Introduction to Breast Reconstruction Surgeries
Reconstruction of the breast after a mastectomy due to cancer or other disease is quite possible with today’s surgical procedures. The procedure is often covered by many HMO’s after breast cancer surgery and legislation is currently before Congress to enact mandatory coverage. Using the newest medical techniques, a plastic surgeon is often able to create a breast that is similar in form and appearance to that of the natural breast. A consultation will provide you with information on the many available options for post-mastectomy breast reconstruction.
In breast reconstruction surgery, the Plastic Surgery Group surgeons recreate all or part of the breast that has been surgically removed. The goal of reconstruction is to make breasts look natural and balanced when wearing clothing. This is done using a breast implant or your own tissue from another part of the body.
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Candidates for breast reconstruction include women who have been:
- Diagnosed with breast cancer and had or will have a mastectomy
- Diagnosed with breast cancer and had or will have breast conservation surgery, such as partial mastectomy or lumpectomy
- Found to have a genetic mutation and will have prophylactic mastectomy
There are many options for breast reconstruction. Deciding which reconstruction method is best for you will be discussed during your consultation. We will consider your personal preferences, as well as body shape, prior surgeries, current medical condition and cancer treatment needs. All reconstructive options have both risks and benefits, and each option usually requires multiple procedures to reach a final result.
Implant Reconstruction Surgery
Depending on your lifestyle and preference, patients may choose implants over tissue-based reconstruction.
Implant-based reconstruction offers an acceptable cosmetic outcome without having to use tissue from another part of the body. There are two types of implants: saline-filled and silicone gel-filled. Both types of implants come in numerous shapes, sizes and profiles. Despite controversy over silicone implants in the 1990s, they have been ruled safe and effective by the Food and Drug Administration. Your surgeon will help determine which implant is best for your body shape.
The best candidates for implant reconstruction are women with an adequate skin “pocket” to hold the implant (skin-sparing mastectomy); those who don’t have adequate tissue of their own or do not want to use their own tissue; or those who have no history of radiation treatment.
Advantages of Implant Reconstruction:
- Decreased operative and recovery time
- Fewer scars
- Satisfactory shape in clothing
Disadvantages of Implant Reconstruction:
- Two-stage procedure: tissue expander followed by exchange for permanent implant
- Maybe difficult to achieve symmetrical shape with the natural breast
- May need to replace implants periodically if implant leakage or contracture occurs
Reconstruction using Abdominal Tissue: Breast reconstruction using tissue from the abdomen to re-create a breast mound provides the most natural result of any technique.
Understanding the different types of flaps that can be used from your abdomen can be confusing. Looking at the makeup of your abdomen can be helpful. Your abdominal wall is made up of multiple layers: skin, fatty layer, fascia (the supportive layer), and muscle. The tissue taken from your abdomen can consist of all of these layers or only a few.
The tissue can also be transferred to recreate a breast in different ways. The tissue may be rotated to your chest on its blood supply or disconnected from its blood supply and connected to a new blood supply in your chest.
Pedicled flaps compromise the abdominal musculature and can result in weakness, bulges or hernia. Recent surgical advances have made it possible to lessen the amount of muscle and fascia taken with the flap. A flap may even be created without removing any fascia or muscle, or only a small amount. Using free flaps, your surgeon is able to spare the muscle and improve blood flow to the tissue. These procedures have been shown to reduce problems such as abdominal weakness, hernia, and bulges that may occur as a result of removing some of the supporting structure of the abdominal wall. Your surgeon will help you decide what type of procedure is best suited for you.
Advantages of reconstruction with abdominal flaps:
- Natural breast shape and consistency
- Improved abdominal shape
- No breast implant required
Disadvantages of reconstruction with abdominal flap:
- Longer surgery
- Additional scarring on abdomen
- Longer hospitalization and recovery
The different types of flaps from your abdomen that may be used to re-create a breast mound are described below:
Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM): this flap is rotated on its blood supply and consists of skin, fatty tissue and muscle, with or without fascia.
Free Superficial Inferior Epigastric Artery (SIEA): this flap is disconnected from its blood supply and is connected to the blood supply in the chest. It consists of skin, fatty layer, and their blood vessels: the superficial inferior epigastric artery and vein. Often the blood vessels are too small for this flap to be used. Less than 20% of patients will have large enough vessels to use this flap.
Free Deep Inferior Epigastric Perforator (DIEP Flap): this flap is disconnected from its blood supply and is connected to blood supply in the chest. It consists of skin, the fatty layer, and its blood vessels: the deep inferior epigastric artery and vein and its perforators. During the DIEP Flap procedure, the fascia must be opened but no fascia or muscle is taken.
Free Muscle-Sparing TRAM: this flap is disconnected from its blood supply and is connected to blood supply in the chest. It consists of skin, the fatty layer and a small portion of muscle with or without fascia. Most of your fascia and muscle is not taken (spared).
Reconstruction using Back Tissue
When back tissue is used for breast reconstruction, it uses the latissimus dorsi muscle, along with the skin and fat that covers the muscle. This procedure is called a latissimus dorsi flap. The tissue from your back is rotated to the front of your chest, with the blood vessels still attached. Since most women do not have enough fatty tissue on their back to recreate a breast using only the latissimus dorsi flap, an implant or tissue expander is commonly used. Often, an additional surgery is necessary to replace the tissue expander that is placed under the latissimus dorsi flap for a permanent silicone or saline implant.
The location of the incision on your back will depend on the amount of skin needed to replace the skin removed during the mastectomy. Often, the incision can be placed so that your bra will hide the scar.
The Latissimus flap may also be used after breast conservation surgery to fill in the misshapen area that can result after removal of breast tissue. Patients generally have no major long-term problems from the latissimus dorsi flap, and can resume activities of daily living and exercise just as before the surgery.
Advantages of Latissimus flap reconstruction:
- Decreased surgery and recovery time
- Better coverage over the implant
- One-time surgery, if the implant placed immediately
- Good option for thin patients who have had radiation therapy
Disadvantages of Latissimus flap reconstruction:
- A breast implant is usually required for the desired projection and size
- May have complications in the back where the tissue was taken from
- Minor muscle weakness in the back can affect professional rock climbers, swimmers and tennis players
Contact the breast reconstruction surgeons with The Plastic Surgery Group to learn more about breast reconstruction surgery. We are pleased to consult with patients at our Montclair, Livingston and Manhattan office locations.
For additional information on Breast Reconstruction, visit: www.plasticsurgery.org