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.
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 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 stands for Transverse Rectus Abdominis Myocutaneous flap, and is most commonly employed for breast reconstruction. In this procedure, the breast with cancer is surgically removed, and a portion of the abdomen tissue group, including skin, adipose tissues, minor muscles and connective tissues, is taken from the patient’s abdomen and transplanted onto the breast site. This procedure is preferred by some breast cancer patients because it combines a mastectomy with an abdominoplasty, and allows the breast to be reconstructed with one’s own tissues instead of a foreign implant. It is contraindicated for patients who need abdominal strength, since the muscle removal weakens the abdomen. There are three main forms of the TRAM flap operation commonly performed by plastic surgeons for mastectomy reconstruction:
- The Pedicled TRAM flap: this was the first operation to describe use of one of the rectus abdominus muscles (sit-up muscle) for breast reconstruction. The surgery begins with an incision from hip to hip. Then, a “flap” of skin, fat and one of the patient’s abdominal muscles is tunneled under the skin to the chest to create a new breast. Recovery from the surgery is difficult and painful. There is the possibility of complications including delayed healing, fat necrosis (part of the tissue turns hard due to poor blood supply), loss of the reconstruction altogether (rare), and abdominal complications such as bulging and/or hernia.
- 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 procedure and no subsequent upper abdominal bulge around the ribcage area (which is typically seen with tunneling).
- The Muscle-Sparing Free TRAM Flap: this operation is associated with all the benefits of the free TRAM but has significantly fewer abdominal complications and side-effects (pain, bulging, hernia, strength loss) because the vast majority of the abdominal muscle is spared and left behind. The PRMA surgeons will opt for this surgery only if the patient’s anatomy does not allow for the DIEP or SIEA flap to be performed.
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.
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 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