Breast Reconstruction

Women who have undergone any type of breast altering surgery will many times choose to have a plastic surgeon reconstruct one or both breasts. The stress of a cancer diagnosis coupled with the anxiety of losing one or both breasts can be very hard to absorb. Fortunately the surgical techniques to rebuild and reconstruct breasts today are far more advanced than they were 20 to 30 years ago. In addition, it's very likely that both mastectomy and reconstruction can be done at the same time.

Breast reconstruction is designed to rebuild the breast so that is as close as possible to the size and shape as the original one. Some women may choose to go smaller and others opt for larger breasts.

The following are current options available for breast reconstruction:

Tissue Expander Implant: a balloon, is placed beneath the skin and chest muscle. Through a tiny valve beneath the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over time. After the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant. Some expanders are left in place as the final implant.

Breast Implant: The most common implant is a saline-filled implant. It is a silicone shell filled with sterile saline (salt water). Silicone gel-filled implants are another option for breast reconstruction. They are not used as often as they were in the past because of concerns that silicone leakage might cause immune system diseases. But most of the recent studies show that implants do not increase the risk of immune system problems. Also, alternative breast implants that have different shells and are filled with different materials are being studied, but these are available only in clinical trials.

Latissimus Dorsi Flap: The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.

Pedicled TRAM Flap (transverse rectus abdominis muscle flap): uses tissue and muscle from the lower abdominal wall (tummy tissue)- pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area.

Free TRAM Flap(transverse rectus abdominis muscle flap): uses tissue and muscle from the lower abdominal wall (tummy tissue) In a free flap, the surgeon cuts the flap of skin, fat, blood vessels, and muscle for the implant free from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer than a pedicle flap. The free flap is not done as often as the pedicle flap, but some doctors think that it can result in a more natural shape.

DIEP Flap(deep inferior epigastric artery perforator): uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This procedure results in less skin and fat in the lower abdomen, or a "tummy tuck." The procedure is done as a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels.

SIEA Flap: An alternative free flap that utilizes the skin and fat of the lower abdomen is the superficial inferior epigastric artery (SIEA) flap. This flap involves no incision through the abdominal muscle because it does not utilize the deep inferior epigastric vessels. In an SIEA flap, incisions are made in the skin and fat only, allowing the flap to be transferred based on the superficial inferior epigastric vessels. This allows for even less post-operative pain, and no risk for hernia. Unfortunately, only a minority of patients are candidates for the SIEA flap because the superficial vessels are very small, limiting flap volume, and increasing the risk of flap loss. In some patients, these vessels may not be present because of previous surgery such as Caesarean-section or hysterectomy.

GAP Flap: 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.

Nipple/Areola Reconstruction: Nipple and areola reconstructions are optional and usually the final phase of breast reconstruction. This is a separate surgery that is done to make the reconstructed breast look more like the original breast. The ideal nipple and areola reconstruction requires that the position, size, shape, texture, color, and projection of the new nipple match the natural one. Tissue used to rebuild the nipple and areola also is taken from your body, such as from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks. A tattoo may be used to match the color of the nipple of the other breast and to create the areola.

Nipple/Areola Tattoo: Tattooing is a simple, fast procedure. There is no need to be scared. If you are matching a new nipple areola to the existing breast, your plastic surgeon will mix various colors and shades to get the correct pigment. If you had bilateral reconstructions, your surgeon can use your preoperative photos to recreate the nipple color, or you can pick a new color that you like against your skin tones. As with any tattoo, the pigment will fade in time. Getting the right shade of color may require more than one tattoo procedure. If you are having nipple tattooing alone, with no nipple reconstruction, you may want to look for a doctor that specializes in giving your tattoo a three dimensional appearance.

Karen Moody ...© All rights reserved