Different Types of Breast Reconstruction
Breast reconstruction involves a series of life-changing surgeries and periods of recovery. There are many different options available to women today though careful consideration is given to the particular treatment course, depending on variety of factors. Generally speaking, reconstructive options are categorized into two main categories: autogenous (utilization of a patient’s own tissues) and alloplastic (implantation). There are pros and cons to each type, and some patients are not suitable candidates.
Reconstruction using Implants
The use of implants for reconstruction is often the easiest option. The recovery from surgery is quick and extensive surgery is often avoided. However, this option requires the most “maintenance” and additional surgeries are needed. The implants themselves are composed of saline (salt water) or silicone and do not last forever. The shells of the implants weaken over 10 to 15 years and eventually rupture, which requires surgicial removal and replacement. Replacement surgery may be necessary if the implants are affected by abnormal scar tissue or migration.
Typically, implants are not placed immediately at the time of mastectomy. A tissue expander is a temporary implant that is initially placed to help stretch the skin and muscle (over 3 to 6 weeks) prior to a second surgery which involves the removal of the expander and placement of the final implant. This implant, which is softer and more natural appearing, is placed into the pocket created by the expander. The expansion process involves weekly injections of saline into the expander during post-operative clinic visits.
Breast Reconstruction using your own tissue
Autogenous reconstructive options involve the use of a patient’s own body tissues to help create a new breast. Most often, “flaps” or regions of fat/muscle are borrowed from one area of the body and transplanted or transposed to the chest area. After a mastectomy, the majority of breast is removed except for varying amounts of the overlying skin. The cavity can be filled with these “flaps” to restore the missing volume and shape. The most common options involve the use of muscle and fat from either the abdomen or the back. These involve the TRAM (Transverse Rectus Abdominus Myocutaneous) flap or the Latissmus Dorsi Myocutaneous flap (from the back). Recovery for these operations is often quite lengthy (3-4 weeks for the latissimus and up to 6 months for the TRAM flap) because of the greater magnitude of surgery and the sacrifice of donor tissues. However there are many benefits, including less long term maintenance and improved appearance and feel.
Latissmus Flap and TRAM flap
Sacrificng the Latissimus muscle leads to temporary weakening of the shoulder and limiting the range of motion. The long-term effects are minimal, however. Utilizing the TRAM flap in a pedicled (attached) fashion sacrifices one of the paired abdominal muscles that are important for strength, walking, bending/lifting, and balance. This recovery is several months to up to a year. There may be some residual long-term weakness of the abdominal muscles.
The pedicled TRAM technique has evolved into a few less morbid (less recovery and long-term weakening) options: the Free TRAM flap, Free Muscle-sparing TRAM flap, and the DIEP (Deep Inferior Epigastric Perforator) flap. These newer options involve the microsurgical transfer (or transplant) of the same abdominal skin and fat, but with more limited amounts of muscle. These procedures requires delicately re-establishing the blood vessel connections from the abdomen to the chest using an operating microscope. Restoration of blood flow is the critical key to success. The surgical procedures are more involved, but the short-term and long-term recovery is significantly improved over the traditional TRAM flap.
The newest of these options is the DIEP flap, which spares all muscle as compared to the Free TRAM flap which still harvests some of the muscle. The DIEP flap is the most technically challenging, but often results in the fastest and easiest recovery compared to the other muscle flaps. Women also enjoy the benefits of a reduction (“tightening”) of skin and fat in the lower abdomen, which helps tighten the abdominal wall in a manner similar to a tummy tuck.
Not everyone is a candidate for these complex microsurgical procedures; women who are smokers, too obese, too thin, or have had certain types of prior abdominal surgeries may not be ideal for the DIEP flap.
What to expect
With either mode of reconstruction, multiple procedures are still required. A total mastectomy involves the removal of breast tissue and the nipple. Nipple reconstruction is an additionalsurgical procedure after the breast mound has been created. This is usually done by rearranging the skin on the newly reconstructive breast itself. Tattooing of the nipple pigment is the final step in reconstruction, which can be done under local anesthesia in the office.
From start to finish, breast reconstruction can take anywhere from 3 to 12 months depending on the type of surgeries required and any additional cancer treatment involved. Patients who undergo chemotherapy and/or radiation therapy may take longer to complete their reconstructions.
Breast reconstruction is often performed at the time of mastectomy – termed “immediate” reconstruction. The benefits are improved tissue pliability and avoidance of a time period without a breast mound. Some coordination between your breast oncology surgeon and Dr. Ha is required so that both mastectomy and reconstructive surgery can be performed at the same time. Delayed reconstruction is also an option, and may be more beneficial in certain circumstances.
Types of Breast Reconstruction Dr. Ha Performs
Dr. Ha and his team at the Dallas Plastic Surgery Institute is experienced with the various breast reconstruction techniques including the complex DIEP flap (microsurgical transplantation).
A summary of breast reconstructive options that Dr. Ha performs include:
• Tissue expander
• Tissue expander with acellular dermis
• Tissue expander with reduction pattern skin flap closure
• Latissimus Dorsi Muscle flap (back) with Tissue Expander
• Latissimus Dorsi Muscle flap alone
• TRAM flap (abdomen)
• Free TRAM flap (microsurgical transfer)
• Free DIEP flap (microsurgical transfer)