Johns Hopkins Bayview Medical Center is a multispecialty, academic medical center committed to patient care, education and research. Part of the Johns Hopkins Healthcare System, this unique campus supports a full spectrum of medical and surgical specialties. This allows a comprehensive approach to each patient.
While the public views plastic surgeons as cosmetic specialists, the truth is that more than half of the procedures performed are reconstructive. According to statistics presented by the American Society of Plastic and Reconstructive Surgeons (the national association of plastic surgeons), half of the plastic surgery procedures done in 1998 -- or 1,169,400 -- were reconstructive. Tumor removal is the most common reconstructive procedure, followed by hand surgery, breast reduction, laceration repair, and breast reconstruction.
- Breast reconstruction
- Tissue expanders and breast implants
- Autogenous tissue reconstruction
- Breast reduction
- Hand
- Trauma and cancer reconstruction
- Skin cancer
The goal of breast reconstruction once was to improve the clothed appearance of a patient. Today, the criteria for a successful reconstruction are much more demanding. Now the emphasis is on reconstructing natural breast contours and symmetry rather than a simple breast mound. Results have improved dramatically over the past two decades due largely to refining a variety of options available for reconstruction. Breast reconstruction is an important final step on the difficult road of breast cancer treatment, bringing completion to the whole process.
Reconstruction is now performed either with prosthetic devices (expanders and implants) or with the patient's own tissue (TRAM and latissimus flaps). Which option to pursue depends on the individual patient's body shape, lifestyle, and preferences, as well as cancer therapy. Surgery on the opposite breast, including reduction and lifting procedures, may also be performed to obtain symmetry at the time of mastectomy or on a delayed basis.
On October 21, 1998, President Clinton signed into law a bill that included a provision protecting breast cancer victims from arbitrary insurance coverage denials for breast reconstruction. The Women's Health and Cancer Rights Act also includes surgery to provide symmetry of the opposite breast. This is only the second time in U.S. history that Congress mandated a medical procedure be covered by a federal health policy.
Tissue Expanders and Breast Implants
Recent advances in expander design have allowed improved results in breast reconstruction with implants. This type of reconstruction can be performed either at the time of mastectomy or in a delayed fashion. Reconstruction is performed in two stages. At the first stage a tissue expander is placed underneath the muscles of the chest wall. This expander is like a deflated balloon. Several weeks after surgery the process of expansion is begun. In office visits, saline (salt water) is injected into the implant to allow it to expand, thereby stretching the skin over it. This expansion process can take between two and four months, depending on breast size and how much fluid can be placed into the expander each time. After expansion is completed and the tissues are adequately stretched, a second surgical procedure is performed that can be on an outpatient basis. The expander is removed and a permanent implant is replaced. This implant may be filled with either silicone or saline. The nipple also is reconstructed.
Utilization of silicone implants for breast reconstruction is back on the rise. Many women fear silicone implants for rumored problems and media hype, but new information is available regarding the implants' safety. The Institute of Medicine (IOM) of the National Academy of Sciences released a report this year which found that women with silicone breast implants are no more likely than the rest of the population to develop cancer, immunologic diseases, or neurological problems. Additionally, implants pose no threat to unborn babies or in breastfeeding. There is no evidence that mothers with implants pass silicone on to infants when breast-feeding. The report further states that there are local, but not life-threatening, complications that are unique to women with silicone breast implants including implant ruptures, deflations and capsular contracture (hardened scar tissue around the implant). Silicone implants allow a natural feel and look for breast reconstruction, and therefore provide an option to consider in consultation with the plastic surgeon.
Implants may be used in conjunction with the patient's own tissue reconstruction in cases when a patient desires autogenous tissue reconstruction, but cannot attain enough size without an implant.
Autogenous Tissue Reconstruction
Autogenous tissue reconstruction takes tissue from one area of the body to reconstruct the breast. Advantages of this form of reconstruction include a softer, more pendulous breast while reducing another area of the body. Autogenous reconstruction also requires two stages. In the first stage the breast mound is created, while in the second stage refinements are made. Liposuction and revisions are performed to achieve the desired, refined shape, and a nipple is created. The two main types of tissue taken include the latissimus flap from the back and the TRAM flap from the abdomen.
The latissimus flap is based on a large muscle in the back, which may be rotated to the front to reconstruct the breast. A large breast may be reconstructed from this tissue alone; however, in thin patients, an implant may be required to give the desired size and symmetry.
The TRAM flap is based on the rectus muscle of the abdomen. Relocating this tissue effectively results in a soft breast as well as a flatter tummy. The tissue may either be rotated up into the chest area or disconnected and reattached microscopically to blood vessels under the arm or in the chest. Which avenue to take depends on the body shape and lifestyle of the patient.
Heavy, pendulous breasts are often a source of persistent pain and discomfort. Chronic infections may occur under the breast fold. Common complaints include severe neck strain, headache, aching shoulders, low back pain, deep brassiere-strap grooving, and postural problems, limiting physical activity. Women may also have numbness in the arm and breast. The best way to treat symptoms associated with large breasts is to surgically decrease their size. Breast reduction surgery is associated with one of the highest rates of satisfaction for the plastic surgery patient.
The surgical procedure takes approximately three to four hours, and requires an overnight stay in the hospital. Insurance coverage is often available for cases of large, symptomatic breasts. Consultation with a plastic surgeon will allow viewing of pre- and postoperative photographs of other patients to better understand the procedure.
Hand surgery encompasses a broad range of procedures, from carpal tunnel release to complex reconstructive procedures that require microscopic techniques. Division members have undergone specialized training in performing hand surgery. Most procedures are performed on an outpatient basis.
For successful outcomes in hand surgery, postoperative hand therapy is critical to return to preoperative function. At Johns Hopkins Bayview Medical Center, we have a dedicated team of hand therapists who make more successful outcomes possible.
Johns Hopkins Bayview Medical Center is a Level I trauma center, accepting the most severe trauma victims. It is also the regional burn center for the state of Maryland. This has afforded us extensive experience with reconstruction required after traumatic injuries. We have the ability to perform any type of reconstruction required, from complex wound closure to skin grafting to muscle flaps and microsurgery required for more extensive damage. An interdisciplinary approach, including surgeons and medical care personnel from different specialties, is possible at an academic center like Johns Hopkins Bayview. The support services also aid in postoperative care to help in achieving successful functional outcomes.
With more active screening programs, skin cancer is on the rise. In particular, the incidence of melanoma in the United States has increased rapidly over the past twenty years. Dermatologists often perform the initial evaluation when a patient is concerned about a skin lesion. When removal of the worrisome lesion will leave a large, noticeable defect, a plastic surgeon is consulted. Here we have experience with all types of reconstruction necessary after skin cancer removal. We have the ability to send the skin to the pathology department while the patient is still in surgery to assess whether all of the cancer has been removed. We are the primary service performing sentinel lymph node biopsies at Johns Hopkins Bayview.
Most procedures are performed on an outpatient basis with sedation anesthesia.
