Deciding on the Right Breast Reconstruction Procedure for You
One of the first decisions you and your plastic surgeon will have to make is determining what type of breast reconstruction would be best for you. In helping you evaluate your options, your plastic surgeon will consider the following factors:
- Whether the reconstruction is delayed or performed at the same time as the initial breast surgery
- Whether you prefer a permanent prosthetic implant or reconstruction from either a flap or from fat grafting
- The type of mastectomy and cancer treatments you have had, if any; Breast tissue may be compromised by a mastectomy or radiation
- Your breast size and general body type
- Whether you have enough skin and fat available for autologous reconstruction (using your own tissue)
- Whether your mastectomy was prophylactic (preventive due to high cancer risk) or therapeutic
- Whether surgery will involve only one or both breasts
Alloplastic vs. Autologous: Know the pros and cons
Breast reconstruction falls into two general categories: alloplastic, which uses an implant, or autologous, which uses tissue harvested from the patient's own body. Tissue can be taken from your abdomen, back, inner thighs or buttocks. The harvested tissue is called a flap or a graft depending on the actual blood supply. A flap includes a small blood vessel that needs to be resutured under a microscope. A graft can be taken without a blood supply, but needs to be handled very gently and optimized so it can recruit a new blood supply within a few days. There are pros and cons to each approach.
- Alloplastic. Implants are a good option for women who have no available flap options, are not good candidates for an autologous reconstruction, or do not desire an autologous operation, which requires harvesting tissue from a secondary surgical site. Alloplastic surgeries offer significant advantages in bilateral reconstruction with respect to symmetry and recovery. In addition, autologous fat grafting can often be combined with alloplastic (implant) reconstruction to enhance the outcome. Relative contraindications to alloplastic reconstruction include a history of radiation to the breast or chest wall and/or compromised tissue at the mastectomy site.
- Autologous. Some women are more comfortable with the idea of using their own tissue. Where the tissue is obtained will depend on a patient's anatomy and availability of skin and fat. Autologous reconstruction has significant advantages in unilateral (one side) reconstruction regarding symmetry with the opposite breast. As an added benefit, use of an abdominal flap may result in an improved appearance of the abdomen.
Types of Implants
Alloplastic Implants can be made of saline or silicone. A saline breast implant is a silicone shell that is implanted while empty, then filled. Using a valve, the surgeon fills the implant with a salt-water solution called saline. The amount of saline injected will affect the breast's shape, firmness and feel. Silicone implants come pre-filled with a cohesive silicone gel. Some silicone implants are shaped to achieve a more natural appearance of the breast. These implants, also known as "gummy bear implants," can significantly improve the quality of alloplastic reconstruction.
Breast reconstruction using alloplastic implants can be performed as a two-stage or one-stage operation. In the more common two-stage reconstruction, a temporary saline implant expander is first placed underneath the pectoralis major muscle as an expander, to keep the skin stretched. Additional support is created using piece of acellular dermal matrix, to create a lattice of tissue around which the patients own cells can grow. Patients usually spend one day in the hospital overnight for pain control. During the follow-up office visits, the plastic surgeon will begin expansion of the implant until the final volume is reached. The second stage, which is usually performed three months later, is an outpatient procedure where the tissue expander will be removed and final silicone implant will be placed. The last steps are reconstruction of the nipple followed by in-office tattooing of the areola (office procedures). In certain unique cases, a tissue expander is not necessary and the final silicone implant is placed at the time of the first operation.
Breast Reconstruction with Autologous Implants is most commonly performed using abdominal-based tissue (TRAM flap). The skin and fat quality of the abdomen makes a very good breast substitute. What's more, many women are happy to donate their extra abdominal tissue in exchange for a reconstructed breast and flatter tummy. All abdominal-based flaps result in a scar in the lower abdomen, often around the bikini line. The different TRAM-flap variants procedures are listed below:
The main difference between this flap and other abdominal-based "free flaps" is the flap's underlying blood supply. A pedicle TRAM derives its blood supply from the superior epigastric vessels and remains connected to the muscle during breast reconstruction. The flap remains connected to the blood supply and is then tunneled into the breast cavity to recreate the breast. While most patients do very well from a pedicle TRAM operation for breast reconstruction, the need to sacrifice the entire rectus abdominus muscle results in mild weakness of the abdominal wall.
Technically more difficult operation than a Pedicle-TRAM, the free TRAM can be safely performed with a team of dedicated and skilled plastic surgeons. During this procedure, the flap is completely disconnected from the body and reattached using refined microsurgical techniques and a surgical microscope. The flap's blood vessels are then connected to blood vessels in the chest or armpit. The majority of the rectus muscle is saved, which preserves abdominal wall integrity and improves recovery.
Deep Inferior Epigastric Perforator (DIEP)
The DIEP flap represents a new class of "perforator flaps" that spares the entire rectus abdominus muscle. This is the most technically challenging of the TRAM-flaps, as the blood vessels must be dissected completely free of the muscle. Whereas the pedicle-TRAM sacrifices the entire rectus abdominus muscle, the DIEP sacrifices none. Compared to TRAM procedures, DIEP surgery results in the best abdominal integrity.
Autologous Fat Grafting (AFT)
Autologous fat grafting is the newest and most innovate way to perform breast reconstruction. In this process, fat is harvested from several locations around the body, gently processed and handled very carefully, and then re-introduced into the skin, fat, and muscle around the original breast. The fat then grows a new blood supply that allows it to become viable living tissue. The advantage of this operation is that it can be consistently done as an outpatient operation. However, to achieve a breast reconstruction of adequate size may require more than one operation.
Other Types of Autologous Reconstruction
A woman may want autologous reconstruction but not be a candidate for a TRAM flap for one of the following reasons:
- She has had a previous TRAM flap procedure
- She has had a tummy tuck or abdominal surgery
- She has an underlying medical problem
- She does not have enough abdominal tissue from which to reconstruct a breast
When a TRAM-flap is not available, secondary autologous breast reconstructions are considered including using the soft tissue and muscle of the inner thigh, or back.