Breast Reconstruction after Mastectomy for Breast Cancer

Every woman has a right to breast reconstruction. This is now a federal mandate and insurance companies have to cover breast reconstruction surgery by law. There is no age limitation for breast reconstruction and there are multiple reconstructive options available. There is no single procedure that is best for everyone; the best option will become clear after detailed discussion between the patient and their plastic surgeon.

As the term implies, "immediate" breast reconstruction is performed at the same time as the mastectomy. Once the general surgeon has removed one or both breasts , the plastic surgeon will then take over and begin creating the new breast(s). Some advantages of immediate reconstruction include: preserving most of the patient's breast skin, a shorter/less obvious mastectomy scar and waking up with the new breast already in place (and avoiding the experience of a flat chest). Immediate reconstruction generally provides better aesthetic results particularly when combined with nipple-sparing or skin-sparing mastectomy.

"Delayed" reconstruction generally takes place starting at 6 months to 1 year after the mastectomy. Many times patients required to undergo radiation following their mastectomies are advised to delay reconstructive surgery in order to achieve the best results. It is common to wait several months after the last radiation therapy session before proceding with the surgery in order to allow the soft tissues to recover completely from the radiotherapy.

The most common method of reconstructive breast surgery in the United States is using expanders and breast implants. Most plastic surgeons perform this as a two-stage procedure. The expander can be placed at the same time as the mastectomy (immediate reconstruction) or after the mastectomy has healed (delayed reconstruction). The expander is used to stretch the skin envelope and recreate the size of breast the patient and plastic surgeon desire. The expander is replaced by a permanent breast implant (saline or silicone) at a separate procedure several months later.

Some patients are candidates for Alloderm one-step implant reconstruction (without expanders): a permanent breast implant is inserted immediately without going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and Alloderm (an acellular dermal graft).

Implant reconstruction can be the best option for some patients. However, reconstruction with expanders and breast implants can be associated with more complications than cosmetic breast augmentation. Potential long-term issues include capsular contracture, deformity, and pain, particularly if the patient has had or is going to have radiation therapy as part of the cancer treatment. There is a risk of requiring further surgery due to these complications. For these reasons, many plastic surgeons and patients prefer autologous reconstruction, ie reconstruction using the patient's own tissue taken from another part of the body (especially if radiation therapy is planned).

Latissimus Dorsi Flap

The Latissimus procedure uses muscle from the back of the shoulder blade which is brought around to the breast mound to create a new breast. During the procedure a section of skin, fat and muscle is detached from the back and brought to the breast area. A majority of patients who undergo the Latissimus Flap procedure also need an expander to obtain a satisfactory result. The expander is replaced by a permanent implant at a second procedure down the line. Patients will have a scar on their back shoulder region that can sometimes be seen through a tank-top, swimsuit or sundress. Women who are very active in sports should know that this procedure can reduce your ability to participate in such activities like golf, climbing, swimming, or tennis.

TRAM Flap (Transverse Rectus Abdominus Myocutaneous Flap)

TRAM flap surgery is a common breast reconstruction technique that uses skin, fat and muscle (rectus abdominus or sit-up muscle) from the lower abdomen. The tissue (or flap) is then relocated to the chest to create the new breast. This procedure also results in a tightening of the lower abdomen, or a "tummy tuck."

There are 3 main forms of TRAM flap reconstruction that are commonly used:

1) The PEDICLED TRAM flap: the flap is transferred to the chest by tunneling the tissue under the skin up to the chest to create a new breast. Unfortunately, sacrifice of all of the sit-up muscles can be associated with significant post-operative pain, prolonged recovery, loss of abdominal muscle strength (up to 20%), abdominal bulging (or "pooching"), and even abdominal hernia.

2) The FREE TRAM flap: this procedure involves disconnecting the flap from the patient's body, transplanting it to the chest, and reconnecting it to the body using microsurgery. Advantages over the pedicled TRAM include: improved blood supply (and therefore less risk of healing problems and fat necrosis), and less muscle sacrifice (so the abdominal recovery is a little easier, potentially more strength is maintained long-term, and the risk of bulging and hernia formation is lower). Since the tissue is disconnected and transplanted to the chest, there is also no tunneling under the skin as there is with the pedicled TRAM and no subsequent bulge in the upper abdomen (which is typically seen with tunneling).

3) The MUSCLE-SPARING FREE TRAM flap: similar to the free TRAM except the amount of muscle taken is typically very minimal (postage-stamp size). This procedure is associated with all the benefits of the free TRAM but with significantly fewer abdominal side-effects and complications (pain, bulging, hernia, strength loss) because such a small amount of muscle is sacrificed.

DIEP Flap (Deep Inferior Epigastric Perforator Flap)

DIEP flap breast reconstruction has replaced the TRAM flap as today's gold standard in breast reconstruction.

The DIEP flap procedure is similar to the free TRAM flap but only requires the removal of skin and fat. NO MUSCLE is sacrificed. The blood vessels required to keep the tissue alive lay just beneath the abdominal muscle. Therefore, a small incision is made in the abdominal muscle in order to access the vessels. As with the free and muscle-sparing free TRAM flap procedures, microsurgery is required to reattach the blood vessels to the chest area. Even though an incision is made in the abdominal muscle NO abdominal muscle is removed or transferred to the breast in the DIEP flap procedure. As a result, patients do not have to sacrifice their abdominal strength and experience less pain and a much quicker recovery. The risk of abdominal bulging and hernia is also very small. Like the TRAM flap, the patient benefits from a simultaneous tummy tuck.

The DIEP flap was first described in the early 1990's but has remained less popular than the TRAM flap, presumably because of the increased complexity and difficulty of the procedure compared to the TRAM. Though the DIEP flap is a very technically demanding operation, the benefits are tremendous for the patient.

SIEA Flap (Superficial Inferior Epigastric Artery Flap)

The SIEA flap procedure is very similar to the DIEP flap procedure. The main difference between the SIEA and DIEP is the artery used for blood supply to the reconstructed breast. The SIEA arteries are generally found in the fatty tissue just below skin. As in the DIEP the SIEA flap reconstruction does not sacrifice the abdominal muscle and only uses the patient's skin and fat to reconstruct the breast. While the SIEA flap procedure is similar to the DIEP it is used less frequently since the arteries required are generally too small to sustain the flap in most patients. Only about 20% of patients have the anatomy required to allow for this procedure.

GAP Flap (Gluteal Artery Perforator Flap)

Women who do not have an adequate amount of abdominal tissue for reconstruction may be eligible for the GAP flap. This procedure uses excess skin and fat from the upper or lower gluteal (buttock) region. Like the DIEP and SIEA perforator flap procedures, all muscle in the area is spared. The incisions are generally easily hidden with most underwear. Most surgeons prefer to only perform reconstruction of only one breast at a time when using this technique. It is important to discuss this possibility with your surgeon. If only one breast is reconstructed, the patient may need surgery on the other buttock in the future for optimal symmetry.

More breast reconstruction options are discussed here.

---

Dr Chrysopoulo
PRMA Plastic Surgery
(800) 692-5565
The Breast Cancer Reconstruction Blog
Follow Dr Chrysopoulo on Twitter