Breast Reconstruction Beverly Hills

Breast Reconstruction Beverly Hills

Breast reconstruction Beverly Hills techniques are constantly evolving and improving. In recent years, newer methods for transferring tissue to make a new breast, more advanced implants and better means of making a new nipple are all contributing to breasts that look far better and more natural than in years past. The goal at Dr. Orringer's practice for our breast reconstruction Beverly Hills patients is to create a comfortable, natural-looking and long-lasting result. Dr. Jay Orringer is constantly evaluating promising techniques and striving to reach this goal.

In basic terms, there are two ways to create a new breast. The first uses some form of implant to recreate the lost tissue, and the other uses tissue transferred from another part of the body (usually the back or abdomen) to create a more natural breast. Each breast reconstruction Beverly Hills technique has distinct advantages and disadvantages, which will be discussed. Both can, when employed in the appropriate situation, achieve very satisfactory results.

Contact the Renaissance Medical Center for Aesthetic Surgery in Beverly Hills today to schedule a breast reconstruction Beverly Hills consultation with Dr. Orringer.

Timing of Breast Reconstruction

Breast reconstruction Beverly Hills can either be started immediately, at the time of the mastectomy, or delayed to a later time. Dr. Orringer prefers immediate reconstruction for the majority of patients, as it decreases the sense of loss that many women feel after having a breast removed for medical reasons. In addition, immediate breast reconstruction Beverly Hills decreases the time needed to complete the reconstruction and usually involves one less major procedure. It also allows for more sparing of skin (skin-sparing mastectomy), a potentially shorter scar and more aesthetically pleasing results.

There are certain situations where immediate breast reconstruction Beverly Hills may not be advised. This can include situations where radiation is anticipated and where certain types of tumors, such as inflammatory cancer, exist. In the delayed setting, breast reconstructions Beverly Hills can still be achieved with very satisfactory results; the reconstruction is simply begun at a later date. When you receive your breast reconstruction Beverly Hills consultation, Dr. Orringer will work with you, your oncologist and your general surgeon in helping to decide the best possible timing.

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Expander and Implant Reconstruction

The first stage of implant breast reconstruction Beverly Hills involves placement of temporary, adjustable-volume implants called tissue expanders. The expanders are usually placed at the time of the mastectomy so that the breast reconstruction Beverly Hills is begun immediately. Expander followed by implant reconstruction is possibly the simplest form of breast reconstruction Beverly Hills, involving the shortest hospital stay and shortest recuperative period. Breast implants, however, require maintenance and may require replacement (and possibly multiple replacements) over the course of a patient’s life. This is especially true in the event of capsular contracture (scar tissue hardening around the implant) and implant rupture or deflation.

Expander Placement

At the time of the mastectomy and expander placement, some saline (salt water) is placed within the expander to begin the creation of the new breast mound. Due to its design, the expander looks much less natural than the more permanent implant that is later placed following expansion. Usually, the final drain tubes are removed one week after breast reconstruction Beverly Hills surgery, and expansion is done in the office. Expansion is performed at one- to four-week intervals depending upon patient comfort. Usually three to five expansions are done in the office, and each takes about five minutes. Following each expansion, a feeling of tightness is usually felt for several days. Expansion continues until a size that appears pleasing is reached. Expansion can be done during chemotherapy, and this is often the case. For those patients requiring chemotherapy, replacement of the expander with the implant can usually be done about one month after completion of chemotherapy.

Completion of Implant Reconstruction

While the initial mastectomy and expander reconstruction is done at a Los Angeles-area hospital, usually with a one- to two-night hospital stay, the subsequent stages of breast reconstruction Beverly Hills are typically done as an outpatient procedure. The expander tends to sit higher than optimal for the final implant. Therefore, at the time of the expander replacement with implant, the implant is repositioned as appears appropriate. At that same time, the opposite breast can be lifted and augmented, if desired, to improve symmetry. This outpatient procedure is done under general anesthesia administered by a board-certified anesthesiologist. Approximately two months later, the nipple is made, usually shaping tissue on the chest wall to make the nipple and areola. A variety of nipple reconstructions exist, and Dr. Orringer individualizes the process for each patient. After the new nipples heal (usually about eight weeks later), medical tattooing is done by Dr. Orringer in his Beverly Hills office in an effort to hide the breast reconstruction scars and improve realistic quality.

Implant types

There are several different options for implant types. While all are made of a silicone rubber shell, most are filled with saline while others, used as part of an ongoing clinical study, are filled with silicone. Some are smooth, while others are textured. Read more about the different kinds of breast implants available at our Beverly Hills, Los Angeles practice for your breast reconstruction.

What are some special considerations with expander and implant reconstructions?

Implant breast reconstruction is often selected because of its potential simplicity, shorter hospital stay and less traumatic recuperative period. For many patients, it is a good choice. However, it should be noted that implants require maintenance and may require replacement – possibly multiple times over the course of a patient’s life. Implants are most often replaced when firm scar tissue develops around the implant (capsular contracture), or if the implant ruptures or deflates. Some patients' implants will do well for 15 years and longer, while others will become firm, rupture or deflate in a much shorter period of time. Implant shells today are thicker and less permeable than they were prior to the late '80s, when many implant rupture studies were done. It is hoped that the implants will therefore maintain integrity and stay softer longer. However, studies of both saline and silicone gel-filled implants are currently ongoing.

Implant reconstructions are not as natural in their feel and appearance as breast reconstruction with one’s own tissues. However, there are fewer scars with implant reconstructions.

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Autologous Tissue Reconstructions (Using Your Own Tissues)

Autologous tissue reconstructions are done either to improve the quality and long-term durability of a breast reconstruction or as a means of reconstructing the breast without an implant. Breast reconstruction using the latissimus dorsi myocutaneous flap transfers skin, fat and muscle from the back, usually to cover an expander or implant with a layer of healthy tissue. This technique trades a scar on the back for a less apparent scar on the front. Many people consider this an acceptable trade-off since they frequently view themselves from the front and rarely see their back. In some patients who are small-breasted and in others with considerable fat over the muscle, the latissimus transfer can be performed and the breast made without an implant.

Latissimus "Back" Flap Breast Reconstruction

After expander and implant breast reconstruction, the muscle acts as a sling to support the implant and gives the breast a more natural appearance than it would have with an implant alone. With skin-sparing mastectomies, where aesthetically important skin of the breasts is preserved, skin from the latissimus back flap can fill the circle from where the nipple was removed. The resulting breast, therefore, often has very little visible scarring. The back skin and fat allow for a very pleasing nipple reconstruction. Latissimus flap with implant breast reconstructions still require implant maintenance, and the implants may need to be replaced. However, the addition of the latissimus muscle over the implant creates a more natural-looking breast with less visible implant edge and implant rippling. In addition, the healthy layer of muscle over the implant may help to keep the implant softer longer.

The transfer of the latissimus is generally well-tolerated. The scar is designed to be hidden in the bra line or in a position low and to the outside of the back to allow for the wearing of low-cut clothing. Scar placement will be planned and discussed in detail with Dr. Orringer prior to the breast reconstruction procedure. The function of the latissimus muscle is reproduced by other muscles, and its transfer very rarely results in functional loss. If you are a mountain climber, competitive skier or swimmer, or if you seriously pursue similar athletic endeavors, Dr. Orringer will not transfer the muscle.

Performed with an expander operation, this breast reconstruction procedure typically adds one to two days to your hospitalization and one to two weeks to your recuperation. The aesthetic breast shape is better, however, and the patient usually leaves the hospital with a breast that has reasonable shape that improves quickly. The expander beneath the muscle allows for breast volume adjustment as desired by a patient. Typically, patients can return to work and exercise activities in three to four weeks.

Abdominal Flap Breast Reconstruction

Some patients at our Beverly Hills, Los Angeles practice opt for more involved breast reconstruction surgery in order to avoid implants. In those cases, tissue is often taken from the abdominal donor site. These procedures are more involved than implant reconstructions and involve a donor site scar. However, they tend to look and feel much more natural than implants. Once successfully transferred, autologous reconstructions (reconstructions done with your own tissues) are permanent in nature. And unlike implant reconstructions, they do not require maintenance. Patients who have redundant skin and fat of the abdominal wall may choose a form of breast reconstruction that uses this tissue. A variety of techniques are used for this, including the traditional TRAM flap, the muscle-sparing microvascular free TRAM flap, and the DIEP perforator flap. Each has potential advantages and disadvantages.

Traditional TRAM Flap Reconstruction

The traditional TRAM flap involves the tunneling of skin, fat and muscle from the abdominal wall to the chest, where the tissue is made into a breast (see pictures). This technique involves taking more muscle and a blood supply to the new breast. The advantage of traditional TRAM flap breast reconstruction is that total loss of the tissue rarely occurs, but because of inferior blood supply, there is a greater potential for partial tissue loss (fat necrosis). Some people complain of a bulge or discomfort where the muscle is tunneled over rib.

Free TRAM Flap Reconstruction

The muscle-sparing microvascular free TRAM flap breast reconstruction involves the transfer of a much smaller segment of muscle, which contains multiple blood vessels (perforators) to the skin. The redundant skin, fat and small muscle segment are transplanted by reattaching blood vessels under a microscope. This microsurgical transplant of tissue allows for a potentially heartier blood supply and the taking of less muscle. However, this method of breast reconstruction requires microsurgical expertise. While it has much less partial flap loss (fat necrosis), it carries the risk of total flap loss if the blood vessels occlude before the tissue has taken. This technique may allow for greater preservation of abdominal wall integrity, since less muscle is removed. At his Beverly Hills, Los Angeles office, this is Dr. Orringer’s preferred method of abdominal flap breast reconstruction.

DIEP Flap Reconstruction

The perforator or DIEP flap procedure spares all of the muscle but relies on one or two “perforator” blood vessels to supply the entire mound of tissue. It is a still-more involved microsurgical procedure than the muscle-sparing free TRAM flap breast reconstruction technique. While it does spare muscle, it does not have as hearty a blood supply as the muscle-sparing free TRAM flap. It may not be as suitable to create a larger breast or in the setting of radiation.

Each of these procedures can be suitable breast reconstruction options depending upon the surgeon, the patient and the situation. Any of the above flaps taken from the abdomen have lengthy scars, but the procedures usually result in improved abdominal contour. While the amount of redundant skin and fat is decreased and the abdominal wall appears flatter, a narrowing of the waist and an hourglass figure are not achieved.

Hospitalization is typically five to seven days, and can be spent at the Serenity Post-Surgical After Care Retreat near our Beverly Hills office. Most breast reconstruction patients can resume their normal activities, including exercise, in about six weeks.

What are some of the special considerations with reconstructions using tissue from the abdominal wall?

These breast reconstruction methods all result in a lengthy scar, which usually extends hip-to-hip, similar to that of a tummy tuck. A scar around the umbilicus (belly button) is present as well. The potential improvement in contour must be a satisfactory trade-off for the scars. In addition, with the traditional TRAM flap and the muscle-sparing free TRAM flap, some weakness of the abdominal wall will result. This particularly affects the ability to do sit-ups. The DIEP flap least affects strength but has a blood supply that is inferior to the muscle-sparing free TRAM flap. Following these breast reconstruction procedures, bulges or hernias requiring repair can occasionally occur. Some numbness is present, particularly from the scar to the umbilicus. This improves (but may not totally resolve) over one to two years.

Some women prefer the contour of implant breast reconstructions, while others prefer the more natural appearance of autologous breast reconstructions (reconstructions using one’s own tissues). Autologous tissue reconstructions trade more scarring, some donor site weakness and a longer hospital stay and recuperative period for a potentially more natural result that does not require the maintenance of implant reconstructions.

Gluteal (Buttock) Reconstruction

Another breast reconstruction technique which is available at some centers is the gluteal perforator flap (GAP flap). This procedure, which uses redundant buttock skin and fat, is appropriate for women who have limited excess skin and fat on the abdominal wall and women who have had a previous tummy tuck, but do not want the type of breast reconstruction that involves an implant. It is a very complex microsurgical reconstruction that is not done by most microsurgeons due to technical considerations. To some patients, the shape of the breast is suboptimal, and the buttock scar is not an acceptable trade-off. Dr. Orringer generally does not offer this procedure at his Beverly Hills practice, favoring breast reconstruction methods involving the use of abdominal and back tissue. Nevertheless, for the right patient and the right situation, this is a very reasonable option, when available.

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How and when is the nipple reconstructed?

The nipple is reconstructed as an outpatient procedure after the breast mound is completed. The timing varies, depending on whether or not chemotherapy or radiation is required and what type of breast reconstruction was performed. For example, in the case of most implant breast reconstructions, expansion occurs over two to three months. Three months after mastectomy, most patients are ready to undergo replacement of the expander with an implant. If chemotherapy is needed, it usually takes about a month for the bone marrow to heal and for the patient to be ready for the outpatient procedure. Usually about eight weeks after the implant is placed, sufficient healing has occurred for the first stage of nipple reconstruction.

Dr. Orringer uses skin and fat overlying the implant to make the nipple and areola in most instances. Occasionally, if the other remaining nipple is quite large, a portion of it is used to make the new nipple. This, in combination with a skin graft usually taken from the inner thigh, can produce a very natural result. If a TRAM flap breast reconstruction procedure is performed, the nipple is usually made when the flap is shaped and the opposite breast lifted or reduced as appropriate, again at about three months after breast removal or one month after chemotherapy. In the event that radiation is required, the nipple reconstruction will generally be postponed until most of the visible signs of radiation have resolved – usually three to six months after completion of radiation. Approximately eight weeks after the nipple is made, medical tattooing is performed by Dr. Orringer in an effort to hide scars and produce a more natural breast.

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If radiation is necessary, can reconstruction still be done?

While radiation can compromise the quality of the reconstructive result, patients treated with radiation can still undergo breast reconstruction. While potentially helping to improve survival and decrease the local recurrence of cancer, radiation permanently damages the soft tissues of the chest wall. As a result, the soft tissues may not tolerate the addition of an expander or implant without the addition of healthy tissue from elsewhere, such as the back (latissimus flap). Implants on the radiated chest wall will always have a much greater tendency to form hard scar tissue around them. A long-term satisfactory implant result in the post-radiation setting is frequently not achieved. When an individual is healthy and has excess skin and fat of the abdominal wall, breast reconstruction using these tissues without an implant is often preferred. The use of tissue from the abdominal wall, in the form of a muscle-sparing free TRAM flap or the addition of a latissimus flap with expander and subsequent implant to the radiated chest wall are Dr. Orringer’s options of choice following radiation.

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The Consultation

Dr. Orringer will typically spend 1½ to 2 hours with you during your consultation at his center in Los Angeles, discussing your history, educating you about your breast reconstruction options, performing a physical examination, and helping you formulate a plan. In addition to the nature of the current problem, other aspects of your medical history will be addressed, including heart or lung problems, diabetes, smoking habits, back problems, previous breast or abdominal surgery, personal or family history of bleeding, and any problems with anesthesia. During your examination, Dr. Orringer will evaluate your current body type and build, breast size and shape, back and abdominal contour, previous breast and abdominal scars, and other relevant considerations. At the completion of the history, physical examination and initial education process at our Beverly Hills office, Dr. Orringer will discuss with you his thoughts regarding the most reasonable and appropriate options for your breast reconstruction.

This is often a challenging time filled with a considerable amount of new information. Dr. Orringer realizes this and encourages you to ask any questions you might have. You'll have the chance to discuss the details of your breast reconstruction procedure again at your preoperative visit. If you require another visit in between, please do not hesitate to schedule one.

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The Surgery

The mastectomy and first stage of breast reconstruction are performed at Saint John’s Hospital in Santa Monica, with anesthesia administered by a board-certified anesthesiologist. Prior to surgery, Dr. Orringer will make surgical topographical markings, designing the incisions with your input and an attempt to place scars where they will be hidden by your commonly worn clothing. After surgery, you will be cared for by nurses skilled in the postoperative care of breast patients in the new wing of the hospital. The number of days your are hospitalized will be dependent upon the procedure, your overall health, and what kind of support system you will have following discharge. A customized booklet that further discusses the procedure, its risks, and what to do before and after your surgery will be provided for you at your preoperative visit. .

The best way to learn more is to contact Dr. Orringer at our Beverly Hills, Los Angeles practice. He can discuss the best breast reconstruction options with you only after physically examining you and discussing your medical history and goals.

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