How and When Is the Nipple Reconstructed?
The nipple is reconstructed as an out-patient after the breast mound is completed. The timing varies often depending on the type of reconstruction and whether or not chemotherapy or radiation therapy is required. In the case of most implant reconstructions, expansion occurs over 2-3 months.
By the end of the third month after mastectomy, most patients are ready to undergo replacement of the expander with an implant. If chemotherapy is needed, it usually takes about 1 month for the bone marrow to heal and for the patient to be ready for the out patient procedure. Usually about 8 weeks after the implant is placed, sufficient healing has occurred for first stage nipple reconstruction.
Dr. Jay S. 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 (NOT the labia), can produce a very natural result.
If a TRAM flap procedure is done, the nipple is usually made when the flap is shaped and the opposite breast lifted or reduced as appropriate, again at about 3 months or 1 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 3-6 months after completion of radiation. Approximately 8 weeks after the nipple is made, medical tattooing is performed by Dr. Orringer in an effort to hide scars and produce a more natural appearing breast.
If Radiation Is Necessary, Can Reconstruction Still be Done?
While radiation does compromise the quality of the reconstructive result, patients treated with radiation can still undergo breast reconstruction. While potentially helping to improve survival and decrease 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, 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.
What Is Gluteal (Buttock) Reconstruction?
Another technique for reconstructing the breast which is available at some centers is the gluteal perforator flap (GAP flap). This procedure uses redundant buttock skin and fat in individuals who have limited excess skin and fat of the abdominal wall or in those women who have had a previous tummy tuck, but do not desire implant reconstruction. 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 does not do this procedure, favoring use of abdominal and back tissue. Nevertheless, for the right patient and the right situation, this is a very reasonable option, when available.
Please contact The Renaissance Medical Center for Aesthetic Surgery, Inc. online or by phone at 310-273-1663 with any questions you may have about breast reconstruction and the procedures we offer. Dr. Orringer will be happy to meet with you in a confidential consultation to talk about all aspects of treatment.