Angeline Jolie recently underwent a prophylactic mastectomy and immediate reconstruction of her breasts.
The technique used on her was the insertion of a tissue expander placed beneath the muscle which is reinforced with a specially treated donor skin.
The expander is removed several months later and replaced with a silicone gel implant.
This is the most common technique currently used.
However there are several other options available that many potential patients are not aware of.
1) The expander can be placed above the muscle thus avoiding the abnormal muscle distortion often seen with sub muscular placement
2) An adjustable implant can be used, enabling a one-stage procedure
The adjustable implant functions as an expander and implant in one
3) Absorbable synthetic mesh can be used instead of human or animal dermis (processed deep layer of skin)
Breast cancer was originally treated by means of a radical mastectomy. The complete breast, skin, and muscle were removed resulting in horrendous defects. At this stage, breast reconstruction was not possible except with the use of flaps, i.e. bringing tissue from other parts of the body.
Surgeons began to realize that by leaving more skin the defect was less and there was no difference in the recurrence rate
This procedure became known as the modified radical mastectomy. The breast tissue was removed leaving sufficient skin to enable closure while at the same time preserving the muscle. Although, the skin was fairly tight, it was now possible to perform breast reconstruction using a tissue expander
Radovan invented the first tissue expander that could be used in breast reconstruction. The expander was placed beneath the remaining skin and slowly filled with saline thus expanding the overlying skin. When sufficient expansion was achieved, the expander was replaced with a gel implant
As Surgeons noted that there was no increased risk by removing less tissue, the mastectomy surgery evolved into a less radical procedure preserving more skin, resulting in the skin sparing mastectomy, the areola preserving mastectomy, and now the nipple areolar preserving mastectomy. Once again no increased recurrence has been seen.
Initially expanders were placed beneath the muscle as the skin was very tight, and there was a concern that the skin incision may disrupt. The muscle was therefore used as a protective layer. As this technique evolved and surgeons left more and more skin, protection of the incision this became less of a concern.
Placement under the muscle resulted in animation deformities, i.e. excessive and abnormal movement of the breast with muscle contraction. Not only being unsightly, but often leading to discomfort and pain. This led surgeons to re-operate on these patients by placing the implants above the muscle and returning the muscle to its original position.
Now with the advent of the skin-sparing and nipple sparing mastectomy it is possible to place the expander or adjustable implant above the muscle. It is however preferable to use a flat expander or flat adjustable implant that can initially be placed virtually empty in order to avoid any tension on the overlying skin flap. Once the adequacy of the circulation is assured and healing has started the implant can be slowly filled my means of saline injections
Surgeons are often reluctant to place an expander above the muscle especially if the mastectomy surgeon has left thin poorly vascularized skin However, now surgeons are leaving thicker skin flaps, especially in prophylactic mastectomies, which facilitate above muscle placement. The skin flaps can also be thickened by placing a mesh either biologic or synthetic, between the implant and the skin. My preference is for an absorbable mesh that encourages tissue in-growth by acting as a scaffold. The skin flaps can also be thickened after surgery by using fat injections, PRP (platelet rich plasma), or a combination of both.
For those patients who have sagging and wish to have the breast lifted while preserving the areolar complex a two-stage procedure can be performed. At the first stage, the nipple areolar complex is raised, a disk of skin is removed from under the nipple and sent for histology. The nipple complex is then sutured back thus performing what is known as a delayed procedure, i.e. the blood supply from inferiorly is cut off encouraging increased blood supply from the superior portion of the nipple. When the surgeon performs the mastectomy, a week or two later there is increased blood flow to the nipple and less chance of nipple loss.
Many surgeons still advocate that a patient undergoing prophylactic mastectomy should have a standard mastectomy removing the nipple areolar complex with a large horizontal incision and placement of the implant under the muscle.
The technique that we now use is nipple areolar complex sparing mastectomy, placement of an adjustable saline implant above the muscle with anterior absorbable mesh support, followed by slow postoperative expansion. If the patient is satisfied with the saline implant the injection port is removed thus enabling the procedure to be performed in one stage without any animation deformity postoperatively.
Alternatively, if the patient wishes to replace the adjustable saline implant at this stage with a gel implant, a secondary procedure is performed. The adjustable saline implant is removed and replaced with a gel implant .If necessary the skin flaps can be thickened with fat injections at the same time.
Click here to read Dr. Loren B. Eskenazi’s article “New Options for Immediate Reconstruction: Achieving Optimal Results with Adjustable Implants in a Single Stage”.