Breast Reconstruction
Breast reconstruction is a procedure that restores one or both breasts to a natural shape, size, and appearance.
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Many women desire to have their reconstructed breast(s) be similar to their original breast(s), but each patient can choose how she would like the results of her reconstruction to look and feel. If only one breast needs reconstruction, a breast lift, breast reduction, or breast augmentation can be performed on the opposite breast to make the breasts as symmetrical as possible.
Breast reconstruction can help reduce the physical and emotional effects of having partial or all breast tissue removed by restoring a more feminine shape to the breast and improving the woman’s self-image. Choosing to undergo breast reconstruction is a highly personal decision, and patients should decide based on their own desires rather than outside influences.
The Benefits of Breast Reconstruction
Breast Contour
When breast surgery causes distortion of one breast after mastectomy or partial mastectomy, breast reconstruction can create a breast mound or restore its normal contour. It can provide improved symmetry to the breasts so that they look similar under clothing or in a bathing suit and in many cases very similar without any clothes.
Improve Self-Esteem and Body Image
The battle women undergo to beat the disease leaves them with scarring and constant reminders of that upsetting time. Nothing can completely take that away but a proper reconstruction can partially erase the physical reminders of the disease. It can help bring back hope and inspiration to others in similar situations.
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Reasons to Undergo Breast Reconstruction
Total Mastectomy
Mastectomy is one of the most common treatments for breast cancer, and it involves the surgical removal of breast tissue. Patients who are at a high risk of developing breast cancer may also undergo this procedure as a preventive measure. One or both breasts may be removed. Depending on the patient’s individual circumstances, breast reconstruction may be performed at the same time as the mastectomy, or reconstruction may be delayed until after the patient has healed and/or additional cancer treatments have been performed. This can come in the form of implants or autologous tissue to recreate a breast mound.
Partial Mastectomy
Partial mastectomy removes only a portion of the breast to rid a woman of the disease. This is accomplished by coring out a piece of breast tissue which includes the cancer. It can be located in any area of the breast therefore occasionally requires complete rearrangement of the remaining breast tissue to provide the most optimal shape.
Nipple Reconstruction
There are various techniques available to preserve or reconstruct the nipple and areola. Depending on where the cancer is located the nipple and areola may have to be removed with the breast tissue and skin. In these cases the nipple and areola can be tattooed or reconstructed when autologous tissue is used for the breast reconstruction.
Breast Reconstruction Options
Expander and Implant Reconstruction
A tissue expander is temporarily inserted into the breast pocket to stretch the breast tissue so that it can adequately cover an implant. Over the course of several weeks, the expander is progressively filled with a saline solution through an internal valve. Once the breast tissue is stretched enough, the expander is replaced by a breast implant. This technique takes longer to achieve the final breast reconstruction than the tissue flap method, but it allows for an easier recovery.
Tissue Flap Reconstruction
This method of reconstruction uses tissue from another area of the patient’s body, such as the back, thigh, or abdomen, to reconstruct the breast mound or to provide enough tissue to cover an implant. The new breast tissue may remain connected to the original blood supply through blood vessels tunneled beneath the skin to the donor site, or it may be detached and rely on the growth of new blood vessels.
Immediate Reconstruction
The breast reconstruction process can start at the time of your mastectomy (immediate reconstruction). Immediate reconstruction can be performed by placing a silicone implant at the time of mastectomy. The skin that is left behind after removal of the breast tissue would need to be healthy enough to tolerate the weight of the implant. Autologous tissue can also be placed in an immediate reconstruction at the time of mastectomy.
Delayed Reconstruction
Should there be any question as to its viability of the skin then a tissue expander is placed to allow the skin time to heal and the permanent implant replaces the expander later (delayed reconstruction). Autologous tissue can also be used to replace the tissue expander (delayed reconstruction). If there are plans to undergo radiation a delayed reconstruction is also recommended. You can expect several appointments over two to three months after your initial surgery in order to expand and stretch the skin on your chest in preparation for the implant or autologous tissue.
Second Stage Reconstruction
Primary reconstruction, whether immediate or delayed, is the reconstruction that is completed after the permanent implant or autologous tissue is placed. The breast reconstruction process then can proceed to a second stage to allow for adjustments to the reconstruction by fat grafting or rearrangement of the autologous breast flap.
Latissimus Dorsi Muscle
This procedure is one of many autologous options and can be performed immediately during the mastectomy or delayed. The latissimus muscle is a very large vascular muscle in the back that is attached at the back of the arm, extends down the lateral chest from the arm past the shoulder blade and attaches close to the spinal column. It entails releasing the muscle from the back with a portion of skin attached. The flap is passed through a tunnel underneath the axilla and sutured to the anterior chest to fill the defect site. An implant or tissue expander, then later an implant, can be placed underneath the flap for additional volume. The latissimus flap is used as a secondary option when the abdomen is not available.
Latissimus Dorsi Muscle
This procedure is one of many autologous options and can be performed immediately during the mastectomy or delayed. The latissimus muscle is a very large vascular muscle in the back that is attached at the back of the arm, extends down the lateral chest from the arm past the shoulder blade and attaches close to the spinal column. It entails releasing the muscle from the back with a portion of skin attached. The flap is passed through a tunnel underneath the axilla and sutured to the anterior chest to fill the defect site. An implant or tissue expander, then later an implant, can be placed underneath the flap for additional volume. The latissimus flap is used as a secondary option when the abdomen is not available.
Pedicled TRAM flap
A TRAM flap uses all or a portion of the rectus abdominis muscle along with fat and skin from your lower abdomen to reconstruct a breast. The portion of the muscle that is used as part of the flap carries with it the blood supply and is how the flap survives. The flap is tunneled up through the abdomen and chest to create the breast mound. Since the muscle is sacrificed, you may experience some abdominal weakness or have difficulty performing sit-ups. This technique is not commonly used because of the morbidity of losing muscle function and support.
Free TRAM flap
Like the TRAM flap, the free TRAM flap also uses the blood supply through the rectus abdominis muscle. However, in this flap the muscle does not get tunneled rather the artery and vein are divided. The muscle is also divided on both ends and the entire flap is then transplanted to the chest. The blood vessels from the muscle are connected to blood vessels in the chest using a microscope. The advantage is tunneling is not required and the flap has more freedom to mold it into a breast mound.
DIEP flap
The DIEP flap utilizes the same lower abdominal skin and fat as the TRAM and free TRAM flap; however, it spares the rectus abdominis muscle and fascia completely. The small blood vessels – an artery and a vein – that come through the muscle to the skin and fat are identified; these vessels are then dissected through the muscle prior to being divided. Once they are divided, the tissue is again transplanted to the chest and the vessels are connected to blood vessels in the chest. Since your muscle is preserved, there is a lower risk of abdominal weakness or hernias and less postoperative pain.
SIEA flap
The SIEA flap also uses the lower abdominal skin and tissue, but the blood vessels that supply this flap do not go through the abdominal muscle. Rather, they only go through the fat. Advantages of this flap include preservation of the abdominal muscles, resulting in less postoperative pain and a speedier recovery. However, these blood vessels may not be present in all women; and even when present, may be too small to provide a reliable blood supply for a flap.
Gracilis-based flaps
These flaps are based on the gracilis muscle, located in the upper inner thigh. It is a small muscle and its function is to adduct the leg. There are other muscles that provide the same function so the loss of the gracilis is minimal to negligible. The muscle along with a portion of skin and fat overlying the muscle is taken along with the blood vessels supplying the flap and detached and reattached into the chest to recreate the breast. Reattachment of these blood vessels requires using microsurgery.
The skin and fat can be oriented transversely, vertically or diagonally and this is how the flaps are named: Transverse Upper Gracilis flap (TUG flap), Vertical Upper Gracilis flap (VUG flap), and Diagonal Upper Gracilis flap (DUG flap).
The choice of flap depends on thigh shape and surgeon’s experience. Of the three the transverse upper gracilis flap is the only one that can conceal the scar in the crease of the thigh. These flaps result in a tighter inner thigh, similar to an inner thigh lift.
PAP Flap
A PAP flap is similar to the gracilis-based flaps, however the skin and fat from the thigh can be from the back of the upper thigh or the inner thigh to reconstruct the breast using microsurgery. Unlike the gracilis flap the PAP flap requires no muscle.
Thigh-based flaps do tend to have more healing problems at the donor site than abdominal-based flaps due to the location of the incision. Lower leg swelling may occur but usually resolves with time.
When one thigh-based flap is used to reconstruct one breast, asymmetry may result due to tightness and thinness of one thigh. Additional procedures may be recommended to improve symmetry between the thighs.
SGAP and IGAP
These are gluteal-based flaps that use skin and fat from the upper buttocks or lower buttocks. These also fall in the category of free flaps because they are removed along with blood vessels that supply that area of skin and fat and reattached to blood vessels in the chest after removing a portion of rib. Both of these flaps are removed without any muscle. The choice of incision and flap depends on the buttock shape and surgeon’s experience. The SGAP is more desirable as it conceals the scar in the upper buttock similar to a butt lift and gives the same tightening effect.
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Special notes regarding recovery
Because free flaps involve microsurgical transfer of the tissue, hospital admission is required for close monitoring. The hospital stay is typically 2-3 days. Reoperation and return to the operating room if there are concerns about the flap and its blood supply may be required.