skin sparing mastectomy reconstruction options

Options
klowey
klowey Member Posts: 14
edited February 2018 in Breast Reconstruction

I'm new to this amazing supportive forum. I haven't yet filled in my own details, but I'm stage 1a. This is my second cancer in the right breast. First was in 2004, Stage 0.

I'm seriously considering a double mastectomy with reconstruction. Here is my question, which is two-fold.

I have read about many women who have had a skin sparing mastectomy and then TEDs and implants.

My first question is, if it is possible to have skin sparing surgery and implants, can they put the implants in through the nipple "hole" or do they have to cut and create vertical or horizontal scars? And, it the answer to this affected by whether or not they do the direct-to-implant method or the TED method?

My second question is about something that really confuses me. I just came across a page from the UCSF website, ucsfhealth.org. Under the topic "Breast Reconstruction: Options After a Skin-Sparing Mastectomy" the subsection "Why Can't I have an Expander after a Skin-Sparing Mastectomy?" says it is not possible to have a skin sparing mastectomy and then implants. I can't seem to be able to post the actual link, but here is the text:

"Because all the breast skin is preserved during a skin-sparing mastectomy, it is not possible to use an expander (or an implant alone) after this procedure. This is because an expander or implant must be covered with muscle, not just skin, or it will look unnatural, feel unnatural and may become infected.

There is no muscle in the chest which can cover an implant, so immediate implant (or tissue expander) placement is not an option after skin-sparing mastectomy.

Another reason why an implant or expander can't be used after skin-sparing mastectomy has to do with the hole in the skin left after skin-sparing mastectomy. There is no way to close the skin if a circle of it is removed.

The only way for a plastic surgeon to close a circular hole are:

To fill the hole with skin from somewhere else (tram flap or latissimus flap).

To turn the hole into an ellipse, creating a long scar. However, creating a long scar across the breast results in the same kind of scar as a traditional mastectomy and defeats the purpose of a skin-sparing mastectomy.

Therefore, a tissue expander or an implant alone cannot be used after a skin-sparing mastectomy because:

These implants must be covered by a muscle and there is no muscle in the chest which can do this. The pectoral muscle can cover an implant, but only after about 6 months of stretching.

The implant not covered by muscle looks and feels unnatural.

The implant not covered by muscle very often (30 percent to 50 percent) gets infected and has to be removed.

To close the skin with an implant or expander reconstruction, you need to make a long scar across the breast, removing extra skin and defeating the purpose of the skin-sparing mastectomy."



· Share on FacebookShare on Twitter

Comments

  • Lula73
    Lula73 Member Posts: 1,824
    edited February 2018

    well, some of that info is accurate and some of it not so much. Typically a tissue expander is used to stretch the chest wall muscle to make room for an implant. However it seems that I have heard of women having a TE placed as a place holder f you will til recon is done. In a skin sparing MX the tissue is not usually taken out through the nipple unless the nipple has been removed. Even still there likely will still be a straight incision out from the nipple typically straight down or out to the side towards the shoulder. TRAM and Latissimus flaps are not done usually for closing a circular hole in the breast unless you’re having a flap based reconstruction. Yes you can do BMX with direct to implant recon-you just have to find a doc that does it and does it well. It sounds like that group does not do them. If you’d prefer not to do implants, you can opt for a natural tissue recon with a DIEP, SGAP or stacked flap option done immediately or delayed with or without skin sparing option. If you’re worried about scars, make sure you are going to a very skilled PS. Look at his/her before & after pics to see how the incisions usually heal. If you don’t like what you see, check out another PS. Those pics don’t guarantee you will heal as nicely however it gives you a very good idea of what can be provided everything goes as planned & you heal well. Hope this helps!

    · Share on FacebookShare on Twitter
  • klowey
    klowey Member Posts: 14
    edited February 2018

    Thank you Lula73 for your comment. I'm glad you also think some of that information does not seem right.

    I would have skin sparing with nipple removal. That being said, is there a chance to take out the breast tissue and do a TUG or implant reconstruction without making any other incisions except the hole in the nipple area (I think it's called a periareola incision)?

    I am also considering a TUG. My PS does both TUG (and other flaps) and implants, including direct implant. I'm not seeing him until next Thursday, so I am obsessed with trying to find out everything I can. TUG would be nicer but the additional risks of complications scare me. How did your DIEP go?


    · Share on FacebookShare on Twitter
  • rdeesides
    rdeesides Member Posts: 459
    edited February 2018

    I just had a skin/nipple sparing mastectomy 3 weeks ago and my only incision is on the top half of my nipple. I’m amazed at how small it is. Nit sure how they did it but sounds like it is a newer technique. I have a tissue expander and will do radiation and will then have the follow up surgery for the implant exchange.

    Rebekah

    · Share on FacebookShare on Twitter
  • NotVeryBrave
    NotVeryBrave Member Posts: 1,287
    edited February 2018

    I had skin and nipple sparing BMX with direct to implant reconstruction. My scars are under the breasts, just above the IMF. Alloderm was used to create an internal "bra" to hold the implants in place under the skin. I did have an infection on one side 5 weeks after surgery but recovered and kept the implant.

    They probably don't look or feel quite as nice as under the muscle - but they also aren't affecting my pectoral muscles. And I could do fat grafting to help with the coverage.

    I'm not sure about the options if they have to take the nipple, but it's definitely worth shopping around.


    · Share on FacebookShare on Twitter
  • Cpeachymom
    Cpeachymom Member Posts: 518
    edited February 2018

    klowey- I found the same info as you when I was first looking into recon options, so I was pleasantly surprised when I met with my plastic surgeon and he told me he does prepectoral implants with fat grafting. I had a skin sparing mastectomy, but have not started and recon yet. My tumor was near the nipple and she had to take extra skin, so I actually have a tripod shaped scar. There are more than a few women on this site who have done direct to implant mastectomy, but I do think it’s limited for which plastic surgeons can do it because it’s fairly new. I agree you should shop around to find what you want

    · Share on FacebookShare on Twitter
  • klowey
    klowey Member Posts: 14
    edited February 2018

    Hi NotVeryBrave . It sounds like you had one of the newer techniques of implants over the muscle, or do all direct-to-implant reconstructions put the implant over the muscle? I thought they usually put the implant under the muscle, but without an expander first

    · Share on FacebookShare on Twitter
  • klowey
    klowey Member Posts: 14
    edited February 2018

    Hi Cpeachymom. So you also had the newer technique of implants over the pectoral muscle. Will that require Alleoderm do you know?

    · Share on FacebookShare on Twitter
  • klowey
    klowey Member Posts: 14
    edited February 2018

    Hi rdeesides. That is awesome! That is what I wanted to hear. So you have a simple nipple scar and an expander. They were able to put the expander in without more scars. Which implant type are you thinking of and will it involve Alloderm?

    · Share on FacebookShare on Twitter
  • rdeesides
    rdeesides Member Posts: 459
    edited February 2018

    klowey-

    My TE is over the muscle and so my implant will be as well. I don’t know what type of implant I will get but I will have Alloderm.

    Rebekah

    · Share on FacebookShare on Twitter
  • Cpeachymom
    Cpeachymom Member Posts: 518
    edited February 2018

    I believe it will be with alloderm. There is a whole prepectoral discussion thread, if you go to the search bar you should be able to find it. There is even one with a list of doctors around the country who are doing prepectoral.

    · Share on FacebookShare on Twitter
  • Lula73
    Lula73 Member Posts: 1,824
    edited February 2018

    klowey- my DIEP went smoothly and I’m thrilled with the results. If you have a tummy, DIEP is the preferred way to go for flap surgeries as a standard.SGAP is typically second, stacked flap third. TUG, PAP and TRAM are all typically further down the line preference wise for various reasons. Here’s a link to a YouTube video of one of the top microsurgeons for flap recon in the world doing a talk in front of hundreds of microsurgeons at an international conference where he discusses different flaps. He specifically addresses TUG & PAP at the 12:45-14:00 minute marks if you want to fast forward.

    https://m.youtube.com/watch?v=lGmoI21Tfbc

    · Share on FacebookShare on Twitter
  • klowey
    klowey Member Posts: 14
    edited February 2018

    Lula73, that video was fascinating . Many thanks! And I am so happy for you that you love your results.

    · Share on FacebookShare on Twitter
  • Lula73
    Lula73 Member Posts: 1,824
    edited February 2018

    klowey-hoping you will love yours too!

    · Share on FacebookShare on Twitter
  • NotVeryBrave
    NotVeryBrave Member Posts: 1,287
    edited February 2018

    I think that direct to implant would be difficult under the muscle. When it's above the muscle then they are basically just replacing the breast tissue that is removed and no stretching is needed - unless you are seeking to go larger.


    · Share on FacebookShare on Twitter

Categories