Types of Breast Reconstruction

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Types of Breast Reconstruction

The three main types of breast reconstruction are:

  • Reconstruction Using Implants
    • Uses an implant filled with silicone gel or saline to recreate the breast mound.
  • Autologous Reconstruction
    • Breast mound built using tissue "borrowed" from another part of your body.
  • Autologous Tissue with Implant
    • Use of a smaller tissue expander/implant with your own tissue

Breast Reconstruction Using Implants

This can be done in one or two stages. One-stage implant reconstruction is an option for certain women. This is done through a collaborative approach between the breast surgeon and the plastic surgeon. This option is best for women with small to moderate sized breasts, good quality of skin tissue, for women having mastectomy for an early stage disease, or for prevention due to a high risk profile.

The plastic surgeon will place the adjustable implant under the skin and muscle just like a traditional tissue expander, and fill the device over time with saline. The device is designed and engineered as a permanent implant. When the ideal volume is achieved, the plastic surgeon can remove the fill tube and close the internal valve in a clinic setting, leaving the device as the permanent implant. The advantage of single-stage implant reconstruction is that only one surgery, one general anesthesia, and one recovery period is required.

Another form of a one-stage implant reconstruction is using a material called Acellular Dermal Matrix (ADM). This procedure involves the breast implant being placed under the muscle of the chest and then secured in place with an ADM to provide a hammock-like support for the breast implant. Two common ADMs in use today are Alloderm® and FlexHD®.

What are ADMs?

ADMs are made from the skin from a human body (donated cadaveric skin) that have been specially prepared for your body to accept it. There have been no reports of infection or disease transmitted by ADMs during breast reconstruction.

In two-stage implant reconstruction, the breast mound is first created by placing a saline-filled tissue expander under the skin and muscle of the chest. Because the skin and breast tissue are removed at the time of mastectomy, it is usually necessary to stretch the remaining skin and chest muscle before inserting the permanent breast implant. The temporary implants (tissue expanders) achieve this gradual inflation using saline injections. The expansion procedure is repeated about six to eight times during weekly or biweekly office visits.

Approximately 12 to 24 weeks after the last expansion, the tissue expander is replaced with a permanent implant. This is performed under general anesthesia as an outpatient surgical procedure. The expanded skin is fashioned into the final breast shape during this procedure. It is also convenient to reduce or lift the opposite breast at the same time, if desired.

Autologous Breast Reconstruction Surgery

Autologous tissue breast reconstruction uses the patient's own tissue to create a breast mound. This method of reconstruction can generally achieve a more durable and natural-appearing result than reconstruction based on prosthetic implants alone. Complete restoration of the breast mound in a single stage is possible in most patients. There is now a large array of choices for autologous tissue breast reconstruction.

Abdominal tissue reconstruction

This method uses the patient's own abdominal tissue to construct a new breast mound. There are two major ways in which the abdominal tissue can be transferred to the chest to build a breast: pedicled (tunneled) or free (completely removed and then microsurgically reattached). Although both methods result in similar breast and abdominal scars, there are some major differences between them.

  • Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
    • This method relies on the rectus muscle as a carrier for blood supply to the lower abdominal skin and fat. After the flap has been harvested, a tunnel under the skin is made between the abdomen and the mastectomy defect to relocate the abdominal flap to the chest. Since the entire rectus muscle is used with the strong covering over the muscle for the reconstruction, the abdominal donor site is closed using either sutures or using a permanent mesh (a strong artificial material) to re-establish abdominal strength.
  • Free Deep Inferior Epigastric Perforator (DIEP) Flap
    • This procedure is an evolution from the pedicled TRAM flap and is only performed in select centers with microsurgical expertise. Since the lower abdominal tissue must be completely detached from the body and transferred to the chest, microsurgery is required to restore circulation to the transplanted skin and fat. The two biggest improvements of this technique over pedicled TRAM flaps are:
      • Virtually no or little rectus muscle is disturbed to better preserve abdominal strength following surgery.
      • The flap is completely removed from the abdomen and reattached to the blood vessels in the chest which provides better blood supply to the new breast.

Gluteal and thigh free flaps

One of the primary reasons for the use of alternate flap includes inadequate abdominal fat in a slender patient or previous abdominal surgeries that have disrupted the blood supply to the abdominal tissues.

The ample soft tissue of the gluteal region make the free gluteal flap a reasonable second or third line option for creating a breast mound. Although this method is more limited in its ability to create a breast that is large, the reconstructed breast will be soft and have a natural shape. There is flattening at the buttock donor site, which can be noticeable in normal clothing.

The Transverse Myocutaneous Gracilis (TMG) flap is taken from the inner thigh region, the same distribution as in a cosmetic inner thigh lift. Part of the gracilis muscle is taken to provide the blood supply to this flap; this is usually not missed following its removal. This flap is used to create a smaller sized breast and almost no contour abnormality can be expected in the inner thigh following this flap.

Autologous Tissue with Implant Breast Reconstruction

This type of breast reconstruction requires the use of a smaller tissue expander/implant with your own tissue because of the limited volume of your back tissue.

Latissimus Dorsi Flap

This flap borrows muscle and skin from the upper back. The tissue, while still partially attached to the body, is tunneled underneath the skin from the back to the chest. Although this method provides much of the needed skin, there is not enough tissue volume to form the breast mound by itself. Therefore, either a tissue expander or implant can be used to stretch the transferred muscle and skin from the back. At a later stage, the tissue expander is replaced with a permanent implant. This procedure is most commonly performed if you have had a mastectomy on one of your breasts followed by radiation and do not meet the criteria for a TRAM or DIEP flap. This procedure is not recommended if you perform a lot of repetitive or strenuous overhead activities with your arms.

Matching the opposite breast (optional)

A reconstructed breast will not precisely match your natural breast. If you have large breasts, you may need a reduction of your opposite breast in order to match the reconstructed breast. If you have smaller breasts that sag, you may need a lift of the natural breast or augmentation with an implant to improve the shape and facilitate symmetry. Both reductions and lifts leave permanent scars on your breasts. The precise location of the scars and technique used to balance the breasts will be explained in great detail by your plastic surgeon when planning for this stage.

Reconstruction of the nipple and areola (optional)

It is preferable to allow your reconstructed breast to "settle" for at least 3 months so that the nipple and areola can be placed in the proper position. Nipple/areola reconstruction is done as an outpatient surgery, usually only with local anesthesia. This procedure usually involves very little discomfort.

The nipple may be made from the tissue and fat of the reconstructed breast. If the nipple of your natural breast is prominent, then a portion of it can be used as a graft to make a new nipple for the reconstructed breast in a procedure called "nipple share". The nipple may also be made using a small wedge taken from the labial region especially in patients where there may be undesirable redundant labial tissues. The areola can be made from a skin graft taken from your abdominal scar (if you had a TRAM/DIEP) or from your inner thigh crease.

The finishing touch in nipple/areola reconstruction is a tattoo procedure to match the color of your natural nipple and areola. This can be done either in a minor procedure room or by a medical tattoo artist several months following the nipple/areola reconstruction.