Breast reconstruction is a type of surgery for women who have had a breast removed (mastectomy). The surgery rebuilds the breast so that it is about the same size and shape as it was before. The nipple and the darker area around the nipple (areola) can also be added. Most women who have had a mastectomy can have reconstruction. Women who have had only the part of the breast around the cancer removed (lumpectomy) may not need reconstruction. Breast reconstruction is done by a plastic surgeon.
Up to 47,700 women are being diagnosed every year with breast cancer, equal to 130 a day. That is double the number 30 years ago. Today, the emotional and physical results are very different from what they were in the past. Much more is now known about breast cancer and its treatment. New kinds of treatment as well as improved reconstructive surgery mean that women who have breast cancer today have better choices.
Today, more women with breast cancer choose surgery that removes only part of the breast tissue. This may be called breast conservation surgery, lumpectomy, or segmental mastectomy. But some women have a mastectomy, which means the entire breast is removed. Many women who have a mastectomy choose reconstructive surgery to rebuild the shape and look of the breast.
Women choose breast reconstruction for many reasons:
- To make their breasts look balanced when they are wearing a bra.
- To permanently regain their breast shape.
- So they don’t have to use a form that fits inside the bra (an external prosthesis).
Several types of operations can be done to reconstruct your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. (A tissue flap is a section of your own skin, fat and muscle which is moved from your tummy, back or other area of your body to the chest area.)
The stages of breast reconstruction surgery
One-stage immediate breast reconstruction may be done at the same time as mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant where the breast tissue was removed to form the breast contour.
Two-stage reconstruction or, two-stage delayed reconstruction, is done if your skin and chest wall tissues are tight and flat. An implanted tissue expander, which is like a balloon, is put under the skin and chest muscle. Through a tiny valve under the skin, the surgeon injects a saltwater solution at regular intervals to fill the expander over time (about 4 to 6 months). 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.
The two-stage reconstruction is sometimes called delayed-immediate reconstruction because it allows options. If the surgical biopsies show that radiation is needed, the next steps may be delayed until after radiation treatment is complete. If radiation is not needed, the surgeon can start right away with the tissue expander and second surgery.
Implant procedures
The most common implant is a saline-filled implant. It is a silicone shell filled with saltwater (sterile saline). 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 silicone 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 you can only get them in clinical trials.
Tissue flap procedures
These procedures use tissue from your tummy, back, thighs or buttocks to rebuild the breast. The two most common types of tissue flap surgeries are the TRAM flap (or transverse rectus abdominis muscle flap), which uses tissue from the tummy area, and the latissimus dorsi flap, which uses tissue from the upper back.
These operations leave two surgical sites and scars – one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but they will never go away completely. There can also be problems at the donor sites, such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue’s blood supply, flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers.
In general, flap procedures behave more like the rest of your body tissue. For instance, they may enlarge or shrink as you gain or lose weight.
TRAM (transverse rectus abdominis muscle) flap
The TRAM flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). The tissue from this area alone is often enough to shape the breast, and an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower belly, or a ‘tummy tuck’.
There are 2 types of TRAM flaps:
A pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area.
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.
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 tunnelled 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.
DIEP (deep inferior epigastric artery perforator) flap
A newer type of flap procedure, the DIEP flap, 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 results in less skin and fat in the lower belly (abdomen), or a ‘tummy tuck’. This method uses 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. The procedure takes longer than the TRAM pedicle flap discussed previously.
Gluteal free flap
The gluteal free flap or SGAP (superior gluteal artery perforator) flap is a newer type of surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It is an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons. The method is much like the free TRAM flap mentioned on page 27. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest area. A microscope (microsurgery) is needed to connect the tiny vessels.
New methods of tissue support
These surgeries move sections of tissue to new places, or add fairly heavy implants, and some tissues need support to keep them in place as they heal. Doctors use synthetic mesh and other methods for this. More recently, doctors are trying a new product SurgiMend®. It is regulated by the US Food and Drug Administration (FDA) as a human tissue used for transplant. But it has had the human cells removed (known technically as being ‘acellular’), which reduces any risk that it carries diseases or the body will reject it. It is used to extend and support natural tissues and help them grow and heal. In breast reconstruction it may be used with expanders and implants. It has also been used in nipple reconstruction.
This product is fairly new in breast reconstruction. Studies that look at outcomes are still in progress, but have been promising. SurgiMend® is not used by every plastic surgeon, but is becoming more widely available.
Summing Up
Breast reconstruction is a type of surgery for women who have had a mastectomy (a breast removed as part of treatment for breast cancer).
One-stage immediate breast reconstruction can be done at the same time as a mastectomy is carried out.
Two-stage delayed reconstruction is carried out over a period of months where stages of the procedure can be delayed to allow for any necessary treatment to be completed, e.g. radiotherapy.
If you are thinking about having reconstructive surgery, it is a good idea to talk about it to a plastic surgeon experienced in breast reconstruction before your mastectomy. This lets the surgical teams plan the treatment that is best for you, even if you want to wait and have reconstructive surgery later.
Breast reconstruction is done using either an implant procedure or a tissue flap procedure. The most common implant surgeons use is a saline-filled one. Alternatively, with a tissue flap procedure, tissue from the stomach, back, thighs or buttocks is used to rebuild the breast.
