It has become increasingly popular over the last several years. Traditionally, when breasts are reconstructed with implants after a mastectomy, the implants or tissue expanders are placed underneath the pectoralis muscle of the chest. This helps cover them with healthy tissue for healing, and also helps camouflage the implant/tissue expander which could be very visible under the thin breast skin left after a mastectomy.
ADM is a soft tissue substitute that comes from human skin. It is processed so that it is sterile and no longer has cells, but retains its structure. The body uses it as a scaffold, and its own cells and blood vessels grow into it. ADM has been utilized in plastic surgery in many different ways for many years, and there is a significant amount of research showing its safety and utility. It has been used in breast reconstruction since 2001.
Typically, a piece of it is used to cover the lower portion of an implant or tissue expander that the pectoralis muscle does not cover, so that the device is completely protected. However, now that we know how well it becomes part of the body, and helps to thicken and improve skin and soft tissue quality, we are able to use it to completely cover an implant or tissue expander and provide the benefits that traditionally came from the pectoralis muscle.
In the majority of cases, your reconstruction will require more than one surgery. Typically, tissue expanders are placed at the time of the mastectomy. This is because, for most women, we do not know if you will need additional chemotherapy or radiation until we have the final results of your surgical pathology.
Results are significantly better, and complications are decreased, if your final reconstruction is performed after you have received and healed from these additional therapies. The use of tissue expanders also allows for precise sculpting of the implant pocket, and gives an opportunity to experiment with desired final implant size. For a more detailed description of how breast reconstruction works in general, please visit the other pages on our website. Some women will be a candidate for direct implant placement. Theses options will be decided after a detailed consultation in the office.
During surgery, the mastectomy is performed, removing all of the breast tissue and, if needed, your lymph nodes are tested. Then, the correctly sized tissue expander or implant is chosen. It is then completely wrapped in the ADM, and then the whole structure is secured to the chest in specific places.
The breast skin is then shaped around the device, and the skin is closed with absorbable sutures. There is at least one drain placed, and typically there is a special vacuum dressing that is applied over the incision. These typically stay in place for about 2 weeks and help to stimulate healing, and remove any fluid from the area to let the ADM heal into the surrounding tissue. The vacuum dressing is powered by a small machine that can be carried around like a purse. We also put numbing medicine into the nerves of the chest to decrease pain after surgery. Typically you are able to go home the same day.
Fat grafting is a procedure commonly used in plastic surgery all over the body. We now have ways of removing fat from one part of the body and processing it in a way, that we can then inject it into another part of the body and have it live.
The processed fat also brings with it special cells that can often improve or rejuvenate skin and soft tissue in the areas it is injected into. Therefore, we know we can use fat grafting in breast reconstruction to help thicken tissue and smooth contour irregularities, and help camouflage implants. “Pre-pectoral” means above the muscle. By placing the implant or expander above the muscle (rather than under) there is less pain in the chest and the arm, and there is a faster recovery. Most patients are able to go home the same day after surgery. Additionally, it is an advantage for women that need to retain the function and strength of their chest muscles, like body builders. Positioning the device above the muscle also eliminates the potential complication of “animation deformity.
Sometimes, this phenomenon can happen when an implant is under the muscle. When the pectoralis muscles are used or “flexed”, it can push on the implant and cause a very visible deformity and pain.
If a patient needs radiation, placing the implant or expander above the muscle, helps protect the muscle from radiation damage, and can leave it in better quality if it should be needed for use in the future. Many women are a good candidate for this technique, but this depends on many factors that will be discussed at the time of your office consultation. It is also an excellent option for a woman ultimately desiring autologous breast reconstruction who is not a candidate for immediate reconstruction. A tissue expander is placed at the time of the mastectomy. Once all additional treatments are finished (like chemotherapy and radiation), the tissue expanders can be removed, and breast created from the patient’s own tissues without ever having to violate or disrupt the pectoralis muscle.
It is very important to limit upper body movement during the first few weeks after surgery to let the ADM heal into your own tissues and prevent fluid buildup. We will initially see you weekly after surgery.
The vacuum dressing and drains are usually removed after 1-2 weeks. If the skin is healing well at two weeks we will also begin tissue expansion at this time. We keep air in the expanders at surgery because it is lighter and puts less stress on the healing skin. This will then be removed in the office, and gradually replaced with saline over a number of weeks until the expanders are the desired size. Everything needs to heal for about three months (or longer if you need chemotherapy or radiation) and then the expanders are removed and exchanged for the permanent implant in a short day surgery. Sometimes this is also combined with additional shaping procedures or fat grafting. Typically additional small surgeries may still be required at this point, like nipple reconstruction, depending on your desires. Once again, for additional information on the whole breast reconstruction process, please visit the other pages on our website.
At Lift Plastic Surgery, we form a close-knit team with you. We utilize our years of collective experience in all aspects of plastic surgery.