Breast Reconstruction
Dr. Feiner has a true passion for taking care of women with breast cancer. It is one of the most rewarding aspects of his plastic surgery career. He moved to Central Florida in 2012 to join the team at MD Anderson Cancer Center of Orlando. He is regarded as an expert in reconstructive microsurgery, having performed over 900 microvascular flap procedures. He was part of the team that performed the first vascularized lymph node transfer in Florida.
Dr. Feiner has extensive experience with all aspect of breast reconstruction surgery, from correcting lumpectomy asymmetry to microvascular breast reconstruction. Now in private practice in Clermont, he continues to provide these services to his patients. Breast reconstruction starts with the lumpectomy or mastectomy; Dr. Feiner works very closely with a select group of talented breast surgeons to provide exceptional care and aesthetic outcomes. Breast reconstruction is a complex process, requiring meticulous planning and an attention to detail. Dr. Feiner is proud to offer his patients the latest cutting-edge techniques in breast reconstruction.
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- Lumpectomy Defects: Asymmetry can occur following lumpectomy and radiation treatment. Numerous options exist to treat these issues and Dr. Feiner has experience with the latest cutting-edge techniques. Fat grafting has proven to be a versatile option to help add volume to lumpectomy defect. Anecdotally, the fat also appears to help soften the radiated skin. Sometimes symmetry must be addressed on the untreated breast with a reduction or a lift. These procedures are typically covered by insurance as part of the cancer treatment.
- Oncoplastic Reduction: Patients with large breasts may be a candidate for a lumpectomy combined with a breast reduction. This adds the benefits of a symmetric breast reduction and allows the breast surgeon to remove a greater amount of tissue around the cancer to ensure its removal with a wide margin. Dr. Feiner coordinates with the breast surgeon and does the breast reduction markings prior to the lumpectomy. During the surgery, he works closely with the breast surgeon to design a safe breast reduction. The breast tissue removed during the lumpectomy is then matched with a reduction on the opposite side to get the best aesthetic outcome.
- Expanders: Tissue expanders are temporary, adjustable saline implants placed at the time of a mastectomy. They are a versatile tool of the reconstructive plastic surgeon. They can be used to stretch and shape mastectomy skin in preparation for reconstruction with either implants or a flap. They allow for lifting and reshaping of the skin in patients with large breasts. They allow for stretching of the skin in patients who desire a larger breast. In addition, they can remain in place as a space holder while you complete the remainder of your therapy (chemotherapy, radiation).
- Implants: Breast implants are the most common method of performing breast reconstruction. Dr. Feiner nearly always performs prepectoral (above the muscle) reconstruction. The advantages of this technique are less pain, faster recovery, no animation deformity, and a more natural shape overall. Cohesive silicone gel (“gummie bear”) implants are preferred to minimize rippling and to create a soft, natural, and stable reconstructed breast.
- Autologous- Flap Procedures: Dr. Feiner is one of only a few surgeons in the state who routinely performs microvascular reconstruction using a patient’s own fat to reconstruct a natural breast. This is a complex and technically challenging surgery that requires a team approach to ensure success. Dr. Feiner has personally designed the program and trained the team at AdventHealth, where he is the only surgeon performing these surgeries.
- Nipple-Areola Reconstruction: Nipple and areola reconstruction is an important adjunct to the reconstructive process to complete the look of the reconstructed breast. Dr. Feiner typically uses a local flap to create the nipple papule with a skin graft to simulate the areola. 3-D tattooing can be added to improve the realism of the result.
- Animation Deformity- Wrinkling: Most of us were trained in the submuscular breast reconstruction technique, placing the implants under the pectoralis major muscle with a sling to support it. Dr. Feiner switched entirely to prepectoral reconstruction in 2014 because of several issues with this technique:
- Recovery and expansion are much more painful
- The muscle tends to flatten the appearance of the reconstruction, pushing the implants out to the sides
- Lack of cleavage- the muscle attachments to the sternum prevent the implants from getting close enough to create cleavage
- Animation deformity- The pectoralis muscle is now in a non-anatomic location and is attached to the overlying skin. When you move your arms or activate the muscle, the skin and breast wrinkles. This can be incredibly noticeable and uncomfortable when it occurs.
Dr. Feiner began correcting this issue in his own patients after he switched to prepectoral reconstruction. He has devised a technique to maintain the support of a patient’s previous reconstruction, while returning the muscle back to its normal position and getting a much better shape from the implant. He utilizes cohesive silicone gel implants and acellular dermal matrix (biologic mesh) to accomplish the reconstruction. The procedure is done on an outpatient basis and these are some of his happiest patients.
- Secondary Breast Surgery and Revisions: Given his extensive experience in complex breast reconstruction, Dr. Feiner has developed a reputation for being able to correct some of the most difficult situations. He enjoys the challenge and looks forward to consulting with you to help you address your concerns.
- 3-D Tattooing (Referral): The decision to reconstruct or to tattoo the nipple and areola is a frequent topic of discussion in breast reconstruction consultation. Some patients desire not to do nipple reconstruction; others desire a 3-D tattoo to maximize the realism of the nipple reconstruction. Dr. Feiner refers his patients to some of the best 3-D nipple tattoo artists in the state.
Breast Reconstruction FAQs
What is a DIEP Flap?
DIEP stands for Deep Inferior Epigastric Artery Perforator Flap. The name refers to the major artery that supplies the circulation for the skin and fat-the term “flap” describes a unit of skin and fat that can be moved from one area of the body to another. This operation allows the surgeon to remove skin and fat from the lower abdomen and to effectively transplant it to the mastectomy site for the purpose of creating a breast. It has the advantage of using a patient’s own fat to make a natural looking and feeling breast without the use of an implant. It also allows the removal of the fat without removing any of the abdominal muscles- this is a major disadvantage of the TRAM (Transverse Rectus Abdominis Myocutaneous) flap procedure that is still commonly performed. The surgery requires the surgeon to reattach small arteries and veins with the use of an operating microscope and represents the state of the art in breast reconstruction. It is not offered by all plastic surgeons as it requires extensive experience and a very specialized skill set. Dr. Feiner has performed over 500 DIEP flaps in his career and is one of a select group of high-volume breast reconstruction surgeons.
What is implant reconstruction?
The most common technique used to reconstruct the breast after mastectomy involves the placement of a silicone gel implant to replace the lost breast tissue. This is often done in stages of surgery. In an immediate reconstruction, the first step in reconstruction starts at the time of the mastectomy with the plastic surgeon and breast surgeon working together. This improves cosmetic outcomes because the team of surgeons can plan the incision for the best cosmetic outcome while simultaneously optimizing the appropriate cancer treatment. In some instances, the permanent implant can be placed at the time of mastectomy in a single stage. More often, a tissue expander is placed during the first stage of surgery.The expander is an inflatable implant that can be inflated slowly with saline or air. It allows the skin to heal after the mastectomy and lets the plastic surgeon control the shape of the new breast. It gives time for healing and can also serve to shape the skin while completing the remainder of cancer treatment (chemotherapy and/or radiation). There is a second surgery to remove the expander and to replace it with the breast implant that has been selected for the desired size and shape. Adjustments can be made to the shape and position during this operation as skin can settle and stretch with healing.
Nipple Sparing vs Skin Sparing Mastectomy?
The decision to preserve or remove the nipple and areola is accomplished by a discussion between the plastic surgeon, breast surgeon and the patient. It is important to understand that the nerves and breast tissue are removed as part of the mastectomy, so this decision is primarily of a cosmetic nature since the remaining nipple will not have sensation and breastfeeding cannot occur. There are several factors that are involved in making this decision and determining the location and position of incisions/scars. The breast surgeon must determine that the cancer is far enough from the nipple to ensure complete removal without compromising the circulation of the nipple. If cancer is close to or involving the nipple, such as in Paget’s disease or inflammatory breast cancers, the nipple must be removed. If the cancer is not near the nipple, the decision to preserve the nipple is then made by the patient and plastic surgeon. Sometimes, the position of the nipple is not ideal, and the nipple must be sacrificed to improve the shape of the breast. In these instances, nipple reconstruction and/or 3-D tattooing can be performed to recreate the appearance. Patients are involved in every aspect of this decision-making process and we spend a great deal of time explaining the various options to help select the most appropriate plan for each individual.
Many different techniques are utilized to perform nipple-sparing mastectomy. The preferred location for the incision and scar is within the crease below the breast where the scar will be hidden best. In those instances where the nipple cannot be spared, there are many different incision types that may be used- the goal is to improve the shape and appearance of the final result and must be customized for each person depending on the pre-surgery shape of the breasts. I often utilize the same incisions and scar patterns that would be seen in a cosmetic lift procedure to optimize the final shape and position of the breast reconstruction.
Prophylactic or preventative mastectomy?
In women with genetic testing that is positive for breast cancer genes or a strong family history of breast cancer, the decision may be made with the breast surgeon to have an elective double mastectomy. This decision involves extensive discussions with surgeons and often a medical genetic counselor. The aesthetics of the reconstruction are especially important in these situations. The process and techniques for reconstruction proceed exactly the same as would occur for someone undergoing double mastectomy for cancer. The difference is that lymph nodes are not typically removed, and chemotherapy/radiation are not factors in the treatment pathway. A single stage operation is ideal but cannot always be performed.
Delayed vs Immediate Reconstruction?
In the vast majority of patients, reconstruction is initiated at the time of the mastectomy. This allows the plastic and breast surgeons to coordinate the treatment to plan for the best possible aesthetic outcome. Reconstruction is an elective process, meaning that it is life improving but not lifesaving. There are some situations where it is preferable to delay reconstruction. Patients who are quite ill, obese or with serious medical conditions are at higher risk for healing problems and infection and should be delayed until the mastectomy has healed. Patients with advanced cancer may opt to delay reconstruction to focus on their cancer treatment and minimize the risk of complications, which could delay those treatments. Also, some patients are unsure about proceeding with reconstruction or may not be ready for the process. In all of these situations, the reconstruction can be safely deferred until the appropriate time. Delayed reconstruction involves similar techniques to immediate, but the main considerations are the quality and availability of skin for creation of the breast shape and the presence/absence of radiation damage.
Nipple Reconstruction vs. Tattooing?
Nipple reconstruction can be performed in patients who have had their nipple removed during the mastectomy process. This is a personal decision for patients. The reconstructed nipple has no sensation or function and is done solely to approve the appearance of the final reconstruction. The process of reconstruction is typically to create projection of the nipple papule to give it a contour and shape. It is done using small, local skin flaps that are folded and sutured to give outward projection. It is often done with an overcorrection at the time of surgery because it tends to contract and flatten due to natural healing processes. Dr. Feiner prefers to reconstruct the areola with a round skin graft that is often taken from areas of excess skin or scars that need to be improved. These grafts tend to darken and can have a very natural pink color to improve the overall aesthetic appearance. Patients can elect to have 3-D tattooing done to enhance the appearance of the nipple reconstruction by adding color, shading and the appearance of natural features. This is done by an experienced medical tattoo expert. Some patients elect to have 3-D tattooing performed without reconstruction. This can create an excellent appearance without having the extra procedure and allows for the illusion of a nipple without having to cover the shape in certain clothing. Finally, some patients decide not to do any reconstruction or tattooing as a personal decision. This is a perfectly acceptable option as well.
Lumpectomy and Partial Breast Reconstruction- What are my options?
The process of lumpectomy is typically combined with radiation as part of breast conservation therapy (BCT). While the majority of the breast is spared, there are still some consequences that can occur with this treatment. The lumpectomy surgeon removes volume from the breast, which can create a size asymmetry and contour deformity compared to the opposite breast. The radiation therapy may darken, tighten and thicken the skin. It also may cause some shrinking of the breast tissue, which can contribute to volume and positional asymmetries. There are surgical options that can help improve these changes. Fat grafting can be performed to add volume to the breast to improve asymmetry. This involves doing liposuction to obtain small pieces of fat. The fat is injected into the areas of deficiency through tiny incisions. Sometimes this is done with a scar release to correct contour issues or tethered scars. Anecdotally, the fat grafting seems to help soften and improve the healing of radiated skin. This has been felt to be due to the presence of stem cells within the transferred fat and research is being done to study this phenomenon further. Breast lifting and reduction may be performed on the opposite breast to create better symmetry and position when significant asymmetry exists.
Oncoplastic Breast Reduction - What does this mean?
Patients with large breasts can opt to undergo an oncoplastic breast reduction. This is an intermediate type of operation between lumpectomy and mastectomy. It is done with the breast surgeon and plastic surgeon working together. The advantages include the ability to take out much more breast tissue than is done with a standard lumpectomy to ensure greater clearance of the cancer. The same amount would then be removed from the opposite breast to match. Both breasts are then reduced in size and lifted as part of the reduction. Sensation is maintained for the nipples and symptoms of large breasts (pain, heaviness, rashes) are improved as they would be for a standard breast reduction. This is a great option for any patient who has considered having their large breasts reduced and prefers a lumpectomy over complete mastectomy.
What is a TRAM flap?
A TRAM (Transverse Rectus Abdominis Myocutaneous) flap procedure is the most common form of autologous (using your own fat) breast reconstruction performed. The lower abdominal skin and fat can be transferred to reconstruct the shape of the breast as is done with a DIEP flap. The same skin and fat are removed for this purpose, but the method for maintaining circulation is different. The blood vessels are maintained within the rectus abdominis abdominal muscle and are never divided or detached. This makes for a technically simpler operation because the blood vessels do not need to be reconnected. This is the reason it is more widely performed. The disadvantage is that one or both of the rectus abdominis (6 pack muscles) are sacrificed in the process and there is a very real risk of abdominal bulge/hernia and weakness that can be debilitating. Dr Feiner rarely does these procedures, reserving them for very selective situations.
