Breast reconstruction is a procedure, or multiple procedures, that reconstructs a breast mound. Reconstruction can be performed using implants or your own tissue.
The most common reason for breast reconstruction surgery is after a mastectomy for breast cancer treatment. Lumpectomy surgery allows women to preserve their breasts, but may also require reconstruction when it involves the removal of a significant portion of breast tissue. Our plastic surgeons and breast cancer surgeons work together to incorporate cosmetic surgery principles into cancer treatment. For example, surgery to remove a large tumor could incorporate a breast reduction pattern or breast lift pattern. The result is an effective cancer operation with a good cosmetic outcome.
Additionally, women with breast implant problems may seek out breast reconstruction with their body’s own tissue. The breast implants may have been placed following breast cancer treatment or for cosmetic breast augmentation.
Women with congenital breast abnormalities, such as those encountered by patients with Poland’s Syndrome, may also need breast reconstruction. Often a breast implant is placed during the late teenage years followed by removal of the implant and more definitive reconstruction with the patient’s own tissue years later.
Breast Reconstruction Using Your Own Tissue
A breast mound can be reconstructed using your tissue — usually abdominal tissue. This is perhaps the most natural type of breast reconstruction. Skin, fat and sometimes a small amount of muscle are taken from another location and transplanted to the chest wall to create the shape of a breast. The blood flow to the transplanted tissue is hooked up to an artery and vein under your rib.
After surgery, staff will monitor the blood flow to the tissue. They will listen to the “heartbeat” of the tissue with a doppler device. If there are any concerns, your surgeon may take you back to the operating room. Problems with the tissue blood flow happen less than 3% of the time. If the blood flow cannot be restored, we will consider another method of reconstruction.
On average, patients stay five nights in the hospital. Recovery is approximately six to eight weeks.
There are three main types of abdominal free tissue transfer — DIEP flap, SIEA flap and TRAM flap. Which kind you have depends on the blood vessels that supply the tissue of your abdomen. This can often be determined with a CT scan of the abdomen prior to surgery or may be a decision made at the time of surgery.
The DIEP flap, or deep inferior epigastric perforator flap, is a microsurgical technique that involves precisely separating the skin, soft tissue and tiny blood vessels, or perforators, from the abdomen without removing any of the abdominal muscles. The blood vessels are matched to supplying vessels at the mastectomy site, and a new breast is formed.
Three months later, a new nipple is reconstructed, and finally tattooing of the nipple completes the reconstruction. Because DIEP flap reconstruction preserves the patient’s abdominal muscles, the patient recovers faster, experiences fewer complications (such as hernia) and maintains her core abdominal strength.
The tissue taken to create a new breast using the DIEP flap is virtually the same as that taken for a cosmetic tummy tuck (abdominoplasty). In fact, the narrow incision at the bikini line used for the DIEP flap is identical to that made for a tummy tuck.
The SIEA flap, or superficial inferior epigastric artery flap, is similar to the DIEP flap technique in that it uses skin and fatty tissue from the abdomen to replace the skin and soft tissue removed in a mastectomy.
The SIEA, however, relies on a distinctive blood supply and requires less tissue removal from the abdomen. The SIEA flap depends on the tiny vessels of the superficial vascular system in the fatty layer just below the skin of abdomen. About 20 percent of women have these types of superficial arteries. Women who do not have adequate superficial blood vessels are not candidates for this procedure. The decision about which procedure to use — DIEP flap or SIEA flap — is made during surgery. Because less tissue is removed, the abdomen generally heals faster with the SIEA flap procedure.
As with the DIEP flap procedure, the SIEA flap preserves the abdominal muscle and leaves a thin scar and a flat belly, similar to a tummy tuck. Three months after surgery, a new nipple is reconstructed, and finally tattooing of the nipple completes the reconstruction.
Plastic surgeons have used the TRAM flap, or transverse rectus abdominis myocutaneous flap, for more than 20 years, transferring extra tissue from the abdomen to the breast, sometimes taking one entire rectus abdominis muscle with the flap, and sometimes taking only a part of the muscle.
Alternative Tissue Sources
If you are not a candidate for use of your tummy tissue, and you don’t want to have implants, there are other tissue options.
Harvest of the inner thigh tissue can be performed with a transverse upper gracilis (TUG) flap or a profunda artery perforator (PAP) flap. In the TUG flap the inner thigh skin, fat and part of the gracilis leg muscle is harvested and transplanted to the chest. A PAP flap also uses the skin and fat from the inner thigh but spares the muscle.
Tissue can be harvested from the upper or lower buttock to reconstruct a breast mound inferior gluteal artery perforator (IGAP) flap or a superior gluteal artery perforator (SGAP) flap. Gluteal tissue is less commonly used for breast reconstruction because the harvest of tissue from the buttock can cause a depression or deformity of the buttock. The fat harvested is also not as soft and pliable as the abdominal tissue.
Another option for breast reconstruction is the use of your back tissue, or latissimus dorsi flap. In this procedure, a part or all the latissimus back muscle along with a small piece of back skin and fat are rotated around the arm to the chest wall. The back tissue may not be enough to reconstruct the entire breast, so you may also need an implant or tissue expander. This type of reconstruction is often used if you had radiation to the breast and the radiated breast no longer safely supports an implant reconstruction. The healthy back muscle covers and supports the breast implant. Often a second procedure is required for exchange of the tissue expander to a permanent implant, see the information on implant reconstruction below. When the latissimus dorsi muscle is harvested most patients do not have any long-term functional deficits from use of the muscle. However, some highly competitive athletes that use this muscle, like swimmers, may have some noticeable shoulder weakness.
Implant Breast Reconstruction
Reconstruction using silicone breast implants is an option for many women, including patients who have had a skin-sparing mastectomy. Implant reconstruction can be an important alternative for women who are not good candidates for reconstruction using their own tissue.
This is a two-step process in which a breast tissue expander, (rigid silicone implant filled with saline) is placed under or above the chest muscle at the time of the mastectomy or in a separate surgery. Over the course of several office visits, your provider slowly inflates the implant with saline solution, allowing the muscle and skin to expand gradually. There may be some discomfort involved with the expansion process although it is not usually painful. This process may take several weeks. Once the tissue is stretched to the desired size, the tissue expander is left in place for approximately three months. Then you have a second-stage outpatient (you go home the same day) operation to exchange the tissue expanders for a permanent implant.
Some patients may be candidates for a procedure called, direct to implant reconstruction. This means that at the time of the mastectomy the permanent breast implant is placed instead of the tissue expander. Your physician can help you determine if this is an option.
It is important to know that implants are a prosthetic medical device and they are not meant to last a lifetime. Your implant may need to be removed or exchanged at some point in the future.
Reconstruction After Lumpectomy or Breast Conserving Therapy (BCT)
After your breast surgeon removes the tumor and surrounding tissue, you may be left with a depression in your breast. Fat grafting uses liposuction to harvest fat from your thighs or abdomen. The fat is then injected into the area of the breast that is depressed. Often multiple fat grafting procedures are needed to achieve the desired result.
If a significant segment of the breast was removed, we may be able to reconstruct the breast with an oncoplastic reconstruction. If your breasts are large enough, the plastic surgeon can rearrange and reduce the size of the breast while simultaneously filling the defect from tumor removal. The incisions used for oncoplastic reconstruction are similar to those used for regular breast reductions. This procedure may be done at the same time as your BCT or lumpectomy or in a second procedure a few weeks later. A reduction of the noncancerous breast and a breast lift may be performed at the same time for symmetry.