Breast Reconstruction

Timing

In some cases, breast reconstruction can be done immediately after your mastectomy, so that you wake up from surgery with a breast mound already in place. This is often possible for women whose cancer has been detected early.

For other women, the medical team may advise delaying reconstruction. The women who may be advised to wait include women whose cancer is more advanced and will require additional treatment, such as radiation and chemotherapy, and women who have high blood pressure, are obese, or who smoke. These issues can complicate breast reconstruction.

DIEP Flap
Donut Mastopexy
TRAM Flap
Tissue Expander and Implant

DIEP

If you are considering breast reconstruction after a mastectomy, you may want to ask your surgeon about a reconstructive surgical procedure called the DIEP (deep inferior epigastric perforator) flap. In this procedure, the surgeon takes skin and fat from the abdomen to recreate a breast mound, but not muscle, as in older procedures.

Our surgeons prefer the DIEP flap (Deep Inferior Epigastric Perforator Flap) to other types of tissue reconstruction of the breast. The reason is that only skin and fat from the lower abdomen are used to recreate the breast; the abdominal muscles are left intact. Although the surgery is more complex and takes more time than other types of breast reconstruction, the advantages include faster recovery and less pain after surgery. With the older TRAM flap surgery, during which abdominal muscles were cut, many women experienced loss of strength in the abdomen and abdominal hernias.

Nonetheless, the DIEP flap is major surgery, involving a long and complex operation. It may not be suitable for women who are very overweight, who are heavy smokers, or who have had previous abdominal surgery.

Advantages of the DIEP flap
The advantages of the DIEP flap over other types of reconstruction include quicker recovery time, because the abdominal muscles are not cut; long lasting results, because an implant is not used; and less pain. There is also less risk of a hernia after surgery (0.5 percent) than with the TRAM flap (4 to 9 percent).

Disadvantages of the DIEP flap
The DIEP flap is major surgery, and requires about five hours to reconstruct one breast, and up to eight hours if you are having reconstruction on both breasts. Most women stay in the hospital for three to four days after surgery and require four to six weeks at home for full recovery. In addition, you will be left with permanent scars on your lower abdomen and around your belly button. There is a small risk (less than 2 percent) of “flap loss” if a clot develops in the blood vessels in the tissue being used to reconstruct your breast. Also, hard lumps of fat may develop in the reconstructed breast that will need to be removed at the time the nipple is reconstructed.

You may also need an additional surgery to restore symmetry with your other breast. This surgery is usually done three months after your initial surgery.

If you have had radiation therapy This method of reconstruction is preferred for women who have had radiation therapy to the chest wall to treat their breast cancer.

Donut Mastopexy

The donut mastopexy is a type of lumpectomy. The procedure allows surgeons to remove an entire segment of the breast through an incision at the edge of the areola. The final scar circles the areola and is virtually hidden.

The term "donut" refers to the way the procedure is done. A circular incision is made around the areola, and the surgeon then separates breast tissue from both the overlying skin and the underlying chest muscles. The cancerous segment of breast tissue is removed, and the surgeon shifts the remaining healthy breast tissue on the chest wall to remold the breast inside the skin.

The ring of skin around the nipple is pulled together with a purse-string suture and tightened up like a drawstring, leaving a circular scar that is hidden around the nipple.

SCCA physicians have performed this new procedure on more than 40 women thus far, with cosmetically excellent results. The operation causes some degree of lifting of the breast, which some women find they like better than the appearance of their breast before surgery. If necessary, you can have a breast reduction on the other side to restore symmetry.

The surgery is considered a good alternative to a mastectomy or traditional lumpectomy for some women. Ask your surgeon if this procedure is right for you.

TRAM Flap

In the past, the most common method of tissue reconstruction of the breast was the TRAM flap, so called because it uses the transverse rectus abdominis muscle, the large muscle that runs from below the ribs to the groin, to create a breast mound.

However, because the TRAM flap sacrifices the abdominal muscles, it increases pain as well as the risk of a hernia, and results in a weaker abdomen. As a result, our surgeons very rarely offer this procedure.

Instead, women who prefer tissue reconstruction should ask their surgeon about a newer procedure, the DIEP flap, which uses only skin and fat from the abdomen to create the new breast mound and does not transfer the rectus muscle.

Tissue Expander and Implant

Most women who have breast reconstruction surgery choose saline implants. This procedure involves expanding the skin with a tissue expander to make room for the implant.

In most cases, this surgery cannot be done immediately following a mastectomy. However, the tissue expander can be put in place at the time of your mastectomy, or it can be placed weeks, months, or even years later.

The tissue expander is placed behind the pectoralis major muscle. It has a valve that is used to gradually fill the expander with sterile saline during visits to the clinic over several weeks.

Once the skin has stretched sufficiently, the expander is removed and a permanent soft saline implant is inserted during an outpatient surgery.

Advantages of the implant
This procedure is done as an outpatient surgery. The recovery time is relatively quick: Most women take off only one week from work. In addition, there are no donor-site scars. Your surgeon will follow your mastectomy scar so that no new scars are created, as there are with tissue reconstruction.

Disadvantages of the implant
The disadvantages of this procedure include infection, leakage, and capsular contracture (hardening of the tissue around the implant). With any of these problems, the implant may need to be removed and replaced.