Breast Cancer Reconstruction - Latest Options After Mastectomy

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.

“Immediate” breast reconstruction is performed at the same time as the mastectomy. Advantages include: preserving most of the patient’s breast skin, a shorter and less obvious mastectomy scar, and waking up with the new breast already in place. It also generally provides the best cosmetic results particularly when combined with nipple-sparing or skin-sparing mastectomy.

Some patients do not have access to a reconstructive surgeon at the time of the mastectomy. Other patients are advised to avoid immediate reconstruction because radiation therapy is likely after the mastectomy. In these cases, the reconstruction can be performed some time after the mastectomy. This is known as “delayed reconstruction”.

Tissue expander reconstruction is the most common method of breast reconstruction in the United States. Most plastic surgeons perform this as a two-stage procedure. The expander is used to stretch the skin envelope and create the size of breast the patient and plastic surgeon desire. The expander is replaced by a permanent breast implant (saline or silicone) at a separate procedure some time later. Some patients are candidates for one-step implant reconstruction (without expanders): a permanent breast implant is inserted immediately without going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and an acellular dermal graft (like Alloderm or FlexHD). These grafts are cadaveric tissue implants that provide support and increase the amount of padding over the implant.

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.

DIEP flap breast reconstruction has replaced the TRAM flap as today’s gold standard in breast reconstruction. The DIEP flap uses only skin and fat. This is disconnected from the lower abdomen and reconnected to the chest area using microsurgery to create a new breast. Since all the abdominal muscles are saved, patients do not have to sacrifice their abdominal strength. They also experience less pain and have a quicker recovery than TRAM patients. The risk of abdominal bulging and hernia is also very small. The SIEA flap is a variation of the DIEP flap. It is associated with an even easier recovery and a 0% hernia risk but requires specific anatomy which not all patients have. Like the TRAM, the DIEP and SIEA procedures also provide a simultaneous tummy tuck.

Women who do not have enough abdominal tissue for reconstruction may be eligible for the GAP (buttock) or TUG (upper inner thigh) flap procedures. The resulting scars are generally easily hidden by most underwear.

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, particularly DIEP breast reconstruction. He and his partners perform 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 cancer reconstruction community!