What type of breast reconstruction is right for me?

The best method of reconstruction for you depends on several factors, including:

  • the size and shape of your breasts
  • whether one or both breasts have been removed
  • the amount of body tissue in the potential donor sites such as: abdomen, thigh, and buttock
  • whether you have received radiation therapy or will be getting it in the future

Your plastic surgeon will recommend one or more options to you based on these factors.

What are the different types of breast reconstruction?

There are three main types of reconstruction:

1) Reconstruction Using Implants

This is generally done in two stages. In the first phase, your plastic surgeon will insert a tissue expander below your pectoralis (chest) muscle. The tissue expander is a pocket that will stretch out your chest skin and muscle. After your incisions have healed (in about two weeks) you will receive expander inflations. A needle will be used to inflate your expander with a saline (salt-water) solution. You will have inflations every one to two weeks for up to three months. After the inflation process, the skin will need to rest for at least three to six months. A second, shorter surgery will be performed to switch the tissue expander for a permanent implant (silicone or saline).

2) Reconstruction Using Your Own Tissue (Autologous Reconstruction)

Autologous reconstruction is reconstruction using tissue taken from another part of your body. There are different types of surgical techniques (referred to as flap procedures), which re-position a portion of your own fat, skin, and sometimes muscle, to reconstruct a breast.

DIEP (Deep Inferior Epigastric Perforator) Flap
In this procedure, a flap of fat, skin and blood vessels is removed from the lower part of the abdomen and transferred to the chest area. A surgeon will use a microscope to connect the blood vessels of the flap to the blood vessels in the chest area. The surgeon will then sculpt the tissue into a new breast mound.

SGAP (Superior Gluteal Artery Perforator) Flap
The SGAP flap, or buttock flap, is ideal for those who have more buttock tissue than lower abdominal tissue. Skin, fat, and blood vessels are taken from the top part of the buttock to create a breast mound. The tissue is moved up to the chest area and a microscope is used to reconnect the blood vessels between the buttock tissue and the blood vessels on the chest. The tissue is then molded to form the new breast mound.

TMG (Transverse Myocutaneous Gracilis) Flap
The TMG, or thigh flap, uses the fat, skin and a small amount of muscle from the inner thigh region to create a smaller sized breast. The gracilis muscle is taken to provide the blood supply to this flap. Since tissue must be completely removed from the body and transferred to the chest, microsurgery is required to restore circulation to the transplanted skin and fat.

TRAM (Transverse Rectus Abdominus Myocutaneous) Flap
Similar to the DIEP flap, this method uses skin and fat from the lower abdomen, but also involves removing part of the rectus muscle (your “abs”) as a carrier for blood supply. Since no blood vessels are cut, the tissue for this flap retains its blood supply in the abdomen. After this flap is cut, it is tunneled under the skin, up to the chest area. There are two types of TRAM flaps: free and pedicled. The pedicled TRAM uses a large part of the rectus muscle, while the free TRAM requires a small portion of the muscle.

3) Reconstruction Using Your Own Tissue Combined with an Implant (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 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, which has a more natural feel. This procedure is most commonly performed if you have had a mastectomy followed by radiation and do not meet the criteria for a TRAM or DIEP flap. This procedure is not recommended if you do a lot of repetitive or strenuous overhead activities with your arms.

What are the pros and cons of each technique?

 

Implant/
expander
Autologous
tissue
Latissimus
dorsi/Expander
Surgery 2 separate shorter
surgeries (2hr)
1 longer procedure (6-10 hrs) 2 separate procedures
(3 hrs & 2 hrs)
Hospitalization Day surgery or
overnight stay
Average 4 days 2 night stay for first procedure,
day surgery for second procedure
Recovery 2-4 weeks following
tissue expander insertion
8-12 weeks 3-4 weeks following first
procedure,
2 weeks following second procedure
Scars Mastectomy scar only Mastectomy scar &
scar at donor site
Scar on back, flap insert at
mastectomy scar
Shape & Feel No natural sag, firm
over time
Very natural feel, soft More natural than implants
alone
Opposite Breast More changes needed
to match implant
Fewer changes needed
to match other side
Fewer changes needed
to match
Complications Breast feels more
firm & less natural
appearing with time
1% risk of microsurgical
failure with complete
flap loss; 5% risk of
abdominal weakness, bulge, hernia.
Decreased strength with
repetitive
overhead activities. Seroma or
hematoma in back at donor site.

 

Can a nipple and areola be reconstructed?

It is possible for you to have your nipple and areola (the dark area around the nipple) reconstructed.

It is best to let your reconstructed breast “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.

Options for reconstruction of the nipple include:

  • using tissue and fat of the reconstructed breast (local flap)
  • using tissue from the opposite nipple if it is large or very pointy
  • using tissue from another part of the body (labia is the most common)
  • tattoo alone

Options for reconstruction of the areola include:

  • tattoo alone
  • skin graft from abdominal scar or groin crease
  • using tissue from your other areola  (if you have a large opposite areola)

Are breast implants safe?

Both saline and silicone gel implants are safe and available for use in Canada. However, there is a chance that implants can become infected, rupture, or your body can form a capsule of scarred and firm tissue around the implant. The possibility that an implant would be “rejected” by the body is rare.

Although in the past there were concerns that silicone gel may be associated with breast cancer and rare autoimmune disorders, researchers have not found significant evidence to support this cause-and-effect relationship. After a temporary ban on the use of silicone implants for breast augmentation by the United States Federal Drug Administration (FDA) in the 90s, the use of silicone implants was approved in Canada in October 2006. The newer generation silicone implants contain thicker silicone gel that is more cohesive and in turn are more “form-stable”.

What reconstruction options are available to women who have had a lumpectomy?

Women who have had a lumpectomy may also have options for reconstructing partial breast defects, although this is not common practice. It is important to preserve the natural remaining tissue while at the same time reconstructing the area that has undergone the lumpectomy. In many cases, this can be more difficult than trying to reconstruct a breast that has been completely removed.

There are a variety of options for reconstruction of the defect. These include the insertion of small local flaps that can be taken from areas such as the side of the chest, upper back or abdomen. Occasionally, the breast can be reconstructed by trying to lift or re-shape the breast, and reorganize the internal breast tissue to fill in the lumpectomy defect.

There is increasing evidence that a person’s own fat can be injected into a lumpectomy defect. This is an exciting area of breast reconstruction, but is still very much in its infancy.

Links to more information

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Canadian Collaboration on Breast Reconstruction

Breast Reconstruction
Cancer Support Community

Reconstruction
Breastcancer.org

What are the Most Common Methods of Breast Reconstruction?
Vancouver Coastal Health

Reconstructive Breast Surgery
Johns Hopkins Medicine

Breast Reconstruction
The University of Texas M. D. Anderson Cancer Center

Breast Reconstruction
American Society of Plastic Surgeons

Breast Reconstruction after Mastectomy
American Cancer Society

Breast Reconstruction
Macmillan Cancer Support

Breast Reconstruction (video)
Memorial Sloan Kettering Cancer Center

Breast Reconstruction (video)
DIPEx

Breast Reconstruction with Flap Surgery
Mayo Foundation for Medical Education and Research (MFMER)

Breast Reconstruction with Breast Implants
Mayo Foundation for Medical Education and Research (MFMER)

Breast Implants: Saline vs. Silicone
Mayo Foundation for Medical Education and Research (MFMER)