Breast Reconstruction
Following a mastectomy, your chest wall will be flat where the breast was removed. The shape of the breast can be restored, however, by wearing an artificial breast form (prosthesis) in a special bra or through reconstructive surgery. A plastic surgeon can rebuild the breast using your own tissue or an artificial breast implant.
Making the decision
The decision to have reconstructive surgery is totally up to you. Some women do not want to undergo more surgery. Other women choose to have reconstructive surgery for numerous reasons. They may feel uncomfortable seeing their body without abreast or find a prosthesis uncomfortable to wear or inconvenient to use.
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When?
During mastectomy surgery or later?
Reconstructive surgery can be done at the time of the mastectomy or delayed until months or years after the mastectomy. Your doctor may recommend delaying reconstruction if you will need future treatments, such as radiation or chemotherapy, or if you have health or other problems. Consider the following when making your decision about when or if to have reconstructive surgery.
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How?
The breast shape can be surgically recreated in one of two ways:
- Using your own tissue: A tissue flap, often taken from the abdomen or back, is moved to the chest to create the breast shape
- Using an artificial implant: The implant, much like those used in breast enlargement surgeries, is placed behind the pectoralis muscle of the chest.
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Autologous Tissue Flaps
Using your own tissue to reconstruct the breast
Autologous reconstruction uses your own body taken from various sites in the body (such as the abdomen, back or buttocks) to create the breast. There are three ways tissue flaps can be created: attached flaps, free flaps and perforator flaps.
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Attached TRAM flap
The attached abdominal tissue flap is the most common autologous reconstruction performed. It is also known as the TRAM flap (Transverse Rectus Abdominis Myocutaneous, the tissue used to reconstruct your breast). TRAM flap surgery can be done to recreate one or both breasts. Tissue and muscle taken from the abdomen are used to recreate the breast.
How does it work?
During the initial surgery, an incision is made from hip to hip at the bikini line, right above the pubic area. The surgeon then cuts the lower end of the rectus abdominis muscle on the side opposite the new breast. The surgeon rotates the muscle and tunnels it up under the skin to the chest area to create the new breast. The upper part of the muscle remains attached in its original position to provide blood to the tissue flap. Skin and fat are also transferred from the abdomen to the new breast to provide fullness and skin coverage. If both breasts are to be reconstructed, both rectus abdominis muscles are used, along with additional fat and skin from the abdomen.
Recovery
Recovery from TRAM flap surgery takes time. Your activities will be limited to allow the abdominal incision time to heal. You will also have several drains inserted in the reconstructed breast and the abdomen to remove fluid that accumulates. You will be given medication to help manage any pain or discomfort. You can slowly return to normal activities and should be back to most of your regular activities after about two months.
Possible complications
Although uncommon, several complications can occur following TRAM flap reconstruction.
- If the blood supply to the new breast becomes restricted, the tissue can become hard or thickened. This is called necrosis and will not harm you.
- Fluid can collect in the new breast or abdomen forming a seroma (clear fluid) or a hematoma (bloody fluid). The body may reabsorb the fluid on its own, or it may need to be drained with a needle.
- Infections at the breast or abdominal incision can occur. They can be treated with antibiotics.
- As you heal and return to normal activities, you may find that some of your activities are limited due to weakened abdominal muscles. Most women do not have difficulty adjusting.
- Occasionally the loss of abdominal muscles will result in a hernia. Hernias occur when intestines slip through muscles and create a bulge, which is sometimes uncomfortable. A hernia may need to be surgically corrected.
- Occasionally other lumps will form in the abdominal wall or the new breast due to the trauma of the abdominal tunneling. Such lumps may soften with time.
Free TRAM flap
A free TRAM flap is similar to a traditional or attached TRAM flap, but less muscle is required.
How does it work?
A portion of the rectus abdominis muscle, along with fat and skin tissue, is completely removed from the lower abdomen and moved to the chest to create the new breast. (With a traditional TRAM flap, the upper portion of the rectus abdominis muscle is left attached in its original position.) The blood vessels of the relocated muscle are reconnected to the blood vessels the underarm.
Free TRAM flap compared with traditional TRAM flap
Advantages
- Since a smaller portion of muscle is used, abdominal strength and function are not affected as much and the risk of hernia is lower.
- Recovery from a free TRAM flap may be faster, although surgical time is usually longer.
- There is a greater chance that the blood flow to the breast may be reduced since the blood vessels of the muscle must be reconnected to the blood vessels in the underarm. Although it does not happen often, some or all of the tissue in the flap may die if the blood flow is severely reduced. This may require further surgery to correct.
Perforator or DIEP flap
In DIEP (Deep Inferior Epigastric Perforator) flap reconstruction, no muscle is removed. Instead, the plastic surgeon locates the blood vessels in the abdomen that supply blood to the fat and the skin of the lower abdomen. Only these blood vessels, and the skin and fat these blood vessels feed, are removed and moved to the chest to form the new breast. The abdominal muscles are left in place. The blood supply must be carefully reconnected to blood vessels in the armpit and/or along the breastbone to keep the fat and skin of the new breast healthy.
DIEP flap compared with TRAM flap
Advantages
- Because the abdominal muscles are not
disturbed, recovery from DIEP flap surgery may be faster and easier. - The risk of a hernia is very low and abdominal muscle strength is maintained.
- Women may have more sensation in their reconstructed breast with the DIEP flap.
- Due to the complexity of reattaching the small blood vessels, DIEP flap surgery requires more time.
- If the flap does not receive adequate blood flow after surgery, some or all of the flap tissue may die and further surgery may be required.
- This type of reconstruction is still new and not performed by many plastic surgeons. It may be difficult to find a local surgeon to perform the surgery, which may result in additional costs.
Other tissue flaps
Other areas of the body can also be used for autologous tissue reconstruction. These alternate flaps may be used in women who do not have enough abdominal tissue for reconstruction, have back injuries and need to keep their abdominal muscles, had prior abdominal surgery, or wish to maintain their abdominal strength for a variety of reasons.
Latissimus dorsi flap The latissimus dorsi is the muscle that runs below the shoulder in the back. Similar to TRAM flap surgery, the latissiumus dorsi muscle is cut and tunneled under the skin to the chest, along with skin and fat from the back. The skin and tissue of the back are not quite the same as the breast, so the reconstructed breast may look and feel a little different. A breast implant is often necessary to create a fuller breast. Muscle strength in the shoulder and back may be weakened, but most women adjust without much difficulty. Recovery from the surgery may be easier than when an abdominal flap is used.
Gluteal flaps
Gluteal flaps come from the buttock and are done as free flaps similar to the free TRAM flap. They can also be done without muscle, similar to the DIEP flap, in which case it is called an S-GAP flap, Superior Gluteal Artery Perforator. Gluteal flaps produce very realistic reconstructed breasts. Minimal muscle is used so strength is not impaired. Due to their complexity, however, a gluteal flap usually cannot be done at the time of the mastectomy. Two procedures are necessary to reconstruct both breasts. The gluteal or sciatic nerves that supply sensation to the buttock or thigh can also be temporarily or permanently damaged during the reconstruction.
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Breast Implants
Breast reconstruction with breast implants
Breast implants are made of an outer shell of silicone-based plastic. Permanent implants are filled with saline (sterile water similar to our own body fluids) or with silicone. The saline filled implants feel firmer, while silicone feels more like natural breast tissue. Implants come in two basic shapes, round or teardrop. The size of the implant depends upon the amount of saline or silicone in the implant and is typically described by bra cup size.
How does it work?
Artificial breast implants are placed behind the pectoralis muscle in the chest. Usually, two or three surgeries are needed.
During the initial surgery, a temporary tissue expander is placed under the pectoralis muscle. This can be done at the time of the mastectomy or any time afterwards. The tissue expander is a collapsed implant that can be filled with fluid (saline) over time through a "port" under the skin. Its purpose is to slowly stretch the muscle and skin to hold the permanent implant. Fluid is added to the expander every one to two weeks until the desired size is achieved. Once the chest wall is stretched sufficiently, a second surgery is performed.
During the second surgery, the expander is removed and the permanent implant is inserted. The nipple and areola can be added through further outpatient procedures. Both the initial surgery to place the expander and the surgery to replace the expander with the permanent implant take about one to two hours.
Possible complications
- Infection or fluid collection: as with any invasive surgery or procedure, you can develop an infection or collection of fluid (clear fluid or blood) at the implant shortly after surgery. These complications may require treatment with antibiotics or removal of the fluids, but rarely require the implant to be removed (if removed, the implant can usually be replaced at a later time).
- Necrosis: the death of the tissue around the implant usually due to poor blood flow to the tissue after the operation. It rarely happens with breast implants and usually does not harm the woman. However, it may leave the breast feeling hard and may distort the look of the breast.
- Capsular contracture: the development of scar tissue around the implant that distorts or changes the shape of the breast. If severe, the capsular contracture may be uncomfortable or painful. Capsular contractures can be corrected surgically by removing the scar tissue and replacing the implant, but they may re-occur.
- Ruptures or leaks: although it doesn’t happen often, breast implants may leak or rupture, spilling the saline or silicone into the surrounding tissues. Leaking usually occurs due to injury, age of the implant or for unknown reasons. The implant must be replaced if leaking occurs. Breast implants may need to be replaced over time to prevent leakage.
- Pain: any of the above situations can cause pain. Occasionally, women develop chronic pain following reconstruction that cannot be explained, but it can be treated.
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Updated 5/18/06
The information in this section will help you plan and prepare for your treatment. However, it is not meant to replace the individual attention, advice, and treatment plan of your oncologist and medical team.
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