Methods of Breast Reconstruction

Breast Reconstruction Methods

The number of reconstructive options for women continues to grow with better options and improved outcomes and aesthetics. The method selected for reconstruction is an individual decision based on multiple factors that can only be decided after a proper examination and discussion with a qualified Plastic Surgeon who specializes in breast cancer reconstruction. Important issues to consider include a woman’s goals, age, cancer type, previous cancer treatments, medical and surgical history, general health, breast and body size, and physical activities.

Natural Breast Reconstruction Using a Women’s Own Tissue

Many women have a little extra tissue, usually in the abdomen, which can provide an ideal breast reconstruction. The main benefit of a natural reconstruction using a women’s own tissue is not having to use a synthetic implant for the reconstruction and having to worry about all the long and short term risks of synthetic implant reconstruction. A natural reconstruction is a life-long reconstruction, whereas an implant reconstruction might only last for several years and then have to be removed or replaced when they rupture.

The most common area to donate for natural reconstruction is from the lower abdomen (DIEP flap). Skin and fat below the belly button are removed and the blood vessels that supply this tissue is dissected free from the abdominal muscles. The skin and fat is then transplanted to the chest by sewing the arteries and veins together using a microscope (this technique is called microsurgery).

Immediate Reconstruction – DIEP Flap
Final View

There are several major advantages to this type of natural breast reconstruction. It is a life long reconstruction and there is no long term risk like there is with synthetic implant reconstructions. Another benefit is removing the excess skin and fat from the lower abdomen that many women have developed during their lifetime. Although it is more work than a tummy tuck (ie abdominoplasty) it creates a similar result of a flatter abdomen with a low scar. The major risk to the surgery is clotting of the artery or vein that is sewn together, which can cause the transplanted tissue to die. This risk should be less than 2% in experienced teams of surgeons who perform this surgery routinely.

Some women might not be candidates for DIEP flap reconstruction. For women who are very thin in the abdomen, or have other reasons why they cannot donate abdominal tissue for their reconstruction (previous tummy tuck, large hernia, etc), other tissues can usually be found in the gluteal (IGAP and SGAP flaps) and inner thigh regions (PAP and TUG flaps).

Implant Based Breast Reconstruction

The majority of all breast reconstructions are performed with synthetic implants and is a reconstructive option offered by most Plastic Surgeons. In general, the women who are the best candidates for implant breast reconstruction are very thin women with small to moderately sized breasts. Thin women who are having both breasts removed might be especially benefited from implant based reconstruction. Implant reconstruction is more difficult and has higher complication rates in heavier women, smokers, and women who have had or require radiation as part of their breast cancer treatment plan.

The main benefit of implant based reconstruction over reconstruction using a women’s own tissue is shorter operating times, quicker (initial) recovery, and potentially less post-operative plan. The downside of implant reconstructions is that implants don’t last forever, have a risk of infection which could lead to reconstruction loss, and progressive scarring that can lead to a poor cosmetic outcome. It can also take a longer time to get to a final reconstruction, and may require more post-operative clinic visits.

The most common approach to implant based reconstruction is the two-stage breast reconstruction. The two-stage approach can be performed in either immediate or delayed reconstructions. In the first stage, a temporary implant called an expander is placed under the skin and chest muscles. Sometimes a biologic mesh (common products include AlloDerm, AlloMax, BioDesign, Strattice, FlexHD) is added to help cover the implant under the skin and acts like an internal bra. The expander is designed to stretch the skin, fat and muscle to create a pocket of adequate size to accommodate a long term breast implant. This expansion is performed during clinic visits (usually weekly) where small amounts of fluid are injected into the expander until the breast has been adequately stretched. This process usually occurs over a couple of months. Once the breast pocket is adequately expanded, a second stage surgery occurs to remove the expander and place a saline or silicone breast implant.

Occasionally, a woman can undergo a single-stage breast reconstruction with a silicone or saline implant, avoiding the need for a temporary expander. These women usually have large breasts and are downsizing their breast size (for example, from a C cup to a B cup). Also, some women who are undergoing nipple-sparing mastectomy can undergo single-stage reconstruction if the conditions are ideal. Your Plastic Surgeon can help determine if you are a candidate for a single stage implant reconstruction.

Long term breast implants can be either filled with saline (salt water) or gel silicone. Both are safe and should last for a couple of decades, but they do have some differences. In general, silicone implants are softer and feel more natural but when they rupture it may not be noticeable. For that reason, women are recommended to get MRI examinations every several years to confirm that the implant is intact. Saline implants can also provide a good reconstruction, but they can have more visible rippling of the skin and a less natural feel. The main benefit of saline implants is that when they rupture, the body will absorb the saline and the breast will “deflate.” Because it is noticeable when a saline implant deflates, routine MRI examinations are not needed.

Combination Method Breast Reconstruction (Latissimus Flap)

Less commonly, using both an implant and a woman’s own tissues might provide the best option for breast reconstruction. The tissue used is frequently from the back, taking a muscle with overlying skin and fat (Latissimus flap).

Because women usually do not have enough tissue in their back to make a full sized breast, an implant is frequently placed below the Latissimus flap to make it larger. In our experience, the Latissimus flap with implant is usually a secondary choice for reconstruction usually reserved for unique cases.

Fat Grafting

Liposuction can be used to harvest fat from one area of the body and injected into other areas. It is commonly done for cosmetic reasons. For breast reconstruction, it is most commonly used as a complimentary procedure for women who have undergone either implant or flap reconstruction to correct mild deformities. Total breast reconstruction with fat grafting has been described, but is not considered a standard approach.

Partial mastectomy (lumpectomy) and reconstruction

All the discussion above was in regard to women who are undergoing mastectomy for their reconstruction. For some women, lumpectomy, followed by radiation therapy, can be a good treatment option for their cancer. From a cosmetic perspective, women who have moderate to larger breasts tend to be better candidates for lumpectomy whereas women with small breasts have a higher chance of poor long term cosmetic outcomes.

For women who are considering lumpectomy, a breast lift (mastopexy) or breast reduction can be performed to help shape the breast which might lead to a better long term cosmetic outcome. The best candidates for this approach are women who, prior to their cancer diagnosis, had considered having a breast lift or breast reduction procedure. There are certain planning challenges for this approach and a healthy discussion between the patient, Surgical Oncologist, and Plastic Surgeon are necessary to optimize both the cancer treatment and cosmetic outcome.

For women who have undergone lumpectomy with radiation in the past, and have a deformity of their breast, there are some options for reconstruction available to them. Because every one of these patients can have a unique deformity, a consultation with a Plastic Surgeon is required to determine the best course of treatment.