Staged breast reconstruction with tissue expander removal

This plastic surgery video by the Medical Director of The Loudoun Center for Plastic Surgery, Dr Michael J Brown MD, shows the second phase of breast reconstruction due to breast cancer. It shows the tissue expanders being removed and having permanent breast implants put in their place.

Breast Reconstruction Surgery

This plastic surgery video deals with a staged breast reconstruction. This woman has had breast cancer, and has had both breasts removed, and had tissue expanders placed. She's now ready for her second-stage operation, which will be the removal of all the scar tissue, removal of the expanders, and placement of a permanent devices. Her surgery was complicated because she had, had a previous breast lift before she developed the breast cancer.

So she's got multiple scars on her breast which really affected what I was able to do for her because I have to maintain a blood supply to these flaps. So you may notice some incisions on her breasts, or scars on her breasts, from her previous surgeries. And in actuality, at this point, the vertical aspect of this incision is actually a removal of the previous scar from her breast lift, it had nothing to do with her breast cancer surgery.

The area that I'm working in right now is actually the only area that I worked on putting the expanders in. The pencil-looking device you see is actually called an electrocautery. And what it does is it uses electricity to create heat, and that heat cauterizes the blood vessels. So it allows us to operate in a relatively blood-less field. As you can see, she's not really bleeding that much. And what you see at the bottom of that wound is actually the tissue expander.

And it's a textured-shell expander, so I have to stick my finger in there and mobilize it. And after I've done that I can go ahead and take the expander out. And you'll see it's pretty full, because I've had to stretch out the skin. So now I'm basically going to assess her breast flaps. Basically there is no breast tissue here, it's just muscle and fat. And her whole breast shape will rely upon the implant, which I will place back in here.

What you can see here is actually her pectoralis muscle. So the red that you see is her pectoralis muscle, which is up in the air. Now because that scar tissue pocket is probably a little restricted for what I would like, I'm actually gonna cut that scar tissue pocket, or the capsule a little bit. So I'm gonna insert these special scissors and release that scar tissue pocket. And this will give her a more natural looking breast than it would've been if I didn't do this.

Staged breast reconstruction is a very complex but rewarding procedure to do because these women obviously would have no breast mounds if they weren't recreated with breast reconstruction. So after I've released the scar tissue I will assess her pocket and all the dimensions that I'm concerned about. And this particular patient, her breast crease or breast fold is not as ideal as I would like it to be, so the majority of this operation is actually in recreating her breast fold, or breast crease.

We call that fold the inframammary fold. So the majority of her work is going to be reconstruction of the inframammary fold followed by reshaping of the breast. So what you're seeing here is I'm actually... I keep looking outside the pocket to make sure I'm where I wanna be. The bright light you see that keeps bouncing around is actually a headlight that illuminates my field-of-view. And I have special glasses on that allow me to see this wound very closely, it's actually magnified 2 1/2 times.

So with the headlight and the magnification I can really see the blood vessels well, and I can treat them before I cut them so there's no bleeding. So what I'm gonna be doing here for the next few minutes is actually reconstructing her fold. So there's a fair amount of skill involved in doing this well. So I have to take my time and mobilize these tissues in just a certain way, then I will sew the tissues back together, creating a very sharp crease. The crease initially will be over-extenuated, and will be more severe than it will actually be once everything settles down, but it does take a little bit of time to settle down.

And the patients are aware of that, and they're really not that concerned about, they're just ecstatic to have a breast mound. So I will sequentially move across her fold, and I will reconstruct this fold in a few layers of stitches that will really improve the shape of her breast. After I've placed all these stitches I will begin working on the other aspects of the refinement of her breast mound. So at this point I feel she has a very nice fold that's gonna withstand the tests of time. And then I'll start to reshape the breast by tailoring the skin and whatever I need to do to improve it.

On this particular patient she had a little bit of too much fullness out towards her side, so she's gonna have a little bit of liposuction towards her armpit, and that will allow her breast to even have a better shape and better definition. Sometimes the breast need a fair amount of liposuction, other times they don't need any. So it really is done on a case-by-case basis. Her breast shapes were different because after the breast cancer surgery was done it was determined that part of the skin on this left breast was not going to live, so it had to be cut.

So that really compromised the shape of the breast that I could achieve at the initial operation. So her expansion really helped her get a better breast shape because it allowed me to stretch the skin and gave me some skin to work with. So at this point I've recontoured the lower half of her breast as well as the armpit side of her breast, and now I'm really to close this wound up again. So I'm gonna basically reassess this all the way through, making sure I'm happy with the shape of the breast, then I will close the wound in various layers.

So what you're gonna see here is I'm actually gonna take this implant, which is a silicon gel implant, and I'm going to close this wound in layers. But before I do that I'm going to close the skin to get a sense of the shape of the breast. So again, this is done just to make sure I'm happy with how things look, and if there's anything else that I wanna do. And once I did this I didn't like the vertical aspect of her breast. Which again, I planned on taking out anyway but this just confirmed it.

So you see here, at this point she's sitting up on the operating table and I like the shape. So I've gone ahead and allowed her to return to a laying down position, and I will close this wound, and cut away all the excess skin, and then close the wound completely. So it's important when you do breast cancer flaps like this that you try and provide complete coverage of the implant, so in case there is a wound complication, the wound is not exposed. This video has obviously been [speeded 00:08:11] up so that we could keep this video within a reasonable amount of time.

But you can see here that I'm operating relatively quickly. But again, this is under a faster-than-normal motion. So after I've closed this pocket, I'll go ahead and cut out the redundant skin and then I will close this wound in several layers for extra safety for the implant. Here she surgery having both sides done, and we'll go ahead and close the wound.

I didn't show this on the other side, but I did the same thing on the other side where I actually used the scar tissue pocket that I created as an extra layer of coverage for the implant. Great care is taken not to puncture the implant while I'm sewing like this. But after I've closed this wound then I'll go ahead and close the final layers of the skin and you can see here her before breast cancer surgery and then after her second stage of breast cancer surgery. Now she will come back and have nipples reconstructed if she so chooses.