Dr. Chrysopoulo, the author of the following post, is a Board Certified surgeon specializing in advanced breast reconstruction surgery. He is part of PRMA Plastic Surgery, www.prma-enhance.com He and his partners perform over 500 microsurgical breast reconstructions per year. You can view examples of the procedures described below on www.prma-enhance.com
Breast reconstruction is not a cosmetic procedure. It’s a right every woman has when faced with breast cancer and mastectomy. 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.
Some patients do not have access to a reconstructive surgeon at the time of the mastectomy. Patients with more advanced disease are advised to avoid immediate reconstruction because radiation therapy is likely after the mastectomy. In these cases, the reconstruction can be performed some time after the mastectomy (once the tissues have recovered from the radiation). This is known as “delayed reconstruction”. Most plastic surgeons prefer to delay reconstruction if radiation is planned because radiation can impact the reconstruction and detract significantly from the results.
Tissue expander reconstruction is the most common method of breast reconstruction in the United States. Most plastic surgeons perform this as a two-stage procedure. The expander is used to stretch the skin envelope and create 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 some time later. Some patients are candidates for 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 an acellular dermal graft (like Alloderm or FlexHD). These grafts are cadaveric tissue implants that provide support and increase the amount of padding over the implant.
Implant reconstruction is completely different to cosmetic breast augmentation with implants. Since there is a lot less tissue padding over the implant (it is removed by the mastectomy), the risk of developing implant-related problems, like hardening, is much higher in mastectomy patients. Implant reconstructions generally speaking also do not do as well as tissue reconstructions in the setting of radiation.
The Latissimus flap procedure uses muscle (latissimus dorsi), fat and skin from the back (below the shoulder blade) that is brought around to the chest to create a new breast. Many patients also need an expander or implant to obtain a satisfactory result in terms of size. Patients typically have a scar on their back that can be seen with some low-cut clothing. Women who are very active in sports may notice some strength loss with activities like golf, climbing, or tennis.
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 (freeTRAM). 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, the need for additional training, and the low reimbursement from most insurance companies. Unfortunately, most patients seeking advanced breast reconstruction after mastectomy will be forced to travel to highly specialized centers for their surgery.