Modern surgical technology makes it possible to construct a natural-looking breast after mastectomy (breast removal) for cancer or other diseases. The procedure is commonly begun and sometimes completed immediately following mastectomy, so that the patient wakes with a new breast mound. Alternatively, reconstruction may begin years after mastectomy.
There are several ways to reconstruct the breast, both with and without implants; your surgeon(s) should work together with you in deciding which is the best for you. Breast reconstruction has not been proven to affect the recurrence of cancer or other diseases, chemotherapy or radiation treatment.
The DIEP (Deep Inferior Epigastric Perforator) flap procedure is the most advanced form of breast reconstruction surgery available today. The surgery uses the patient’s own abdominal tissue to reconstruct a natural, soft breast after mastectomy. Blood vessels, and the skin and fat connected to them, are removed from the lower abdomen and transferred to the chest to reconstruct a breast without the sacrifice of any of the abdominal muscles.
The DIEP flap is similar to the muscle-sparing free TRAM flap but only requires the removal of skin and fat. Unlike the TRAM procedure, all the abdominal muscle is preserved. After the skin, tissues and perforators (collectively known as the “flap”) have been dissected, the tissue is transplanted and connected to the patient’s chest using microsurgery. The surgeons then shape the tissue to create the new breast. Patients experience less pain after the surgery, enjoy a faster recovery, and maintain their abdominal strength long-term. The risk of abdominal complications such as bulging and hernia is also very small, much smaller than with the TRAM method of breast reconstruction. Many women who undergo this operation enjoy the added benefit of a flatter abdomen with results that mimic a “tummy tuck” procedure.
Expander Implant – Post Mastectomy Reconstruction
There are many stages of breast reconstruction, first, the breast mound is created with a flap or implant. Then the nipple and areola are made, and often revisional contouring is done with fat grafting.
Post-mastectomy reconstruction with a tissue expander and implant involves stages. A tissue expander is a temporary device that is placed on the chest wall deep into the pectoralis major muscle. This may be done immediately following the mastectomy, or as a delayed procedure. The purpose of the expander is to create a soft pocket to contain the permanent implant. Tissue expanders are available in a variety of shapes and sizes.
Once the expansion is completed and the patient is medically cleared for another operation (about one month after chemotherapy), the second stage of reconstruction is performed. This is an outpatient procedure that involves exchanging the expander for an implant and creating a more refined breast shape.
TRAM flap transverse rectus abdomens myocutaneous flap uses lower abdominal skin and fat attached to abdominal muscle to reconstruct the breast. This old-fashioned way of breast reconstruction method uses rectus muscle as a result muscle function as abdominal support is lost. It may cause a hernia after surgery, loss of muscle function with daily actives, postoperative recovery is slower and patients experience more pain.
The SIEA (Superficial Inferior Epigastric Artery) flap is very similar to the DIEP flap procedure. The main difference is the artery used to supply blood flow to the new breast. The SIEA blood vessels are found in the fatty tissue just below skin whereas the DIEP blood vessels run below and within the abdominal muscle (making the surgery more technically challenging). While the surgical preparation is slightly different, both procedures spare the abdominal muscle and only use the patient’s skin and fat to reconstruct the breast. SIEA is used less frequently than DIEP since the arteries required are generally too small to sustain the flap in most patients. Less than 20% of patients have the anatomy required to allow this procedure. As with the DIEP procedure, patients receive an abdominoplasty (tummy tuck) at the same time as an added benefit to SIEA flap breast reconstruction.
Latissimus Dorsi Flap
The latissimus dorsi (LD) flap is a standard method for breast reconstruction that was first utilized in the 1970’s. The latissimus dorsi muscle flap is the donor tissue available on the back. It is a large flat muscle which can be employed without significant loss of function. It can be moved into the breast defect still attached to its blood supply under the arm pit (axilla). A
latissimus flap is usually used to recruit soft-tissue coverage over an underlying implant. Enough volume can be recruited occasionally to reconstruct small breasts without an implant.
The TUG (Transverse Upper Gracilis) flap procedure uses tissue from the inner portion of the upper thigh (just under the groin crease) to reconstruct a “natural”, warm, soft breast. The resulting thigh scar is generally very well hidden near the groin crease. Patients also receive an “inner thigh lift” as an added benefit of the surgery. The procedure uses skin, fat and the gracilis muscle to reconstruct the new breast. Unlike loss of other muscles (like the rectus abdominus), loss of the gracilis muscle does not result in any noticeable functional impairment. The tissue is dissected from the inner thigh and transplanted to the chest where it is reattached microsurgically.
The TUG flap is a very good option for women who:
want to avoid an abdominal scar
do not have enough abdominal tissue for DIEP or SIEA flap breast reconstruction
have had a previous abdominoplasty (“tummy tuck surgery”)
have had multiple previous abdominal surgeries
The most common alternate flap choice is the gluteal artery perforator (GAP) free flap using skin and fat from the buttocks. This procedure utilizes either the superior or inferior gluteal vessels, but without having to harvest any of the gluteus maximus muscle. Instead, blood supply is provided through the perforator vessels that are teased out from the gluteus muscle, using a muscle incision alone. The surgeon will apply judgment in the operating room to determine how many perforators are needed to provide sufficient blood supply for the flap to survive. This flap can be harvested from one buttock, with a well hidden scar, or can be harvested from both buttocks for bilateral breast reconstruction. Flap elevation is completed while the patient is sleeping face down, and then the patient is turned over to allow the flap to be attached to the chest with the microscope. A significant disadvantage to this type of reconstruction is that it is technically more difficult to perform. Also, the tissue from the buttock is somewhat harder to shape into a breast