstruction study looked into the risk factors of smoking, obesity and radiation and their links to complications on patients who had pedicle TRAM flap (see above for explanation) reconstruction. Not surprisingly, the 10-year study of 200 patients found that active or former smoking (four weeks) and obesity contribute to a significant complication rate, while being moderately overweight, pre-operative radiation or chemotherapy do not.


"This study gives a ‘heads up' to physicians and their patients with these risk factors who may be about to undergo breast reconstruction," said Ivica Ducic, M.D., Ph.D., and chief resident in the division of plastic surgery at Georgetown University. "We all know that smoking and being overweight carry health problems, but this study illustrates that these factors can seriously compromise the outcome of surgery. For surgeons, the study can educate them about proper patient selection or a need to delay surgery, giving the patient time to stop smoking or lose weight. For the general public, it simply reiterates how lifestyle choices can affect health and the options available to you when you are ill."


The fourth study looked into using a new non-invasive technology for examining and monitoring lumps in patients who underwent mastectomy and reconstruction. When a woman opts for flap reconstruction, approximately 15 to 20 percent of the flaps develop scar tissue, according to Andrew L. Da Lio, M.D., co-author and assistant professor of plastic surgery at UCLA.


"This scar tissue feels like a lump," said Dr. Da Lio. "For obvious reasons, many woman want a definitive answer about the nature of these masses. Previously a biopsy of the area was taken and tested."


But Dr. Da Lio and his associates surmised that because cancers grow faster than the rest of the body, thereby consuming glucose (sugar) faster, if they injected these patients with a safe level of radioactive glucose (PET scan), the lumps, if cancerous, would light up. This procedure has been done in other areas of cancer detection and surveillance — for example, on patients with brain cancers to determine the response of brain tumors to radiation and/or chemotherapy.


Ten patients were injected with radioactive glucose before a biopsy was taken. In two patients, a cancerous mass was found that was later confirmed by biopsy. The study concluded that the PET scan can be a useful tool to help the reconstructive surgeon identify the nature of tumors in patients who underwent breast reconstruction. In addition, it looks at the entire body from a cancer surveillance standpoint, looking for early tumors that may have spread from the primary breast cancer.


"This technique is also a way to put a patient's mind at ease," said Dr. Da Lio. "It's a simple, safe way to discover a tumor, potentially much earlier than in a routine exam or mammogram."

Procedure Status
Due to public concern about the perceived health risks of silicone-gel breast implants, a number of women continue to seek implant-removal surgery. When a woman decides to have her silicone-gel implants surgically removed or replaced with saline-filled implants, she may also opt for removal of the scar tissue barrier or "capsule" that naturally forms around the implants when they are inserted. This procedure is called a capsulectomy.


Position statement: The American Society of Plastic Surgeons (ASPS) believes that women should understand the risks and benefits of implant removal and capsulectomy. The most current research available indicates that for most women, removal of the breast implant and the surrounding capsule will have no affect on any systemic disease they may have.


Notable stats: The most recent (1994) nationwide survey of plastic surgeons has revealed the following about implant removal:


Patient Profile
The most common implant-removal/capsulectomy patient is a woman in the 19-34 age range who has local physical symptoms that are probably related to the implant, such as scar tissue formation that has become uncomfortably firm. However, there are a number of women who seek implant removal for symptoms that may not be medically linked to the presence of the implants. Also, a small percentage of women seek implant removal out of fear alone, even if they are exhibiting no troubling symptoms whatsoever.


The best candidates for implant removal are women who are experiencing pain, discomfort or deformity related to their breast implants and who understand fully how their appearance may change as a result of the surgery.


Implant removal and capsulectomy are not generally recommended for women whose gel-filled implants are intact and trouble free. The Food and Drug Administration has stated that the risk of removing trouble-free implants is potentially greater than the risk of leaving them in.


Regulations and Warnings
There are no state or federal laws that mandate the training and qualifications of doctors who call themselves medical specialists and perform implant-removal and capsulectomy surgery.


Patients considering these procedures are advised by ASPS to choose a qualified plastic surgeon who has been granted privileges to perform implant-removal surgery at an accredited hospital. Patients may phone 1-800-635-0635 for a list of board-certified surgeons in their area who have experience in performing implant removal.


Limitations, Risks and Complications
Limitations: If the implant shell has been damaged or ruptured, it may be impossible to remove all the escaped gel from the surrounding tissues, especially if the surrounding scar capsule, which usually contains the leaked gel, has also been injured or damaged.


It is not possible to predict with certainty how a woman will look after implant-removal surgery. Much depends on the nature of the scar capsule and whether the implant has ruptured.


Risks and complications: Even if every effort is made to place incisions in inconspicuous areas, the implant-removal procedure may leave a longer scar than that which resulted from the original implant-placement procedure. Breast sensation may be diminished or altered.


Silicone gel that leaks from an implant and is retained in the breast tissue may interfere with cancer detection because it can block X-rays and interfere with mammography. Silicone shadows that are viewed on a mammogram may have to be biopsied (just like benign lumps of any kind) to make sure they do not hide a cancer.


Larger quantities of gel that escape from a ruptured implant and migrate into surrounding tissues may form lumps called "granulomas," which while benign, may be difficult or impossible to remove without causing deformity.


Capsulectomy, in which the scar capsule is removed along with the implant, is generally a more involved operation than simple implant removal. The surgery usually takes longer, may be more expensive and more often requires general anesthesia.


On the other hand, simple implant removal without capsulectomy may leave scar tissue behind which may be detectable by touch, mammography or other imaging studies.


Patients should be aware that to date, there is no convincing scientific evidence that the gel contained in silicone-filled implants is harmful or toxic. Studies involving millions of women have produced no evidence that links gel-filled implants to any known autoimmune disease or cancer.


Most patients are up and around within a day or two and back to work and light activity within one week. Gauze dressings that may have been applied will be removed at the surgeon's discretion. Likewise stitches will be removed when the physician deems it appropriate.


Patients who had replacement implants may be required to wear a surgical bra while the stitches heal.


Some bruising and swelling may persist for three or four weeks. This document is designed to provide accurate and authoritative information in regard to the subject matter covered as of the date of publication and is subject to change as scientific knowledge and technology advances and as practice patterns evolve. The views expressed herein represent the collective, but not necessarily the individual, views of the members of the American Society of Plastic Surgeons.


Publication Date: Fall 1995

Insurance Coverage Required for Post-Mastectomy Reconstruction if Mastectomy is Covered


Arizona – covers surgical services for breast reconstruction and at least two external postoperative prostheses.


Arkansas – Enacted in 1997; covers prosthetic devices and reconstructive surgery.


California – Enacted in 1978, covers prosthetic devices or reconstructive surgery incident to mastectomy, including restoring symmetry; law was amended in 1991 to include coverage for pre-1980 mastectomies.


Connecticut – Enacted in 1987; covers at least a yearly benefit of $500 for reconstructive surgery, $300 for prosthesis, and $300 for surgical removal of each breast due to tumor.


Florida – Covers initial prosthetic device and reconstructive surgery incident to mastectomy; 1997 amendment states that the surgery must be in a manner chosen by the treating physician and specifies that surgery to reestablish symmetry between the two breasts is covered.


Illinois – Enacted in 1981; covers initial prosthetic device and reconstructive surgery incident to post-1981 mastectomies.


Indiana – Enacted in 1997; covers prosthetic devices and reconstructive surgery following a mastectomy.


Kentucky – Enacted in 1998; covers all stages of breast reconstruction surgery following a mastectomy that resulted from breast cancer.


Louisiana – Enacted in 1997; covers reconstructive surgery following a mastectomy, including reconstruction of the other breast to produce a symmetrical appearance.


Maine – Enacted in 1995; covers both breast on which surgery was performed and the other breast if patient elects reconstruction, in the manner chosen by the patient and physician


Maryland – Enacted in 1996; requires coverage for reconstructive surgery resulting from a mastectomy, including surgery performed on a nondiseased breast to establish symmetry.


Michigan – Enacted in 1989; covers breast cancer rehabilitative services, delivered on an inpatient or outpatient basis, including reconstructive plastic surgery and physical therapy.


Minnesota – Enacted in 1980; covers all reconstructive surgery incidental to or following injury, sickness or other diseases of the involved part, or congenital defect for a child.


Missouri – Enacted in 1997; covers prosthetic devices and reconstructive surgery necessary to achieve symmetry.


Montana – Enacted in 1997; effective Jan. 1, 1998; covers reconstructive surgery following a mastectomy resulting from breast cancer, including all stages of one reconstructive surgery on the nondiseased breast to establish symmetry and costs of any prostheses.


Nevada – Enacted in 1983; covers at least two prosthetic devices and reconstructive surgery incident to mastectomy. The law was amended in 1989 to cover surgery to reestablish symmetry.


New Hampshire – Enacted in 1997; effective Jan. 1, 1998; covers breast reconstruction, including surgery and reconstruction of the other breast to produce a symmetrical appearance, in the manner chosen by the patient and physician.


New Jersey – Enacted in 1985; covers reconstructive breast surgery, including cost of prostheses. The law was amended in 1997 to extend coverage to reconstructive surgery to achieve and restore symmetry.


New York – Enacted in 1997, effective Jan. 1, 1998; covers breast reconstruction following mastectomy, including reconstruction on a healthy breast required to achieve reasonable symmetry, in the manner determined by the attending physician and the patient to be appropriate.


North Carolina – Enacted in 1997; covers reconstructive breast surgery, including reconstructive surgery performed on a nondiseased breast to establish symmetry.


Oklahoma – Enacted in 1997; effective Jan. 1, 1998; covers reconstructive breast surgery performed as a result of a partial or total mastectomy, including all stages of reconstructive surgery performed on a nondiseased breast to establish symmetry.


Pennsylvania – Enacted in 1997; covers prosthetic devices and breast reconstruction, including surgery of the opposite breast to achieve symmetry, within six years of the mastectomy date.


Rhode Island – Enacted in 1996; covers prosthetic devices and reconstructive surgery to restore and achieve symmetry incident to a mastectomy. Surgery must be performed within 18 months of the original mastectomy.


South Carolina – Enacted in 1998; effective Jan. 1, 1999; covers prosthetic devices and breast reconstruction, including the nondiseased breast, if determined medically necessary by the patient's attending physician with the approval of the insurer.


Tennessee – Enacted in 1997; effective July 1, 1997; covers both breast on which surgery was performed and the other breast if patient elects reconstruction, in the manner chosen by the patient and physician.


Texas – Enacted in 1997; effective Sept. 1, 1997; covers breast reconstruction, including procedures to restore and achieve symmetry, for contracts delivered, issued for delivery or renewed on or after Jan. 1, 1998.


Virginia – Enacted in 1998; effective July 1, 1998; covers reconstructive breast surgery performed coincident with a mastectomy performed for breast cancer or following the mastectomy and surgery performed to reestablish symmetry between the two breasts.


Washington – Enacted in 1983; covers reconstructive breast surgery if mastectomy resulted from disease, illness or injury. The law was amended in 1996 to include surgery to reestablish symmetry.


Wisconsin – Enacted in 1997; covers breast reconstruction of the affected tissue incident to mastectomy and specifies that such surgery is not to be considered cosmetic.