Angelina Jolie's Breast Reconstruction: Inside the O.R

Dr. James Romanelli and Dr. Dana Khuthaila, who specialize in breast reconstruction on Long Island, examine the techniques used for Angelina Jolie&#039…

By the time actress Angelina Jolie entered a Los Angeles operating room to undergo a preventive double mastectomy, she and her physician had already spent months discussing options, carefully assessing a battery of tests, and preparing for surgery. All medical decisions are best made after careful analysis on a case-by-case basis, but that is especially true when it comes to mastectomies, breast cancer, and breast reconstruction.

At our Long Island, New York breast surgery practice, these are probably the most difficult discussions we have with patients. Although it’s impossible to remove emotion from the decision-making process, we find that better-informed patients generally approach their procedures with positive attitudes. That’s why we applaud Jolie for using her star power to draw attention to this issue. It’s pretty safe to say more people now know about BRCA (BReast CAncer) gene mutations than knew before Jolie’s article appeared.

It probably also surprised many people that Jolie actually underwent three separate procedures over the course of nearly three months. The first operation, called a nipple delay, allowed the surgeon to remove a small portion of tissue directly behind the nipple for examination to ensure no cancerous cells were present. This step is for patients who want to preserve their nipple or nipples during a mastectomy. (For patients whose nipples aren’t preserved, cosmetic nipple tattoos are used.) Jolie underwent the double mastectomy about two weeks later, with tissue expanders inserted at that time. After several weeks of tissue expansion, her permanent implants were added in a final procedure.

Reconstruction options

Breast reconstruction options fall into three general categories:

  • Direct-to-implant reconstruction: Inserting implants at the time of mastectomy
  • Tissue expander reconstruction: Inserting expanders to gradually stretch the skin before using implants to complete the reconstruction
  • Autologous methods: Using the body’s own tissue to rebuild the breast mound

Because Jolie opted for reconstruction using breast implants (as do many New York City and Long Island patients at our practice), her plastic surgeon was present during the mastectomy to insert tissue expanders before her physician closed the incisions. Although using tissue expanders requires an additional surgery, they maximize blood flow to the breast skin and nipple and allow doctors to optimize the final implant size, location, and appearance. The size of the expanders is gradually increased with injections of a saline solution as the tissue is prepared for the implants. In Jolie’s case, the final reconstruction surgery occurred 10 weeks after the double mastectomy.

Using a patient’s own tissue

An autologous flap procedure uses a combination of skin, fat, and/or muscle that is moved from an area such as the abdomen, upper back, upper hip, or buttocks to the chest, where it is shaped into a new breast. The different procedures, such as TRAM flap, LAT flap, and SGAP flap, correspond to different areas of your body from which the donor tissue is harvested. One of the most innovative procedures, DIEP flap, uses donor tissue from a woman’s lower abdomen, similar to the TRAM flap method. It offers the advantage of a shorter recovery time and doesn’t damage abdominal muscles. It requires a surgeon with the skill to perform complicated microsurgery, but it is becoming the leading, state-of-the-art procedure for flap reconstruction.

Is breast reconstruction covered by insurance?

Federal law requires that breast reconstruction, including aesthetic changes to the unaffected breast in the case of single mastectomy, be covered by insurance. Furthermore, a 2010 New York state law requires that reconstruction options be discussed with all patients prior to mastectomy. Clearly it is very important that all women understand they are entitled to breast reconstruction.