Breast reconstruction is a type of surgical procedure to re-create the breast(s) following mastectomy (surgery which removes all or part of the breast(s), or to correct a congenital breast defect (such as Poland Syndrome). Reconstruction can be performed at the time of mastectomy (immediate reconstruction) or even months or years later (delayed reconstruction).
Breast reconstruction can be performed by using implants (either saline or silicone) or by using your own tissue (skin, fat and sometimes muscle) from another area of your body. Sometimes, reconstruction can be done using a combination of both techniques.
Breast reconstruction is done by a plastic surgeon who usually works closely with the breast surgeon (mastectomy surgeon).
There is no ‘right or wrong’ choice for reconstruction. What’s right is what works for you. Look around, ask questions, and seek support in your decision.
Keeping US Abreast is there for support and information as well as to empower you to make informed decisions. We do not offer medical advice. We do, however, offer support by others who have undergone similar (if not the same) procedures.
Below are facts to help you navigate through the tons of sometimes confusing information on the web.
Implant Based Breast Reconstruction.
Implants consist of a silicone outside (shell) filled with either saline (salt water) or silicone. The implant is placed under the chest muscle and may require additional support to hold it in place (special graft or mesh).
There are 2 types of implant reconstruction; one stage and two stage.
Single stage reconstruction (direct to implant reconstruction) is where the implant is placed at the time of the mastectomy. This is a decision made by your surgeons.
Two-stage reconstruction is where a tissue expander is placed at the time of the mastectomy, or at the time of the initial breast surgey. The partially filled saline implant is gradually expanded (during office visits every 1-2 weeks) to the desired size to allow the skin to stretch. This expansion takes place over several months, when it is then exchanged for a permanent implant (which is either silicone or saline).
Implant reconstruction usually requires a short hospital stay (1 or 2 nights including the mastectomy) with follow up outpatient surgery procedures for implant exchange (tissue expander exchange to implant), nipple reconstruction (if nipples were removed) and breast contouring or symmetrizing procedures (if only one breast is reconstructed).
Flap Breast Reconstruction.
Involves taking skin, fat, blood vessels and sometimes muscle and moving them from one part of the body to another to re-create the breast (s). Tissue can be taken from the back, abdomen, inner or outer thighs or upper or lower buttocks.
Flaps are divided into 2 types – pedicled flaps and free flaps.
Pedicled flaps, involve leaving the original blood supply intact, but tunnel the muscle, fat and skin from one site to another. This tunneling requires that the donor site and recipient site be close together.
Free flaps involve disconnecting the original blood supply from the donor tissue (fat, skin and sometimes muscle) and reconnecting the transferred tissue to a new blood supply. This requires the use of a microscope in the operating room (microsurgery). The surgeon needs to be specially trained in these procedures. The surgery also takes longer than either implant or pedicled flap surgery.
The choice of procedure is based on your discussion with your surgeon, their familiarity with the procedure and your body type. These breast reconstruction procedures require longer surgery and a longer recovery.
Latissimus dorsi (back muscle) – original blood supply is not disrupted, instead, muscle, fat, skin and blood vessels are tunneled from the back to the front of the chest. Can be done with or without implant, however depending on size of the breast and projection desired, may need implant as well.
Pedicled TRAM (Transverse Rectus Abdominus Muscle) – original blood supply is not disrupted, instead, the flap is tunneled under the skin to the chest wall.
PedicledTRAM, usually best suited for a unilateral, or 1-sided reconstruction. It may require implant placement for breast volume/projection.
May or may not include muscle depending on actual procedure.
Free flaps that Include muscle:
Free TRAM (Transverse rectus abdominus)– Muscle as well as fat, skin and blood vessels transferred from abdomen to re-create breast (s).
TUG– (Transverse upper gracilis) – muscle, fat skin and blood vessels transferred from inner thighs to re-create breast(s)
Free Flaps Not including muscle:
The following donor sites include fat, skin and blood vessels only, no muscle.
DIEP– (Deep inferior epigastric artery perforator) – tissue taken from abdomen
SIEA– (Superficial inferior epigastric artery perforator)- tissue taken from abdomen
SGAP– (Superior gluteal artery perforator)- tissue taken from upper buttocks (muffin top)
PAP– (Profunda Artery Peforator) – tissue taken from lower buttocks/upper thigh
LTP/TFL– (Lateral Thigh Perforator/Tensor Fascialata) – tissue taken from side of thigh (saddle bags)
Flap surgery is not recommended for all patients. A discussion with your surgeon regarding the options based on your health history, age and lifestyle is recommended.
Questions to Ask Your Surgeon Regarding Reconstructive Procedures.
- Am I a candidate for breast reconstruction?
- If yes, which type of procedures could I have?
- If no, why am I not a candidate?
- What type of reconstruction do you think best for me and my lifestyle? Why?
- Are you board certified in Plastic Surgery?
- How many of ___ procedures have you done?
- What is your rate of complications?
- How long is the surgery?
- What happens to the reconstructed breast over time?
- How long will an implant last?
- What happens if my weight changes?
- What happens if I need radiation?
- What other surgeries will I need with:
- Tissue expander/Implants
- Flap reconstruction
- How much discomfort/pain will I experience?
- How long will I be in the hospital?
- How long is the recovery?
- Are there specific restrictions in activity?
- Will my breasts be equal in shape, size?
- Will my reconstructed breast look the same as my other breast?
- Will I have any sensation or feeling in my breasts and/or nipples?
American Cancer Society: www.cancer.org
Breast reconstruction: www.breastreconstruction.org
American Society of Plastic Surgeons (ASPS): www.plasticsurgery.org