What Now After Mastectomy?... Know Your Breast Reconstruction Options
Breast reconstruction is not a cosmetic procedure. It's a right every woman has when faced with mastectomy after breast cancer. Fortunately, there are several reconstructive options.
When the breast reconstruction is performed at the same setting as the mastectomy it is referred to as "immediate" reconstruction. The biggest advantage of immediate reconstruction is that the patient wakes up from the surgery still "whole" and completely avoids having to live without a breast. Other advantages include shorter scars and, generally speaking, a better cosmetic result.
Some patients do not have access to a reconstructive surgeon at the time of the mastectomy. Other patients 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. This is known as "delayed reconstruction".
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 is one of the most common tissue reconstructions performed in this country. It uses the skin, fat and muscle (latissimus dorsi muscle) from the mid-back. This tissue is tunneled under the armpit skin and onto the chest to recreate the breast mound. Some women will also require an implant under this tissue for additional breast volume. The loss of function from moving the latissimus muscle is generally very well tolerated in all but the most active women.
TRAM flap surgery is a common procedure that uses skin, fat and varying amounts of the sit-up muscle (rectus abdominis) from the lower abdomen. The tissue (or flap) is then relocated to the chest to create the new breast. This procedure also results in a tightening of the lower abdomen, or a "tummy tuck". Unfortunately, sacrifice of all or part of the abdominal muscle can result in bulging (or "pooching") of the abdomen and even a 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.
Some women are not candidates for these abdominal tissue flaps. Other tissue reconstruction options include the sGAP (upper buttock), iGAP (lower buttock), and TUG (upper inner thigh) flap procedures. All these procedures provide natural reconstructions with additional body contouring benefits (buttock or inner thigh lift respectively).
Like the DIEP flap, the GAP and TUG flap procedures are unfortunately not offered by most plastic surgeons as they require advanced training in microsurgery and reimbursement is very low. Only about 40 surgeons in the US perform these advanced breast reconstruction procedures routinely.
When the breast reconstruction is performed at the same setting as the mastectomy it is referred to as "immediate" reconstruction. The biggest advantage of immediate reconstruction is that the patient wakes up from the surgery still "whole" and completely avoids having to live without a breast. Other advantages include shorter scars and, generally speaking, a better cosmetic result.
Some patients do not have access to a reconstructive surgeon at the time of the mastectomy. Other patients 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. This is known as "delayed reconstruction".
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 is one of the most common tissue reconstructions performed in this country. It uses the skin, fat and muscle (latissimus dorsi muscle) from the mid-back. This tissue is tunneled under the armpit skin and onto the chest to recreate the breast mound. Some women will also require an implant under this tissue for additional breast volume. The loss of function from moving the latissimus muscle is generally very well tolerated in all but the most active women.
TRAM flap surgery is a common procedure that uses skin, fat and varying amounts of the sit-up muscle (rectus abdominis) from the lower abdomen. The tissue (or flap) is then relocated to the chest to create the new breast. This procedure also results in a tightening of the lower abdomen, or a "tummy tuck". Unfortunately, sacrifice of all or part of the abdominal muscle can result in bulging (or "pooching") of the abdomen and even a 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.
Some women are not candidates for these abdominal tissue flaps. Other tissue reconstruction options include the sGAP (upper buttock), iGAP (lower buttock), and TUG (upper inner thigh) flap procedures. All these procedures provide natural reconstructions with additional body contouring benefits (buttock or inner thigh lift respectively).
Like the DIEP flap, the GAP and TUG flap procedures are unfortunately not offered by most plastic surgeons as they require advanced training in microsurgery and reimbursement is very low. Only about 40 surgeons in the US perform these advanced breast reconstruction procedures routinely.
About the Author:
Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction, particularly DIEP flap breast reconstruction. In-network for most US insurance plans. PRMA Plastic Surgery, San Antonio, Texas. (800) 692-5565.
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