Undergoing a mastectomy for breast cancer or for high-risk situations is a stressful experience, and breast reconstruction is a very important part of the healing process. Dr. Orringer is committed to providing you with the highly personalized, caring service you deserve. He believes that every patient is unique, and he takes the necessary time to evaluate and establish an individualized plan that might best help achieve your goals, based upon your lifestyle, body type, and other considerations.
Breast Reconstruction Patient, Ms. Angelina Jolie
Dr. Jay Orringer is internationally known for his breast reconstructive work. He has lectured on his innovative incisions and state-of-the-art techniques in an effort to achieve the most natural result possible in the mastectomy setting. Dr. Jay Orringer believes that it is a privilege to share in your care and to work toward restoring a sense of wholeness for you.
If you are about to undergo a mastectomy, it is important to understand your breast reconstruction options prior to your surgery. By speaking with Dr. Orringer during the early stages of planning your mastectomy, you can understand better the options available to you. Even if you are considering lumpectomy and radiation, it may be valuable to discuss the possible implications of radiation and their effects on any future reconstruction.
- Timing of Breast Reconstruction
- Your Breast Reconstruction Options
- Expander and Implant Reconstruction
- Replacing the Tissue Expander with a Breast Implant
- Special Considerations with Expander and Implant Breast Reconstructions
- Autologous Tissue Reconstruction
- Autologous Tissue Reconstruction Techniques
- Fat Grafting in Breast Reconstruction
- Autologous Tissue Reconstruction in Conjunction with Tissue Expander and Implant Reconstruction
- Preeminent Beverly Hills Breast Reconstruction Surgeon
Timing of Breast Reconstruction
You can undergo breast reconstruction at the time of your mastectomy or delay the procedure until a later date. In most instances, Dr. Orringer prefers to perform reconstruction at the time of your mastectomy, as it decreases the sense of loss and expedites the process of restoring the breast. It also allows for more sparing of skin, possibly including the nipple and areola, a potentially shorter scar, and a potentially more aesthetic result.
However, there are certain situations when undergoing breast reconstruction at the time of your mastectomy may not be recommended. You can still often achieve a pleasing result in the delayed breast reconstructive setting. Dr. Orringer will work closely with you, your oncologist, and your general surgeon to help you determine the right time for your procedure.
Your Breast Reconstruction Options
Breast reconstruction options are rapidly evolving and improving. The new, innovative techniques that have been developed in recent years enable you to achieve more natural looking and beautiful results than ever before. Dr. Orringer is constantly evaluating promising new techniques in order to provide you with the best possible results. Today, nipple-sparing mastectomy and reconstruction as well as innovative, more aesthetic incisions are significantly improving breast reconstruction results.
Dr. Orringer offers the two general categories of breast reconstruction:
- Expander and implant reconstruction
- Autologous tissue reconstruction (use of own tissue) including microsurgery
Expander and implant reconstruction uses a breast implant to restore your breast appearance. Autologous tissue reconstruction involves transferring tissue from another part of the body to create a potentially more natural feeling and appearing breast.
Expander and Implant Reconstruction
The first stage of implant reconstruction usually involves the placement of a temporary, adjustable volume implant called a tissue expander. The tissue expander is usually placed at the time of your mastectomy so that your breast reconstruction procedure can begin immediately.
Dr. Orringer will place some saline (salt water) into the tissue expander to begin the creation of the new breast mound. Expansion is generally performed at 1-2 week intervals depending on patient comfort. In most cases, 3-5 expansions will be performed at our Beverly Hills plastic surgery office. Each expansion takes about 5 minutes.
Expansions will be performed until a pleasing size is reached. This process can be done during chemotherapy, and replacement of the tissue expander with a breast implant can usually be done about one month after chemotherapy treatments are completed. While implants can be placed at the time of the mastectomy, expander placement allows for potentially more patient involvement with regard to desired size. It also may be a safer approach with regard to the health of the nipple and skin as a minimal initial volume can be used until the health of the tissues has been determined, usually within the first 3-5 days.
Replacing the Tissue Expander with a Breast Implant
Once the expansion phase is complete, Dr. Orringer will replace the tissue expander with a breast implant. This often occurs three months after the mastectomy and expander placement, if no chemotherapy or radiation therapy is required. If chemotherapy is required, he will usually wait at least one month after completion of chemotherapy for the second stage reconstruction. If radiation is required, the quality of the reconstruction will be negatively affected to some extent, so he typically waits at least 6 months following completion of radiation therapy before the second stage reconstruction
Depending upon the nature of the tissues after radiation, some type of autologous tissue (using one’s own tissues) may be recommended with or without an implant. Dr. Orringer may recommend breast augmentation often with a breast lift on the other breast to potentially improve symmetry at the time of the second stage implant reconstruction.
If the nipple has been removed, approximately two months after the breast implant is placed, Dr. Orringer will often use the tissue on the chest wall to create the nipple and areola. He individualizes the nipple reconstruction technique to address your unique situation. After the new nipple has healed, medical tattooing is performed in an effort to hide scars and create a more natural looking appearance. If thin, radiated tissues are present, three-dimensional nipple tattoo reconstruction alone might be recommended.
Dr. Orringer discusses with you a variety of types of breast implants:
- Saline implants (round and shaped)
- More traditional round silicone implants
- Cohesive gel ("gummy bear") implants (both round and shaped)
Both smooth and textured (rough surface) implants exist. Because of a very low incidence of a lymphoma known as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) associated almost exclusively with textured implants, Dr. Orringer is currently only using smooth surface implants.
The size and style of breast implant Dr. Orringer recommends will be individualized to your body build and aesthetic goals. “Gummy bear” implants include the newest fifth generation silicone gel implants that are somewhat firmer gel that might have somewhat less implant rippling than more traditional silicone implants. Dr. Orringer uses a variety of breast implant manufacturers and styles depending upon the unique patient situation.
Special Considerations with Expander and Implant Breast Reconstructions
Expander and implant procedures are potentially the simplest form of breast reconstruction, and they typically result in a shorter hospital stay, shorter recovery time, and fewer scars than autologous tissue reconstruction procedures. As a result, it is an option that many patients choose.
However, it is important to understand that breast implants require maintenance and may need to be replaced, possibly multiple times, during the course of your life. Breast implants may last 15 years or longer. However, like all medical devices, breast implants wear over time and have a variable life expectancy. Other reasons your implants may need to be replaced include:
- Implant rupture
- Development of firm scar tissue around the implant (capsular contracture)
- Implant deflation
- A desire for a potentially more cosmetic outcome
- Newer technologies might improve upon the old result
It is also important to understand that expander and implant reconstructions often will not achieve results that look and feel as natural as breast reconstructions performed using autologous tissue techniques. However, products such as AlloDerm, FlexHD, and Strattice can be used to somewhat improve the padding over an implant, as well as provide a hammock like support for the implant. This may potentially improve the look and feel of your implant reconstructed breast. In addition, these products might decrease the degree of implant encapsulation (scar tissue firmness around an implant).
Autologous Tissue Reconstruction
Autologous tissue reconstruction (reconstructions performed with your own tissue) potentially results in a more natural looking outcome than expander and implant reconstruction procedures, but it is also a more extensive surgical procedure and involves a scar on a location other than the chest.
Many women who choose autologous tissue reconstruction do so in order to avoid the use of breast implants with their breast reconstruction procedure. During this type of reconstructive procedure, Dr. Orringer will remove tissue from one part of the body and use it to rebuild part or all of the breast mound. Because this technique involves microsurgery, it has its own blood supply and tends to maintain its volume well, unlike liposuctioned injected fat, where much of the fat will resorb.
These procedures are more involved than implant reconstructions and also result in a donor site scar. However, they tend to look and feel more natural than implant reconstructions. In addition, autologous reconstruction procedures are permanent in nature and unlike implant reconstructions, do not require maintenance (implant replacement).
Autologous tissue reconstruction procedures typically result in hospitalization for 3-7 days. While recovery varies with the individual, most patients can resume the majority of their normal activities, including exercise, by about 6 weeks.
Autologous Tissue Reconstruction Techniques
Dr. Orringer discusses a variety of techniques when performing autologous tissue reconstruction. These include:
- DIEP perforator flap – This procedure is the most muscle-sparing procedure of the various abdominal flap options. It requires microsurgical training and expertise.
- Muscle-sparing microvascular free TRAM flap – This procedure saves more muscle than the traditional TRAM flap procedure. However, it removes more muscle than the DIEP flap. As it requires muscle removal, Dr. Orringer usually no longer uses this option.
- Traditional TRAM flap – This older technique involves the tunneling of skin, fat, and muscle from the abdominal wall to the chest, where the tissue is made into a breast. While still performed in areas where microsurgery may not be done, Dr. Orringer no longer uses this option.
- SGAP Flap – This microsurgical option transplants upper buttock soft tissue to create the new breast mound. It is often a good option for those women with little excess abdominal wall soft tissue and those having already had a tummy tuck or extensive liposuction.
Each of these procedures can potentially deliver excellent results. Abdominal scars similar to that of a full tummy tuck result from the abdominal flaps. However, as with a tummy tuck, overall abdominal contour is often improved. The SGAP flap creates some upper buttock volume loss but lifts the buttock. Dr. Orringer will make an individualized recommendation for you based upon your unique situation and personal preferences.
Fat Grafting in Breast Reconstruction
Dr. Orringer often uses liposuctioned fat, called fat grafting, to soften mastectomy defects and implant imperfections such as ripples. However, not every patient should have, or will choose to have, fat grafting. The amount of volume maintenance is highly variable and multiple treatments may be required to achieve a more desired result. In addition, fat associated cysts, lumps, and calcifications may occur that can interfere with examination and this could require further evaluation such as ultrasound, MRI, excision and biopsy. This has to be considered and the decision individualized.
Autologous Tissue Reconstruction in Conjunction with Tissue Expander and Implant Reconstruction
Autologous tissue reconstruction can also be performed in conjunction with expander and implant reconstruction to improve the long-term durability of an implant reconstruction. This is known as a hybrid reconstruction. In these situations, skin and fat are usually transferred from the abdomen or back in order to cover a breast implant. This transferred tissue over the implant potentially gives the reconstructed breast a more natural appearance than can typically be achieved with an implant alone. In addition, the healthy layer of fat over the breast implant may help to keep the implant softer longer. While muscle transfer used to be commonly done in breast reconstruction, current microsurgical techniques known as perforator flaps allow for transfer of skin and fat without muscle transfer. Often the excess skin and fat are removed from the lower abdominal wall in tummy tuck fashion.
Scars are usually designed in an effort to best conceal them in bathing suits or underclothing. The addition of one’s own tissue typically adds 1-2 days of hospitalization and generally 1-2 weeks to the recovery period of an expander and implant reconstruction procedure. While recovery varies with each individual, most patients are typically able to resume most normal work and exercise activities by 4-6 weeks.
Breast Reconstruction Patient, Ms. Shannen Doherty
Preeminent Beverly Hills Breast Reconstruction Surgeon
Throughout his career, Dr. Orringer has had a passion for breast reconstruction. He's known for his innovative approach to mastectomy incisions, and he strives to use aesthetic principles in planning incisions whenever possible.
Dr. Orringer has taught his innovative algorithm for aesthetic mastectomy incisions and has performed nipple sparing mastectomy reconstructions for more than a decade. He has also been recognized as a leader in the field. Dr. Orringer has lectured and published on a variety of topics on breast reconstruction and shares his innovative techniques with colleagues. Dr. Orringer lectured and taught at the prestigious Santa Fe Breast and Body Symposium on his Algorithm for Aesthetic Mastectomy Incisions, Considerations for Reconstruction in the BRCA Positive Patient and Techniques to Help Maintain the Nipple During Mastectomy.
He has also lectured on his breast reconstructive approaches at the Annual Meetings of the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery. His lecture topics have included reconstruction in the BRCA patient, current aesthetic techniques for mastectomy incisions, and complex nipple-sparing mastectomy reconstruction.
Breast Reconstruction FAQs
Can reconstruction be performed if I choose lumpectomy instead of mastectomy?
Yes. In certain cases, reconstruction may be performed in conjunction with lumpectomy, a concept often referred to as oncoplastic reconstruction. This approach integrates cancer removal with reshaping of the breast to help preserve contour and symmetry. It often involves breast lift or reduction, which may allow for further clearance of margins and improved breast shape prior to radiation. The suitability of oncoplastic reconstruction depends on tumor size, breast size and shape, location of the lumpectomy, and whether radiation therapy is planned. Dr. Orringer works closely with the general surgeon and oncology team to determine whether this option may be appropriate and how it could affect cancer treatment. How radiation could affect long-term breast appearance is also discussed and considered.
What is the difference between pre-pectoral and sub-pectoral implant placement in reconstruction?
Pre-pectoral reconstruction places the implant above the chest muscle, while sub-pectoral reconstruction positions it partially beneath the muscle. Each approach has advantages and limitations depending on tissue quality, skin and fat thickness, radiation history, anatomy, patient health, and preference. Pre-pectoral placement may reduce muscle-related discomfort and animation-associated changes, while sub-pectoral placement provides additional implant coverage and might produce an overall more pleasing shape with less implant visibility, including rippling. Dr. Orringer carefully evaluates these factors and recommends an approach that is individualized to each patient.
Can breast or nipple sensation be restored during reconstruction?
Loss of sensation is a common concern following mastectomy. In select cases, Dr. Orringer performs nerve reconstruction (neurotization) to the nipple. This is a newer technology and outcomes vary widely, depending upon surgical anatomy and healing. Dr. Orringer discusses these possibilities candidly during consultation so patients understand what may be feasible and what limitations exist.
How does abdominal-based flap reconstruction affect core strength or future activity?
Procedures such as the DIEP flap use skin and fat from the lower abdomen while preserving the abdominal muscles. Because muscle is not removed, many patients retain very good core strength long term. Tightening the muscle and repairing post-pregnancy muscle separation often provides a sense of greater strength and stability. However, recovery requires time. Patients often require 4-6 weeks before resuming greater physical exertion. Pregnancy after abdominal-based reconstruction is often still possible. Dr. Orringer reviews lifestyle, fitness goals, and future plans when recommending any flap-based approach.
How do weight changes or pregnancy affect reconstructed breasts over time?
Weight fluctuations may influence both implant-based and autologous reconstructions, though the effects differ. Implants maintain their size, while surrounding tissues may change with weight gain or loss. Autologous tissue reconstructions may change more naturally with the body over time. The autologous breast reconstruction tissue from the abdomen will gain weight just as it did when it was on the abdomen. Pregnancy and hormonal changes can also affect breast shape. Dr. Orringer emphasizes planning reconstruction with long-term body changes and goals in mind, whenever possible.
How does radiation therapy influence reconstruction planning and long-term outcomes?
Radiation therapy will affect skin quality, tissue elasticity, and healing. This may influence both the timing and type of breast reconstruction recommended. In patients who require radiation, Dr. Orringer carefully considers how treatment may impact implant-based reconstruction versus autologous tissue options. Dr. Orringer performs some form of immediate reconstruction in the vast majority of instances. Radiation effects are permanent to some degree. In general, reconstructions using tissue do better on an irradiated chest wall than implants, but in some instances, implant reconstructions may still be done. In occasional cases, reconstruction may be staged or delayed to allow tissues to recover somewhat. These decisions are made collaboratively with the oncology team and are individualized to balance safety, durability, and aesthetic considerations over time.
Please contact Dr. Jay Orringer at The Renaissance Medical Center for Aesthetic Surgery, Inc. to schedule your breast reconstruction consultation today. We serve patients in Beverly Hills, Los Angeles, Santa Monica, and Hollywood, Newport Beach and Northern California, as well as nationally, and internationally.
