Any woman facing mastectomy because of breast cancer has the right to have breast reconstruction. Breast reconstruction is not a cosmetic surgery procedure and is covered by insurance plans as long as the mastectomy is covered. There are many reconstructive options to choose from.
“Immediate” breast reconstruction is performed at the same time as the mastectomy. Advantages include: preserving most of the patient’s breast skin, a shorter and less obvious mastectomy scar, and waking up with the new breast already in place. It also generally provides the best cosmetic results particularly when combined with nipple-sparing or skin-sparing mastectomy.
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”.
The most common breast reconstruction procedure performed by American plastic surgeons utilizes implants to restore the breast shape and form. These can be either saline or silicone. Implant reconstruction is typically performed as two separate surgeries. The first involves placing a tissue expander (temporary implant) under the skin and pectoral muscle. This is used to expand the skin to the required size. The expander is later replaced by the permanent implant at a second surgery. A few surgeons prefer using a one-stage approach and place the permanent implant at the same time as the mastectomy. While not all patients are candidates, this is a very attractive option for many women because they avoid the entire tissue expander phase of the reconstruction.
Breast reconstruction with implants can provide excellent cosmetic results. However, the long term risk of complications is much higher than in women who have cosmetic breast enhancement with implants. The most common risks include contracture (hardening of the new breast), and implant ripples that can be felt and seen through the breast skin. These risks are increased if the patient has to undergo radiation as part of the cancer treatment.
The Latissimus flap, or “lat flap”, uses back tissue to reconstruct the new breast. The latissimus dorsi muscle, along with the overlying fat and skin, is rotated from below the shoulder blade region and through the armpit onto the front of the chest. This tissue is then shaped to form the new breast. Thinner patients typically also need an implant placed under this tissue to achieve an appropriate final breast size. The resulting scar over the mid-back is visible with some clothing and beach wear. Avid golfers and tennis players usually notice an initial loss of strength due to the latissimus muscle sacrifice, though in most cases other muscles compensate over time.
Tissue can also be taken from the lower abdomen to create the new breast. The TRAM flap uses the same tissue that is removed by a tummy tuck. This skin and fat is transferred along with variable amounts of the rectus (sit-up) muscle. This tissue can be tunneled under the upper abdominal skin (pedicled TRAM), or disconnected from the body and reconnected to the chest using microsurgery (free TRAM). All forms of TRAM flap can improve the abdominal contour just like a tummy tuck. Unfortunately, women can notice loss of abdominal muscle strength due to the sacrifice of the rectus muscle. There is also a risk of bulging of the tummy and even hernia.
DIEP flap breast reconstruction has replaced the TRAM flap as today’s gold standard in breast reconstruction. The DIEP flap uses only skin and fat. This is disconnected from the lower abdomen and reconnected to the chest area using microsurgery to create a new breast. Since all the abdominal muscles are saved, patients do not have to sacrifice their abdominal strength. They also experience less pain and have a quicker recovery than TRAM patients. The risk of abdominal bulging and hernia is also very small. The SIEA flap is a variation of the DIEP flap. It is associated with an even easier recovery and a 0% hernia risk but requires specific anatomy which not all patients have. Like the TRAM, the DIEP and SIEA procedures also provide a simultaneous tummy tuck.
There are a handful of other tissue options available for women who are not candidates or prefer to avoid using their abdominal tissue. These include the inner, upper thigh (TUG flap), lower buttock crease (IGAP), and upper buttock (SGAP). The best tissue option will depend on a number of factors, primarily the patient’s body habitus.
Microsurgical breast reconstruction procedures like the DIEP, TUG and GAP flaps are not offered routinely by many American plastic surgeons. There are many reasons for this, primarily the complexity of the surgery and the need for additional training. Unfortunately most patients seeking one of these breast reconstruction options after mastectomy will be forced to travel to specialized centers for their surgery.
Dr Chrysopoulo is a board certified plastic surgeon specializing in breast cancer reconstruction, particularly DIEP breast reconstruction surgery. In-network for most US insurance plans. PRMA Plastic Surgery, San Antonio, Texas. (800) 692-5565.