Breast Reconstruction is a surgical procedure for patients who have had a mastectomy or lumpectomy as part of their breast cancer treatment. The patient may choose this procedure to rebuild one or both breasts to near normal appearance, shape, and look. Breast Reconstruction is often performed in stages that involve multiple procedures and can either begin immediately following a mastectomy or be delayed to a later time. Reconstruction can be implant-based or autologous. Implant-based reconstruction relies on breast implants to help rebuild a new breast, whereas autologous reconstruction uses the patient’s own tissue from another part of the body to build a new breast.
Immediate versus delayed breast reconstruction depends on some of the following factors:
- Physical exam by a breast reconstruction plastic surgeon
- Surgical risk factors (such as smoking and being overweight)
- Treatments needed after the mastectomy surgery
- Other conditions that may impair wound healing
It’s important to discuss your options with your plastic surgeon and oncologist.
Why reconstuct the breast?
Reconstruction of the breast(s) is a physically and emotionally rewarding procedure for women who have lost one or both breasts due to cancer or other conditions. The creation of a new breast can dramatically improve a survivor’s self-image, confidence and overall quality of life. Realistic expectations of your breast reconstruction are important to keep in mind. Although the surgery will result in a relatively natural- looking breast, a reconstructed breast will never look nor feel exactly the same as an unoperated breast.
Am I a candidate for breast reconstruction?
Breast reconstruction is a highly personal decision which should be reached after careful discussion with your surgical team. It is a decision that should be done for yourself and not to fulfill someone else’s expectations.
Your surgical team which will include the Surgical Oncologist and your Cosmetic & Reconstructive Specialists of Florida team will work together with you to decide which reconstruction options will best suit your particular case.
Consultation with Your Reconstructive Surgeon
Our physicians at CRS Plastic Surgery are here to help you in your reconstruction. During your initial evaluation with our specialists, you will be asked numerous questions about your health, diagnosis, lifestyle, and desired reconstructive results. Some factors to be considered in deciding which reconstructive options will work best for you include:
- Unilateral versus bilateral reconstruction
- Total mastectomy or nipple-sparing mastectomy
- The need to perform a lift (mastopexy) or reduction on the healthy breast for symmetry
- Size, shape of breasts
- Your body type
- Your lifestyle
- The need for radiation or chemotherapy
- Medical conditions
- Prior surgeries
Once one of our reconstructive physicians has reviewed the above factors, he will discuss with you the different options of breast reforming as well as the timing of the surgery.
The two most common types of reconstruction are either implant-based reconstruction or autologous-based reconstruction (i.e. DIEP Flap).
Implant Based Reconstruction
Implant-based reconstruction is a very popular technique which provides an adequate cosmetic outcome without having to use tissue from another part of the body. Most implant-based reconstructions require two surgeries: the first being the placement of tissue expanders and the second being the replacement of expanders with permanent implants. This is commonly referred to as a staged reconstruction.
In some cases, the implant can be directly placed at the time of the mastectomy making it a “single stage direct implant.” This option will be decided between you and your surgeon prior to the mastectomy if it is determined that you are a good candidate.
Staged Reconstruction with Tissue Expanders
Staged reconstruction with tissue expander(s) involves the placement of tissue expander(s) typically at the time of the mastectomy by inserting the expander(s) into a pocket formed under the muscle and remaining skin of the chest wall. This first stage is followed up by a series of outpatient visits to the office for expansions.
During the expansion process the tissue expander will be filled or expanded with saline solution by your reconstructive plastic surgeon. The expander is gradually filled to cause the stretching of the muscle and skin in order to create a pocket for the future permanent implant. The amount of saline to be added to the expander at each office visit will vary depending on the initial fill amount during the placement of the expander, the quality and tightness of the skin. The entire expansion process usually takes 2-3 months but may be prolonged if you require other treatments such as chemotherapy or radiation.
Once the “pocket” has reached the desired size, the expander(s) is left in place, stretching your skin for an additional 3-5 weeks. The next step is to replace the tissue expander(s) with permanent implant(s). This surgery is done as an outpatient procedure. The permanent implant(s) can be either saline or silicone and will be significantly softer than the tissue expander(s). Our plastic surgeon will discuss with you the various options for permanent implants at your pre-operative visit.
Single Stage/ Direct Implant Reconstruction
Patients who have adequate breast skin remaining following a mastectomy may be good candidates for direct-to-implant breast reformation. The main factor that determines whether a patient is eligible for this type of reconstruction is whether the remaining skin (often in conjunction with the use of dermal matrix such as Alloderm®) is able to accommodate the volume of the permanent breast implant.
In this single stage reconstruction, the implant is placed behind the pectoralis major muscle immediately following a mastectomy. To prevent the implant from “bottoming out” over time, Alloderm®, or other dermal matrix, is secured to the chest wall along the lower and outer folds of the breast. Over the following months, the breast implant will settle into place, and at that point, the reconstruction of the breast is complete. If the patient’s mastectomy was done utilizing a “nipple-sparing” approach, no further procedures would be needed. Secondary procedures are available to improve symmetry, breast shape or breast contour. Nipple and areola reconstruction are also available for patients who underwent a total mastectomy.
The single stage approach allows our surgeons to place a breast implant directly and immediately following a mastectomy, thus eliminating the need for tissue expander(s) and expansion visits. More importantly, it allows the patient to awaken from their mastectomy with an already well-defined breast shape.
Advantages to Implant Based Reconstruction
Advantages to Implant Based Reconstruction
- Decreased length of surgery and down time
- No additional scars
- Satisfactory shape
Disadvantages of Implant Based Reconstruction
Disadvantages of Implant Based Reconstruction
- May require numerous visits during the expansion process
- Most often requires multiple surgeries (expander, permanent implant)
- Difficulty in achieving nipple projection with nipple reconstruction due to thinner skin
Autologous reconstruction is the main alternative to implant-based reconstruction. This approach utilizes your own tissue—skin, fat and sometimes muscle from another part of your body - to form a breast shape. The tissue (also called a “flap”) will come from the belly, inner thighs, or the buttocks to create the reconstructed breast. The most common donor site being the abdominal area.
Autologous reconstruction is popular because of its long-lasting results. Implants may require replacement after 10-20 years. The use of your own tissue from the belly, buttocks, or inner thighs makes a good substitute and has a very natural feel, but as with the use of implants, the newly created breast will have little, if any, sensation. The physical effects of each type of autologous reconstruction are highly individual to your body, your range of motion, your physical strength, and your normal day-to-day activities.
Advantages of Autologous Reconstruction
- Reconstructed breast will feel more natural
- For unilateral reconstruction, it provides for better symmetry
- No implant associated risks present
- Better nipple projection and reconstruction
Disadvantages of Autologous Reconstruction
- Longer operation
- Longer recovery
- Additional scar at donor site
Abdominal Tissue Transfer
The use of abdominal tissue to reform the breast is called Transverse Rectus Abdominis Myocutaneous or TRAM flap. In its original form, this was used as a pedicled flap (pTRAM). This means that the blood vessels that supply the abdominal tissue are not separated from the body. Rather, the tissue stays connected and is moved to the chest through a tunnel underneath the skin. Some of the risks of this procedure include bulging of the abdomen, hernia, and fat necrosis of the flap (firm areas in the breast).
The alternative to a pedicled TRAM is a free TRAM (fTRAM). In this procedure, the same abdominal tissue is utilized as in the pedicled TRAM, however, the skin, fat, blood vessels, and possibly a small piece of the abdominal muscle are completely removed from the body. The blood vessels are then re-attached to the blood vessels in the chest, and the skin and fat is used to reconstruct the breast mound. Among the benefits of a fTRAM over a pTRAM include a better blood supply, less donor site morbidity of the abdomen, and a potentially better aesthetic outcome.
To decrease the risk of bulging in the abdomen, hernia, or abdominal weakness following breast shape alteration, the Deep Inferior Epigastric artery Perforator (DIEP) flap was developed. This flap also uses the tissue of the lower abdomen but does not use any of the abdominal wall muscles. The aim is to perform a DIEP flap whenever possible but there is no guarantee that all the muscle will be spared. The decision of fTRAM versus a DIEP flap can only be made in the operating room based on the individual patient’s anatomy.
Things to Keep in Mind with Autologous Reconstruction
Remember that while you are healing from your surgery, there will be at least two areas of the body that are healing at the same time - your reconstructed breast(s) and the donor tissue site(s), depending on whether one or both breasts are being reconstructed at the same time. Some women may also have a sentinel node biopsy or axillary node dissection at the same time which ultimately means an additional incision.
It is important to note that weight gain or loss can affect the size of an autologous tissue reconstruction.
Autologous reconstructions tolerate radiation therapy better than implants alone. If radiation is part of your treatment plan, make sure to discuss this with our reconstructive plastic surgeon at the time of your consult.
Breast reconstruction with autologous tissue is a lengthy procedure. A unilateral autologous reconstruction can be between four to six hours long (including mastectomy). A bilateral autologous reconstruction can be between seven to ten operating room hours.
Since the tissues used to reconstruct the breast require blood flow to survive, there is a small risk that blood flow issues may arise. If blood flow is lost, it requires a return to the operating room to evaluate the flap and an attempt to vascularize and salvage it. While the risk low (approx. 1-4%), there is always a possibility of partial or total flap failure.