I’m Dr. Noel Natoli, a board-certified plastic surgeon at Long Island Plastic Surgical Group and one of the partners here. I’ve been in practice with the group, October will be my 10-year anniversary. I’ve been doing breast reconstruction the whole time. Including training, almost 16 years now.
In discussing breast reconstruction, there are a couple of main broad categories to give an overview. One is implant-based reconstruction and the other is tissue-based reconstruction. Flap reconstruction is using a patient’s own tissue for either partial or complete reconstruction of the breast. With an implant-based reconstruction, very similarly, the breast tissue is removed and inserted in its place can be an implant. Both of these implants have a silicone shell. Any patient who’s having reconstruction or a breast augmentation is actually putting a small amount of silicone in their body, but this is filled with salt water, whereas this one here is filled with a gel, a silicone-based gel.
There are better candidates for implant reconstruction than tissue reconstruction, and vice versa. A good candidate for an implant-based reconstruction is going to be a patient who is on the thinner side that doesn’t maybe have enough tissue to be a candidate for a tissue reconstruction, and a better candidate for an implant-based reconstruction is going to be a patient that’s not expecting to have radiation therapy or who hasn’t had radiation therapy. It doesn’t mean having radiation therapy means a patient can not have an implant-based reconstruction, but it does mean it can be a little more complicated and the risks can be higher in that situation. Also, patients with less breast ptosis, which is the droopiness of the breast, and patients that may not be healthy enough to sustain a longer surgery, like a tissue-based surgery.
In the patients who are using their own tissue, if someone’s a good candidate for that, they’re going to have some extra tissue in this area. If we’re looking for a belly reconstruction. If patients have lumpectomies, often we’re able to take a portion of their tissue, whether it be from their back and to augment the breast, or even to do something like a breast reduction or a lift to do the reconstruction. In patients for whole breast reconstruction, meaning a mastectomy patient, then often we’re able to take tissue from either their thighs, their belly is the number one donor site used for this, or the buttock region, to reconstruct the breast. The patients, even though it’s a trade-off, we’re adding a scar in that area, those patients aren’t complaining about getting a tummy tuck or getting a thigh lift out of the surgery as well.
Long-term benefits of having tissue reconstruction are that there’s really not much to do with them once we’re happy with the way things look, whereas implant-based reconstruction is there’s a foreign body that’s in the patient and the FDA gives a shelf life to implants. If there’s no problem with them, say at even 10 years when the FDA recommends implant exchange, there’s no reason to do anything with it, but with implant-based reconstruction, say 20 years rolls around, the patient hasn’t had an implant exchange, we really say, “You know what? At this point, we’re looking at the risk of these implants deflating or having a problem with them is getting kind of high,” because there’s a 1% rupture rate per year is what we’re basically assuming.
In that case, at that point, that patient is going to have a same-day surgery for an implant exchange. When you see some of these young patients like BRACA-positive patients who are having implant-based reconstructions at age 20, that’s a lot of implant exchanges over their lifetime, even if they are waiting 20 years. They have to be on board with several tire changes because that’s, at the end of the day, what we’re looking at.
There are certain things that preclude patients from having immediate reconstruction, but by and large we do recommend immediate reconstruction. We can always get the patient the best aesthetic result if we’re able to do the reconstruction at the time of the mastectomy or the lumpectomy, for that matter. When we go in later, then the scar burden tends to be a lot higher. What happens with the skin envelope when the breast tissue is gone, if we don’t put anything as a place keeper in that envelope, then the tissue tends to contract, you get stiffness, you get fibrosis. These are all things that mean the skin wrinkles and tightens, and sometimes the skin is actually cut out just because it’s aesthetically not pleasing. Then if we go back later to do it, there’s skin missing. Whereas if we’re doing the implant reconstruction or a tissue-based reconstruction at the same time, we’re using all that skin, we’re not losing anything and we have the best chance of creating the most pleasing aesthetic breast for the patient and something that’s going to better match the other side.
Implant-based and flap-based surgeries do have somewhat different recoveries. I would say that, again, in terms of hard restrictions for the patients, I tell my patients it’s four weeks that you’re not lifting your arms, you’re not lifting more than 20 pounds, you’re not doing repetitive movements with the arms. We really just want the upper body quiet for four weeks. The risks or downsides of flap surgery are that it’s definitely a longer procedure. There’s more upfront recovery for the patient and longer upfront downtime for the patient. The restrictions for patients with both types of surgery is about four weeks, however, the patients tend to feel still under the weather and tired for a longer time with the flap-based reconstruction. They’re healing another donor site, whether it be the belly, the thigh or the buttock region. Usually, it takes about two to three months for those patients to really start to come around the corner and feel well. Whereas, I would say by two months, the implant-based reconstruction patient is feeling quite well.
The implant-based reconstruction is a quicker recovery, I would say, upfront, because there is no other donor site, which means we’re not putting a scar anywhere else on the body, we’re not taking from anywhere else. It’s just the implant, it’s coming off a shelf and going into the patient. The implant-based reconstruction patients usually go home the next day, sometimes even the same day, rarely, but usually a day or two in the hospital. Whereas, the deep reconstructions and the micro-based reconstructions usually spend at least three nights in the hospital.
There are two types of reconstructions we do with implants, putting it in front of the muscle or behind the muscle. That’s sometimes referred to as retropectoral or prepectoral reconstruction. Prepectoral is a pretty hot topic now because the recovery is definitely less painful and it’s easier for patients. I tell most of my breast reconstruction patients that it’s going to be a good two weeks before you feel like doing too much and it’s a good one to two months before you really feel back to yourself. The recovery tends to be longer than we think, based on surveys we’ve collected on patients and data that we have. By four weeks, with either reconstruction, there’s not really any limitations, a patient can exercise, do planks if they’re up to it and whatever they want, but in implant-based reconstruction, I really do tell patients it’s going to be two to three months before they really feel back to themselves. Whereas, someone with a tissue-based reconstruction, it can be four to six months before they really feel like they’ve made a complete turnaround in recovery.