Breast Reconstruction

Breast reconstruction is performed after a mastectomy, usually for breast cancer. There are many decisions in the process that need to be discussed, and I will try to touch on some of the key options. Discuss each step with your surgeons -- both the surgical oncologist, who will do the mastectomy, and your plastic surgeon, who will do the breast reconstruction -- to make informed decisions about how your care will proceed.

Mastectomy
Mastectomy
Mastectomy is the removal of breast tissue from one breast. This is usually performed because cancer or pre-cancerous cells have been found in the breast. Often, the option exists to undergo a lumpectomy with radiation instead of a mastectomy. This is a personal decision, which depends on how large your breast is, the size of the area that needs to be removed, and how you feel about keeping your breast. Simply, the smaller your breast and the larger the area that needs to be removed, the more abnormal your breast is likely to look after the lumpectomy and the radiation is complete. Once a breast has been radiated, it is usually a bad idea to put in an implant. This may not be important to you now, but it can become an issue if cancer recurs in that breast, or if the breast is small and tissue has been removed and augmentation is desired. Please see capsular contracture below for more information on the effect of radiation on implants. Mastectomy may be recommended over lumpectomy if the area to be removed is large, if it is difficult for your breast surgeon to find the edge of the abnormal tissue (known as "close" or "positive" margins), or if the pathology indicates an underlying increased risk for cancer. Your breast surgeon may want to check your lymph nodes at the same time as the mastectomy by performing a sentinel lymph node removal (removing just one or two nodes) or removing many lymph nodes (with an axillary dissection).

Bilateral Mastectomy
Bilateral mastectomy -- the removal of breast tissue from both breasts -- is performed for various reasons. Sometimes, there is bilateral breast cancer. For patients with cancer found in only one breast, there is a slightly increased risk of breast cancer in the opposite breast, and some feel uncomfortable about the increased surveillance necessary to make sure that breast stays cancer free. How high the risk is depends on the type of cancer, your genes, and your family history of breast cancer or other cancers. If it is very high, your oncologist may recommend a bilateral mastectomy. From a cosmetic-only standpoint, implant-type reconstruction is usually simpler and more attractive after a bilateral mastectomy, because the breasts will match each other well. The disadvantages of a bilateral mastectomy compared to unilateral mastectomy are increased recovery time, length of operation, and potential impact on your life.

Skin-Sparing Mastectomy
For many patients, the skin-sparing mastectomy is possible. In this type of mastectomy, only the nipple and areola are removed from the breast skin, in addition to the breast itself. The nipple and the areola contain ductal breast tissue, and should be removed to decrease the cancer risk. If a skin-sparing mastectomy is possible for you, your plastic surgeon can usually give an almost scar-free result, if she or he closes the skin properly. If you undergo implant reconstruction, the plastic surgeon can use a small "purse-string" type of closure. Or if you undergo flap reconstruction, the surgeon can use a small amount of skin from the flap.

The wonderful result can be a scar-free breast after all the reconstruction has been completed. This type of surgery may not be right for you if you have a separate lumpectomy scar, if your cancer is very close to the skin, or if your surgical oncologist does not feel comfortable performing this surgery because of the small access it allows during the operation.

Reconstruction
TRAM Flap
TRAM flap stands for “transverse rectus abdominus myocutaneous” flap. Basically, excess fat is taken from your abdomen and used to recreate your breast.

“Transverse” refers to the horizontal ellipse of skin that is used from the abdomen, creating a tummy-tuck-like result with a low horizontal incision.

“Rectus abdominus” is the name of the muscle that is used for blood supply to the flap.

The flap is therefore made up of some muscle, and some skin and fat, or is “myocutaneous”.

There are two of these rectus muscles, visible up and down on either side of the belly button, and they give athletes the “six-pack” appearance. Blood vessels come through this muscle and into the fat above it. When the TRAM flap is performed, a section of the muscle or all of the muscle is used, and continues to be connected to the fat, even after it is in the breast. The muscle atrophies with time and is non-functional.

The “pedicled” TRAM flap is literally swung upward from the abdomen into the breast, never disconnecting the muscle, which is still connected to the upper abdomen.

The “free” TRAM flap is removed from the abdomen, and reconnected to a new blood supply in the chest or armpit.

Lastly, a new type of TRAM called the “DIEP” (deep inferior epigastric perforator) flap carefully spares the muscle and only takes the blood vessels from the abdomen. Each of these flaps take hours to perform depending on how complicated it is. Pedicled TRAM flaps, for example, take three to six hours to perform, depending on the surgeon. DIEP flaps, however, take six to nine hours to perform, and are only performed by surgeons specially trained in performing this flap.

TRAM flaps have the huge advantage of looking and feeling incredibly natural; after all, it is your own fat! The disadvantage is that the surgery involves your abdomen as well as your breast. Many patients, however, consider this to be an advantage, as it is a free tummy tuck. Your plastic surgeon will examine you and discuss whether you are a good candidate for one of these flaps.

Latissimus Flap
A latissimus flap uses a muscle from your back (latissimus dorsi) and the overlying fat to reconstruct the breast. The flap is simply swung forward from your back to your breast. In almost every case, an implant will also be necessary, because there is not as much back fat as there was breast tissue. Latissimus flaps look more natural than just implants alone. They are often a good option for patients needing radiation to their chest, or for those who have a history of radiation from a previous cancer.

Tissue Expanders and Implants
At the time of reconstruction, a tissue expander -- a silicone shell that has a port on it, which allows its volume to be adjusted -- is placed under the pectoralis muscle in the chest. The expander is used to slowly stretch the muscle and skin to provide space for a breast implant.

A small amount of saline is initially placed in the expander. Over the weeks following the surgery, a small needle is used to access the special port in the expander, and additional saline is put into the expander. This is usually a painless weekly process, as long as not too much saline is put in at each time. The process of expansion is usually complete after about two to four months. At that time, in surgery, the expander is removed and the final breast implant is put into place, using the old incisions. The muscle stays on top of the implant, which helps to hide the implant and make the breast look more natural. If you need chemotherapy, the expansion can take place while you recieve chemotherapy. Switching to the implants, however, cannot take place until two weeks or more after thte chemotherapy is complete.

Nipple reconstruction
Nipple reconstruction is usually performed in a second or third surgery, after your flap or implant is completed, and your skin has had some time to recover. The nipple can be reconstructed using adjacent skin, or using a skin graft from another location on the body. Alternatively, the nipples and areolae can be tattooed on, but this type of nipple reconstruction alone looks extremely flat.

Radiation and Breast Reconstruction
There are many extremely strong opinions out there concerning the timing of radiation with your reconstruction, and what type of reconstruction you may receive.

Some surgeons will only perform the reconstruction after your radiation therapy is complete. That way there is no radiation to the flap, if the flap type of reconstruction is used. Other surgeons will perform an immediate reconstruction, as the skin-sparing mastectomy is only possible if the reconstruction is done with the mastectomy, and that is such a cosmetic benefit.

Capsular Contracture
For all radiation patients and at all times, flap reconstruction is generally preferred, because there is a high risk of “capsular contracture” when radiation is used with implants. Capsular contracture is the tightening of the natural scar tissue around a breast implant. This makes the implant feel firm, look unnatural, and can even be painful. This contracture can occur at any time after the radiation, from months to years, if the implant is put in after or before the radiation is performed. Therefore, most surgeons use flap reconstruction, namely TRAM or latissimus flaps, because there is no possibility of contracture. Sometimes, however, implants are the only reconstruction option, and the risks of radiation must be weighed against the benefits of reconstruction. Discuss your individual case with your plastic surgeon.

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