Breast Reconstruction

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Breast Reconstruction Facts

Breast reconstruction refers to one or more operations performed to restore some of the components of the breast of women who have undergone mastectomy (removal of the entire breast). Breast reconstruction after mastectomy has evolved over the last several decades to become an integral component in the therapy for many women with breast cancer. A complete breast reconstruction includes recreating the breast mound, the nipple and areola complex so that the breasts are symmetric with regard to pigmentation, shape, size, projection, and position.

The goals of breast reconstruction include the following:

  • to provide permanent breast contour
  • to make the breasts look balanced
  • to give the convenience of not requiring an external prosthesis

Breast reconstruction can be performed using the following:

  • artificial material (silicone shell filled with either silicone gel or saline [a salt-water solution]) placed under the skin
  • The woman's own tissues (skin, muscle, fat) from another part of the body (flap reconstruction).
    • Pedicled flap: In this type of flap reconstruction, the tissues remain partially connected to the area of the body from which they are taken. Specifically, the original blood supply to the transplanted tissues is left intact.
    • Free flap: In this type of flap reconstruction, the tissues are cut off from the original area and grafted to the chest. The blood vessels are attached to establish a new blood supply is created for the grafted tissues.
  • a combination of artificial material and the woman's own tissues

Timing of breast reconstruction - Immediate versus delayed

Immediate breast reconstruction is reconstruction that is performed at the same time as the mastectomy. Delayed breast reconstruction is reconstruction that is performed weeks, months, or years after the mastectomy.

Surgeons differ in their opinions about when breast reconstruction should be performed. Some prefer to do it immediately after mastectomy, while others advise to delay breast reconstruction. If radiation therapy needs to be administered after mastectomy, then breast reconstruction is generally delayed until the skin in the treated area has healed. Excellent results can usually be achieved by either immediate breast reconstruction or delayed breast reconstruction.

The advantages of immediate reconstruction are that it avoids additional operation and general anesthesia at a later date, reconstruction is easier as the tissues are not damaged by scarring, and the breast skin retains the size and shape of the original breast.

The advantage of delayed reconstruction is that the woman has more time to consider the alternatives. After a mastectomy, many women choose a procedure recommended by the plastic surgeon and are more confident about the selection of the type of reconstruction. Additionally, these patients have a lower risk of a wound healing complication as a result of their reconstruction that could potentially delay the initiation of chemotherapy.

Women who choose immediate reconstruction have to make the decision at a time of great stress; however, for some women, the idea of having the breast tissue reconstructed immediately after mastectomy relieves much of the stress associated with mastectomy. Women who delay reconstruction may go through two periods of emotional readjustment: the first period is adjusting to the loss of a breast and the second readjustment involves accepting the reconstructed breast as their own.

Some types of reconstruction can be completed in a single procedure, whereas other types may require 2 or more operations to complete the reconstructive process.

Breast cancer awareness

What is Mastectomy?

Mastectomy vs Lumpectomy

Some factors that may influence a woman to choose a mastectomy over a lumpectomy are:

  • If the tumor is large and, after the lumpectomy, very little breast tissue would remain
  • If she does not want to undergo radiation therapy after the surgery
  • If she believes she will have less anxiety about a recurrence of breast cancer with a mastectomy

Breast Reconstruction Using Implants

Implants are designed to recreate the original breast shape and contour. A breast implant is a silicone shell filled with either silicone gel or saline. The implant comes in a variety of shapes and sizes. Silicone-filled implants are filled with either solid silicone gel or liquid silicone gel.

A tissue expander (balloon) is inserted beneath the skin and above the chest muscle either during the mastectomy procedure or at a later operation. The surgeon periodically injects saline into the balloon to gradually fill it over several weeks or months so that the overlying skin can expand. After the skin over the breast area has stretched enough, the tissue expander is removed in a second operation and a permanent breast implant is inserted. Some expanders are left in place as the final implant. Some women do not require tissue expansion before receiving an implant; for these women, the surgeon inserts an implant directly.

Because of concerns about the safety of silicone gel-filled breast implants, the Food and Drug Administration (FDA) has decided that breast implants filled with silicone gel may be used only in an FDA-approved clinical trial. Most plastic surgeons are able to provide a person with information regarding the use of silicone implants. If not, they should be able to provide a referral to a plastic surgeon in the area who participates in these trials.

Silicone gel-filled breast implants are preferred to saline-filled implants because they provide a more natural feel to the reconstructed breast. However, there have been some concerns about safety if silicone leaks from the implant. If a silicone implant ruptures completely, the implant has to be removed surgically.

Saline-filled implants have an advantage. If saline leaks out, one can easily recognize that a problem has developed for the breast mound and contour is lost. Silicone implant leak and rupture can be more difficult to identify. However, saline-filled implants do not have the natural feel of silicone-filled implants, so they have a less realistic appearance. Saline-filled implants are more likely to wrinkle or leak than silicone implants.

Flap Reconstruction in Breast Reconstruction

Flap reconstruction is a reconstructive surgery in which a flap of skin and fat with or without muscle is transplanted from a part of the body (for example, the lower abdomen, back, thigh, or buttock) to the chest area where it is shaped to form a new breast mound. Like the implant surgery, this operation can be performed at the same time as the mastectomy or it can be delayed.

Advantages of flap reconstruction include the following:

  • may eliminate the use of foreign material in the body
  • reconstructed breast usually looks and feels more natural
  • will last the woman's life span
  • when successful, requires minimal touch-up or redo operations throughout a woman's lifetime

Disadvantages of flap reconstruction include the following:

  • increased complexity and length of the surgery
  • may require a longer recovery period if muscle is included in the reconstruction
  • additional donor site scars

Because flap reconstruction involves small blood vessels, women who smoke or have diabetes, vascular diseases, or connective tissue diseases are usually advised that they are at higher risks of wound healing complications in both implant and flap-based reconstructions.

Some women may require an implant, in addition to the flap reconstruction, for recreating the breast.

If flap reconstruction is the selected option for reconstructive surgery, the surgeon must decide from which part of the body the required tissues are taken. The tissues for breast reconstruction can be taken from the following areas:

  • Back
    • Latissimus Dorsi Myocutaneous Flap: Pedicled rotational flap composed of skin, fat, and muscle
  • Abdomen
    • Transverse Rectus Abdominus Myocutaneous or TRAM flap: Pedicled rotational flap composed of skin, fat, and muscle
    • Free Transverse Rectus Abdominus Myocutaneous (Free TRAM) flap: Microvascular transplant of abdominal flap composed of skin, fat, and muscle
    • Deep Inferior Epigastric Perforator or "DIEP" flap: Microvascular transplant of abdominal flap composed only of fat and skin (muscle sparing)
    • Superficial Inferior Epigastric Perforator or SIEP flap: Microvascular transplant of abdominal flap composed only of fat and skin (muscle sparing)
  • Buttock
    • Superior Gluteal Artery Perforator or SGAP flap: Microvascular transplant of buttock flap composed only of fat and skin (muscle sparing)
    • Inferior Gluteal Artery Perforator or In-the-Crease IGAP flap: Microvascular transplant of buttock flap composed only of fat and skin (muscle sparing)
  • Thigh
    • Tensor fascia lata thigh flap: Microvascular transplant of thigh flap composed of skin, fat, and muscle
    • Lateral transverse thigh flap: Microvascular transplant of thigh flap composed only of fat and skin (muscle sparing)

Prior to mastectomy, all women should have the opportunity to meet with a qualified plastic surgeon to discuss breast implant and flap breast reconstruction options. The surgeon and the woman will discuss each alternative and choose the most appropriate one to meet the specific clinical requirements and personal preferences. However, if this did not occur, it is never too late to learn more about breast reconstruction. Many women who did not proceed with immediate breast reconstruction are still good candidates even years after their mastectomy.

More Flap Reconstruction in Breast Reconstruction

Latissimus dorsi myocutaneous flap

The latissimus dorsi is a broad muscle on the back. The latissimus dorsi myocutaneous flap reconstruction uses this muscle and the overlying fat and skin from the upper back to reconstruct the breast. The surgeon transplants this muscle and the overlying fat and skin with its blood supply to the front of the chest by tunneling it under the arm to the chest to create a breast mound. An implant is usually placed behind the muscle to provide volume and projection to the breast. This type of reconstruction leaves scars both from where the skin and muscle flap is taken, and on the reconstructed breast. The scar in the front is oval in shape, and the scar on the back is usually horizontal.

The latissimus dorsi myocutaneous flap reconstruction can generally recreate small to medium sized breasts. An implant (inserted during the same operation) is almost always necessary to create a breast of moderate size. Some women with large breasts may need to have a breast uplift procedure (mastopexy) or breast reduction in the other breast at a later date. Although not very common, some women may have weakness in their back, shoulder, or arm after the surgery.

Transverse rectus abdominus myocutaneous (TRAM) flap

The transverse rectus abdominis muscle is located in the lower abdomen between the waist and the pubic bone. In TRAM flap reconstruction, the surgeon transplants the muscle and the overlying fat and skin from the lower half of the abdomen to the chest area to form a breast mound.

There are 2 types of TRAM flaps:

  • Pedicled flap: This type of reconstruction involves leaving the flap attached to its original blood supply and tunneling it under the skin to the breast area.
  • Free flap: This type of reconstruction involves cutting and moving the flap of muscle, overlying skin, fat, and blood vessels from its original location and then grafting it to the chest wall using microsurgery to connect the blood vessels and nerves.

While the pedicled TRAM flap requires the transfer of the entire rectus abdominus muscle, the free TRAM flap requires the transfer of a small segment of the lower aspect of the muscle. The effect on the abdomen in both the pedicled flap and the free TRAM flap is a tightening of the lower abdomen ("tummy tuck"). The scar on the abdomen is usually horizontal and just below the bikini line. During the operation, the umbilicus (belly button) is repositioned. After the muscle of the abdominal wall has been removed, a mesh is commonly placed under the skin to strengthen the abdominal wall to prevent the development of a hernia (protrusion of the intestines).

The TRAM flap is a popular reconstruction option, especially for women with excess abdominal fat or an abdomen that has been stretched out by pregnancy. Also, abdominal tissue feels more like a natural breast to the touch. However, the new breast has little, if any, sensation. The option of the TRAM flap may not be available to women with back problems, women who smoke, women who do not have enough fat in the abdominal area, or women who have many surgical scars on the abdomen, including a prior abdominoplasty or tummy tuck.

Because this type of reconstruction involves the abdominal region, the initial discomfort may be greater and recovery takes longer than other flap reconstructions. Permanent weakness of the abdominal wall usually occurs. Although not very common, the grafted tissues may become infected or the blood supply may be reduced.

Free deep inferior epigastric perforator (DIEP) flap

In this type of flap reconstruction, only skin and fat (not muscle) is completely detached from the abdomen and transplanted to the chest area to form the breast mound. The free DIEP flap requires microsurgery to connect the tiny blood vessels to the deep inferior epigastric artery (blood vessel supplying the abdominal wall). The appearance of the new breast is usually good, and there is no risk of hernia because the fascia and muscle from the abdomen is not removed. The operation to reconstruct the breast using the free DIEP flap takes longer than a pedicled flap, about 6-8 hours. There is a chance (up to 5%) that the tissue in the area may die if the blood supply to the new breast is not good enough.

Free superficial inferior epigastric perforator flap (SIEP) flap

This type of flap is similar to the free DIEP flap except that the blood vessel used is the superficial inferior epigastric artery.

Gluteal free flap

In this type of reconstruction, skin and fat are cut off from the buttock region and transplanted to the chest to create the breast mound. This reconstruction also requires microsurgical techniques to reconnect the blood vessels. This flap is technically more difficult to perform, with a significantly higher complication rate than the free TRAM flap; therefore, it should only be performed by experienced microsurgeons specifically trained in gluteal free flap reconstruction. The SGAP procedure has a donor site incision high on the buttock region whereby the IGAP flap donor site incision is hidden in the natural crease where the buttock and upper thigh connect. These flaps are generally performed when a women lacks adequate abdominal wall fat to perform a TRAM or DIEP/SIEP flap or when the abdomen is scarred from previous surgical procedures.

Tensor fascia lata myocutaneous free flap

Skin, fat, and muscle from the lateral area of the thigh are used to reconstruct the breast mound. The major disadvantage of this type of flap reconstruction is the resulting scar at the donor site, which extends down the outer aspect of the thigh region and cannot be easily hidden. Nevertheless, this is an alternative for some women who cannot undergo other types of flap reconstructions.

Lateral transverse thigh Adipocutaneous free flap

Only skin and fat from the lateral area of the thigh are used in this type of flap reconstruction. The advantage of this technique over the tensor fascia lata myocutaneous flap is that no muscle is removed from the thigh and, therefore, the donor site contour deformity is relatively smaller. Usually, secondary liposuction for optimal contour of the lateral part of the thigh has to be performed.

Reconstruction of the Nipple and Areola in Breast Reconstruction

Once the breast mound has been reconstructed, the nipple and areola (pigmented area around the nipple) can be recreated approximately 2-3 months after the first breast reconstructive surgery. By that time, the swelling in the reconstructed breast reduces and the new breast settles into its natural sag. This enables the surgeon to position the nipple accurately, in line with the nipple of the other breast.

It is a relatively simple outpatient procedure. However, some women may decide not to have it performed because they feel that the reconstructed breast alone is sufficient.

A nipple can be created using skin from the following areas:

  • inner thigh
  • behind the ear
  • reconstructed breast
  • labia (the skin folds of the vulva, just outside the vagina)

The skin can be tattooed to match the other nipple and areola. Reconstructed nipple and areola have very little sensation.

Women who decide not to have nipple and areola reconstruction performed can consider the option of nipple prosthesis. Nipple prosthesis can be stuck to the reconstructed breast to give an even appearance. They can be bought ready-made or made to match the other nipple.

Contra-Lateral Balancing Procedures in Breast Reconstruction

Many women require surgery on the breast opposite of their breast cancer to achieve symmetry with their reconstructed breast site. Some women may require enlargement (breast augmentation) of the contra-lateral breast while others may require a breast reduction. Older women with ptotic breasts (that "droop") may require a mastopexy, or breast lift, in order to match the breast after reconstructive surgery. It is very important to discuss breast size prior to the first reconstructive procedure such that the reconstruction site may be designed with a woman's personal preferences guiding the surgical plan.

Surgical Complications in Breast Reconstruction

Wound healing complications including infection and contour or shape irregularities can occur with all forms of reconstruction. Infection can be higher with those forms of reconstruction that require the placement of breast implants or donor site mesh. Several physical conditions may place a woman at higher risk of infection and likely shape irregularities. These conditions include obesity, diabetes mellitus, smoking, connective tissue disorders, prior irradiation, or medical conditions that require a woman to take steroid medications. Bleeding requiring a blood product transfusion is relatively rare. However, small blood collections, or hematomas, may require a small operation to remove the blood and prevent future infection or poor shape to the surgical site. Collections of serum, or seromas, may accumulate in a flap reconstruction donor site, which may require aspiration with a needle and syringe in the doctor's office.

Other complications can include pain or lack of sensation in a flap donor site or breast reconstruction site. The abdomen can be weak following a TRAM flap as can the back and upper arm in the setting of a latissimus dorsi flap. Abdominal wall hernias can occur following TRAM or DIEP flaps, although they are less frequent in the DIEP flap reconstruction patients.

One significant complication of flap reconstruction is flap necrosis, where a portion of a flap reconstruction has poor blood supply. A woman can notice hard portions of her flap that may feel like the initial breast cancer. Women diagnosed with breast cancer should continue monthly self breast reconstruction site exams. Lumps felt in a flap based reconstruction should be brought to the attention of a woman's plastic and oncologic surgeon. Annual mammography of a reconstructed breast should be discussed with the surgical oncologist.

Breast implant reconstructions have been associated with numerous complications, the incidence of which increases with time and when the patient has required irradiation. Patients may develop pain at the reconstruction site as a scar develops around the implant. This is known as capsular contracture. This scar tissue may become so significant that the shape of the reconstructed breast is altered to such a significant degree that women may require additional surgical procedures to remove the scar tissue (capsulotomy or capsulectomy). Once a woman develops capsular contracture, she is at continued risk for recurrent capsular contracture requiring additional, repeat operations. It is not uncommon for patients with initial implant-based breast reconstructions complicated by capsular contracture to seek flap-based reconstructions. It is important for these women to seek information from qualified plastic surgeons who offer a complement of flap-based reconstructions when facing recurrent capsular contracture.

Breast implant reconstructions can also require additional surgical procedures to address implant wrinkling, folding, migration, inappropriate size, or deflation/leakage/rupture. The incidence of the problems should be discussed with the plastic surgeon.

As with all surgery, complications may occur such as heart attack, stroke, pneumonia, kidney problems, and the formation of blood clots in the legs or lungs, and potentially death. All women should have a complete physical exam and discussion of the development of these possible medical problems with their treating physicians prior to any form of surgery, including breast reconstruction.

Postoperative Drains in Breast Reconstruction

Most reconstructive surgeons use drains in the reconstructive and flap donor sites after surgery. Nurses in the hospital, in addition to the surgeon, will instruct the patient as to the daily care of these drains. It is important for the patient to strip the drain of any thick contents multiple times during the day to keep the drain tube from becoming blocked. It will also be important for the patient to measure the amount of fluid that collects in a drain over a 24-hour period. When the amount of fluid is decreased, it will be an indicator that the drain can be removed. Some surgeons will want the patient to be on a low dose of an antibiotics while the drains are in place. It is important that the patient takes the medication as prescribed. Additionally, surgeons may have specific instructions for their patients regarding the appropriateness of showering while drains are in place. Please ask the plastic surgeon or the office staff for showering limitations.

Postoperative Garments in Breast Reconstruction

Most plastic surgeons have very specific recommendations regarding postoperative garments, specifically bras and girdles. Please consult with the plastic surgeon regarding any changes in the garment selection. The timing of converting to an underwire bra or discontinuing a compressive girdle may have distinct implications to wound healing.

Reviewed on 11/20/2017

Medically reviewed by John A. Daller, MD; American Board of Surgery with subspecialty certification in surgical critical care

REFERENCE:

"Overview of breast reconstruction"
UpToDate.com

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