Breast Reconstruction Options After Mastectomy
Breast reconstruction is not a cosmetic procedure. It’s a right every woman has when faced with mastectomy after breast cancer. Fortunately, there are several reconstructive options.
“Immediate” breast reconstruction is performed at the same time as the mastectomy. Advantages include: preserving most of the patient’s breast skin, a shorter and less obvious mastectomy scar, and waking up with the new breast already in place. It also generally provides the best cosmetic results particularly when combined with nipple-sparing or skin-sparing mastectomy.
In some instances immediate reconstruction is not recommended or is not possible and the reconstruction is performed several months after the mastectomy. This is called “delayed” reconstruction. Women with more advanced disease are usually not candidates for immediate reconstruction because of the need for radiation therapy after the mastectomy. While some plastic surgeons still perform immediate reconstruction in these cases, most prefer to delay the reconstruction until a later date to allow the tissues to recover.
The most common breast reconstruction procedure performed by American plastic surgeons utilizes implants to restore the breast shape and form. These can be either saline or silicone. Implant reconstruction is typically performed as two separate surgeries. The first involves placing a tissue expander (temporary implant) under the skin and pectoral muscle. This is used to expand the skin to the required size. The expander is later replaced by the permanent implant at a second surgery. A few surgeons prefer using a one-stage approach and place the permanent implant at the same time as the mastectomy. While not all patients are candidates, this is a very attractive option for many women because they avoid the entire tissue expander phase of the reconstruction.
Implant reconstruction can be the best option for some patients. However, reconstruction with expanders and breast implants are associated with more complications than cosmetic breast augmentation. Complications following radiation therapy are also higher with implants compared to reconstructions using the patient’s own tissue.
The Latissimus flap is one of the most common tissue reconstructions performed in this country. It uses the skin, fat and muscle (latissimus dorsi muscle) from the mid-back. This tissue is tunneled under the armpit skin and onto the chest to recreate the breast mound. Some women will also require an implant under this tissue for additional breast volume. The loss of function from moving the latissimus muscle is generally very well tolerated in all but the most active women.
Tissue can also be taken from the lower abdomen to create the new breast. The TRAM flap uses the same tissue that is removed by a tummy tuck. This skin and fat is transferred along with variable amounts of the rectus (sit-up) muscle. This tissue can be tunneled under the upper abdominal skin (pedicled TRAM), or disconnected from the body and reconnected to the chest using microsurgery (free TRAM). All forms of TRAM flap can improve the abdominal contour just like a tummy tuck. Unfortunately, women can notice loss of abdominal muscle strength due to the sacrifice of the rectus muscle. There is also a risk of bulging of the tummy and even hernia.
Over the last decade or so, the TRAM has been replaced by the DIEP flap as the new breast reconstruction gold standard. The DIEP provides a natural, warm, soft reconstruction together with an improved abdominal contour, just like the TRAM flap. However, unlike the TRAM, the DIEP flap spares the abdominal muscles completely. The tissue is disconnected from the body completely and reattached at the chest using microsurgery. This makes the post-op recovery easier and also significantly decreases the risk of abdominal bulging and hernia.
Women who do not have enough abdominal tissue for reconstruction may be eligible for the GAP (buttock) or TUG (upper inner thigh) flap procedures. The resulting scars are generally easily hidden by most underwear.
Microsurgical breast reconstruction procedures like the DIEP, TUG and GAP flaps are not offered routinely by many American plastic surgeons. There are many reasons for this, primarily the complexity of the surgery and the need for additional training. Unfortunately most patients seeking one of these breast reconstruction options after mastectomy will be forced to travel to specialized centers for their surgery.
Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery, particularly DIEP breast reconstruction. In-network for most US insurance plans. PRMA Plastic Surgery, San Antonio, Texas. (800) 692-5565.