Reconstructive surgery is performed on the breasts of both men and women to correct some defect or abnormal structure that interferes with activities of normal daily life, such as:

  • Breast reconstruction after mastectomy
  • Reduction mammaplasty to reduce the size and change the shape of large, pendulous breasts that cause medical problems resulting from their excessive size and weight
  • Surgical correction of gynecomastia in men that does not resolve spontaneously or respond to medical treatment

Postmastectomy Breast Reconstruction

Indications

The patient will not tolerate postmastectomy deformity for reasons that may include the maintenance of personal, family or sexual relationships

Selection Criteria and Risk Factors

Detailed application of selection criteria should be conducted in consultation with the oncologist (if cancer is the reason for mastectomy), general surgeon, plastic surgeon and radiation therapist (if radiation is a pre- or postoperative consideration). Significant risk factors include:

  • Obesity (especially >25 percent over ideal body weight)
  • Small vessel disease (heavy smoking or smoking history, autoimmune disease, insulin-dependent diabetes)
  • Tumor cell type and characteristics
  • Major concurrent pulmonary, cardio-vascular, psychiatric or other disease
  • Substance abuse; personal and family problems
  • Patient compliance (ability to understand procedures and options, ability to tolerate pain)
  • Abdominal scarring from previous surgery (may prohibit use of a pedicle or free flap of abdominal myocutaneous tissue in breast reconstruction)
  • History of radiation to the chest wall

Outcome and Patient Expectations

  • A breast reconstructed after mastectomy should have good contour and texture
  • However, because most or all breast tissue has been removed at mastectomy, it is highly unlikely that the reconstructed breast will (1) produce milk, (2) respond to hormonal signals or (3) experience normal sensory perception

Procedures

  • Immediate reconstruction after mastectomy may be a viable option after consultation with the oncologist and plastic surgeon
  • Delayed reconstruction may be the best option under other circumstances – e.g., given the patient's medical history, type of breast cancer, need for postoperative therapeutic irradiation

The procedure used for reconstruction may be (1) insertion of an implant, (2) use of a pedicled or free myocutaneous flap of autogenous tissue to form a new breast mound, or (3) a combination of implant and flap.

Postoperative Recovery

  • The patient is released from the hospital three to five days after an uncomplicated procedure; stitches are removed after 7 to 10 days
  • Full recovery from a mastectomy reconstruction or a flap procedure may require 6 weeks

Follow-up

  • The plastic surgeon will conduct regularly-scheduled examinations to ensure the success of the breast reconstruction
  • The primary care physician should coordinate other follow-up examinations – e.g., mammography to detect any recurrence of cancer locally in the chest wall or in the remaining breast (if only one breast was removed)
  • Suspicious radiographic findings should be coordinated with findings on physical examination

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Reduction Mammaplasty

Indications

Heavy, pendulous breasts cause a variety of physical and psychosocial symptoms:

  • Back and neck muscle strain, postural change, headache, shoulder pain, grooves cut into shoulders by brassiere straps, ulnar nerve paresthesia
  • Chronic breast pain
  • Problems with personal hygiene
  • Inability to participate in sports, problems in personal and sexual relationships

Because breast size may be related to obesity in some patients, a trial of weight reduction may be beneficial. Weight reduction may not have any impact on breast hypertrophy, but it may improve the patient's tolerance for the proposed surgery and could diminish risk factors.

Selection Criteria and Risk Factors

  • Obesity >25 percent over ideal body weight
  • Cardiovascular disease (e.g., angina), pulmonary disease (e.g., asthma)
  • History of thromboembolism
  • Diabetes, especially insulin dependent
  • History of heavy smoking
  • Prior radiation therapy for breast cancer

Mammogram is indicated in any patient with increased breast cancer risk as indicated by physical examination, medical or family history, or age >30 years.

Outcome and Patient Expectations

  • Breasts are reduced in size and improved in contour and "lift"
  • Sensory loss may occur
  • Scarring is an inevitable postoperative outcome; hypertrophic scars or keloid may require secondary surgical correction
  • In a small number of cases, secondary surgery may be necessary to correct a postoperative nipple inversion caused by scarring

Procedures

The plastic surgeon will individualize a procedure to the patient based upon factors such as the amount of breast tissue to be removed, the pendulosity of the breasts, and other factors. The procedure is usually performed in a hospital under general anesthetic. If the amount of breast tissue to be removed issmall, the procedure may be performed in an outpatient center. Potential complications include those associated with any operation: infection, bleeding and hematoma. Specific complications include postoperative necrosis of fat or nipple tissue due to circulatory compromise. Stitches are removed in 1 to 3 weeks. The patient will experience postoperative pain for several days. A surgical brassiere will probably be prescribed for several weeks, until swelling and bruising subside.

Follow-up

  • Postoperative mammography is repeated in patients who have had preoperative mammography, to provide a baseline for future breast cancer screening
  • Continuation of a weight-reduction regimen complements the outcome of reduction mammaplasty in overweight or obese patients

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Surgical Correction of Gynecomastia

Indications

Gynecomastia is most frequently seen in boys 13-15 years old and in older men due to age-related hormonal changes. In more than 90 percent of the  boys, the condition will resolve spontaneously within a year. Up to 40 percent of adult men may be affected by some degree of gynecomastia.

  • The length of time breast enlargement has persisted and the presence of pain from distension are important considerations in determining if surgical correction is indicated
  • The possibility of breast cancer is an important consideration in adult males

"Rule out" conditions that can cause gynecomastia include:

  • Diseases that may be associated with gynecomastia including hepatitis and cirrhosis, lung cancer and pulmonary inflammatory diseases, cancer of various organs, thyroid or testosterone imbalance
  • Use of street drugs such as marijuana and heroin
  • Use of steroids to gain weight or increase muscle mass
  • Past or current pharmacologic therapy with a variety of drugs

Procedures

  • Large, ptotic breasts may require a reduction mammaplasty, perhaps with free nipple graft
  • A different surgical approach may be selected for the thin patient with moderate breast enlargement
  • The procedure is often done under general anesthesia in an outpatient setting

Outcome and Patient Expectations

  • The patient will have a more "male" breast after surgical correction of gynecomastia, and pain associated with breast distension should be eliminated
  • Postoperative scars may be visible; other postoperative outcomes can include skin depression deformities, redundant skin and nipple-areolaptosis

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