Additional surgery to complete a breast reconstruction
Breast reconstruction usually requires three stages:
- The breast mound is re-created using an implant or autologous tissue.
- Six months later a second procedure may be performed to improve symmetry with the contralateral breast.
- The final stage involves nipple reconstruction and tattooing of the areola. Sometimes the other areola is also tattooed to achieve a similar colour match on both sides.
If the reconstruction is being performed using a tissue expander, the volume can be gradually adjusted by injecting saline through a small port in the implant. Once the desired volume is reached, the expander can be exchanged for a permanent silicone implant. However, once the permanent implant is in place no further corrections can be made. If the breast volume needs to be altered again, additional surgery is necessary.
Immediately after an autologous breast reconstruction, the shape of the breast may be less natural. Over the first several months, gravity will take affect and the appearance will improve.
The free flap transfer and initial shaping is just the first step in achieving a full and natural breast reconstruction. Following the principles of a sculptor, we try to create a breast in the first step that is slightly bigger than the desired volume and resembles the final result as close as possible. Obtaining a definite result in one procedure is impossible. As removing tissues is so much easier than adding, specific areas of the flap can be aspirated or resected during the second operation 6 months later. This will improve breast symmetry which is the final goal of the procedure. If more tissue is needed, the flap can be augmented by lipofilling in specific spots to improve the shape or throughout the flap if a pure volume augmentation is necessary. Augmentation by implants is possible as well but performed less and less as results of lipofilling become more predictable and successful. Nipple reconstruction is performed by using the modified C-V flap. Scar revisions and adjustments to the borders of the footprint can easily be performed. During the second operation, the contralateral breast can also be corrected in case of unilateral reconstruction.
Nipple reconstruction can be performed using skin that is already present on the breast. Nipple reconstruction is performed once the reconstructed breast has achieved its final position on the chest wall and acceptable shape and volume symmetry has been obtained between both breasts.
A clover-leaf pattern is designed, tilted and rotated (fig. 1). A small straight linear scar remains which can later be camouflaged by tattooing the pigmentation of the nipple-areolar complex. A protective, perforated dressing is positioned around the new nipple for a period of 4 weeks after surgery.
The restitution of the areola is done by tattoo only. The use of skin grafts coming from different areas of the body is no longer done. Tattooing is performed about 3 to 4 months after the last surgical procedure around the nipple. Tattooing of the areola is performed on both sides to guarantee the same color on both sides. Equal colors fool the eye and camouflage the “reconstruction-effect”.
Some small adjustments may be necessary to the other breast. The aim is to achieve symmetry in both shape and volume. The decision on whether to perform surgery on the unaffected side is discussed with each patient at the start of the reconstructive process. During the first consultation, long term objectives are agreed. The patient is encouraged to comment on the unaffected side. If she is entirely satisfied with the shape and volume, then this breast serves as a model for the reconstruction.
If the patient is not satisfied with the unaffected breast, correction may be performed at a later stage. During the first procedure, an attempt is made to reconstruct a breast in keeping with the patient’s physique. At a second stage, the unaffected breast can be corrected so that both breasts are as symmetrical as possible. The reconstructed breast serves as a model for the unaffected breast.
Possible adjustments include breast augmentation, breast reduction or a breast lift (see the relevant chapters). If there is an increased risk of breast cancer, a prophylactic mastectomy on the unaffected side may be considered and bilateral reconstruction offered as a simultaneous procedure.
Weelisch DK, Schain WS, Noone RB, Little JN. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg. 1987;80:699-704.
Kroll SS, Reece GP, Miller MJ, et al. Comparison of nipple projection with the modified double-opposing tab and star flaps. Plast Reconstr Surg. 1997;99:1602-1605.
Anton MA, Eskenazi LB, Hartrampf CR Jr. Nipple reconstruction with local flaps: star and wrap flaps. Perspect Plast Surg. 1991; 5:67–78
Cronin ED, Humphreys DH, Ruiz-Razura A. Nipple reconstruction: The S flap. Plast Reconstr Surg. 1988;81:783–787.
Rubino C, Dessy LA, Posadinu A. A modified technique for nipple reconstruction: the ‘arrow flap’. Br J Plast Surg. 2003:56;(3):247–251.
Losken A, Mackay GJ, Bostwick J III. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg. 2001;108:361-369.
Shestak KC, Gabriel A, Landecker A; et al. Assestment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg. 2002;110:457-463.