Breast reconstruction is not a cosmetic procedure. It’s a right every woman has when faced with mastectomy after breast cancer. Fortunately, there are several reconstructive options.
When the breast reconstruction is performed at the same setting as the mastectomy it is referred to as “immediate” reconstruction. The biggest advantage of immediate reconstruction is that the patient wakes up from the surgery still “whole” and completely avoids having to live without a breast. Other advantages include shorter scars and, generally speaking, a better cosmetic result.
“Delayed” reconstruction generally takes place after the mastectomy has healed. Many times patients required to undergo radiation following their mastectomies are advised to delay reconstructive surgery in order to achieve the best results. It is common to wait several months after the last radiation therapy session before proceeding with reconstruction to allow the soft tissues to recover completely from the radiotherapy.
The most common reconstructive procedure in the US is implant reconstruction. This is typically performed as a two-stage process. The first surgery involves placement of a temporary implant (tissue expander) which is used to obtain the desired breast size. Tissue expanders can be placed at the same time as mastectomy or at a later date. Several weeks after the desired size is achieved, the expander is replaced by the permanent implant at another surgery. Some surgeons perform implant reconstruction as a single stage surgery placing the permanent implant at the same time as the mastectomy. This is known as the “one-step” procedure. Not all women are candidates for this.
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 procedure uses muscle (latissimus dorsi), fat and skin from the back (below the shoulder blade) that is brought around to the chest to create a new breast. Many patients also need an expander or implant to obtain a satisfactory result in terms of size. Patients typically have a scar on their back that can be seen with some low-cut clothing. Women who are very active in sports may notice some strength loss with activities like golf, climbing, or tennis.
A more attractive option for many women is the TRAM flap procedure. This uses tissue from the lower tummy, rather like a “tummy tuck”. Skin, fat and part of the sit-up (rectus) muscle is transferred to the chest to recreate the breast mound. Advantages include a natural reconstruction along with an improved abdominal contour. Disadvantages include loss of abdominal strength and a risk of abdominal bulging (“pooching”) or hernia.
The DIEP flap is the latest evolution of the TRAM flap. It provides all the advantages of the TRAM while decreasing the risks. Like the TRAM, it provides a very natural breast reconstruction which is warm and soft and ages with the patient. However, the DIEP preserves all the abdominal musculature so is associated with a lower rate of abdominal bulging and hernia. Since the muscle are preserved, recovery is also easier and abdominal strength is maintained long term.
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.
Unfortunately, advanced microsurgical procedures like the DIEP, TUG and GAP procedures are complex, require extra training and generally are not well reimbursed. For these reasons, they are not routinely offered by plastic surgeons in this country and most patients have to travel to centers specializing in these breast reconstruction surgery options.
Dr Chrysopoulo is a board certified plastic surgeon specializing in advanced breast reconstruction procedures, particularly DIEP flap breast reconstruction. Over 500 DIEP flaps per year. In-Network for most US insurance plans. (800) 692-5565. Are you a Facebook fan? Connect with others touched by breast cancer in our FB breast reconstruction community!