What are my options and considerations for reconstruction?
Immediate Reconstruction – This is done immediately following your breast surgery so that you wake up with a new breast. The reconstruction is done by a plastic surgeon during the mastectomy operation itself. The surgeon and the plastic surgeon work together as a team rather than sequentially. Talk to your surgeon before surgery to see if you are a candidate for the procedure.
Implants – Breast implants are silicone sacs filled with either saline or silicone that are placed behind your chest muscle. Sterile saline (salt water) filled implants are used by physicians much more often than silicone-gel filled implants because of concern that silicone leakage could debilitate the immune system. Usually, the plastic surgeon will implant a tissue expander first. This is like an implant, but it is not fully inflated, and so at first, is smaller than your implant will be. In the weeks following surgery, your plastic surgeon will inject saline into the tissue expander until it is fully expanded. Then you will undergo surgery to remove the tissue expander and replace it with your permanent implant.
Flap Reconstruction – Flap reconstruction depends upon your body type and anatomy. Here, tissue and muscle from another part of your body (tummy, back, thigh, buttocks) is used to make a new breast. There are a number of different techniques available:
- Transverse Rectus Abdominis Myocutaneous (TRAM) Flap – TRAM reconstruction is the most common reconstruction available, taking tissue from the abdomen in a "tummy tuck" procedure. Women who are very thin and lacking excess abdominal fat are not usually candidates for this type of procedure.
- Latissimus Dorsi Flap – This reconstruction involves the latissimus dorsi muscle (a back muscle located underneath the shoulder) which is turned around to recreate a breast. Normally, an implant will also accompany this procedure in order to create a symmetrical breast. Women with smaller to moderate size breasts are the best candidates for this procedure. While it should not affect upper body strength, it may cause unevenness in the back's appearance.
- Gluteal Flap – In this reconstruction, tissue is taken from the upper and lower parts of the buttocks and used to reconstruct the breast. This procedure is usually used if the TRAM flap is not an option due to scarring or lack of excess tissue. It is a complicated procedure because of the need to reattach many blood vessels.
- Deep Inferior Epigastric Perforator (DIEP) Flap – This surgery is much the same as the TRAM flap except the muscles of the abdomen are preserved in this procedure.
- Superficial Inferior Epigastric Artery (SIEA) Flap – The SIEA Flap and its accompanying veins can be an option for some women whose superficial vessels in the abdominal fatty tissue provide the dominant source of blood flow to this region. This procedure is otherwise the same as the DIEP procedure and represents a second choice for women whose superficial vessels are more dominant than the deep inferior epigastric perforators (DIEPs). It is not known before surgery whether a woman has an adequately sized SIEA blood vessel. These are looked at by the microsurgeon during surgery, and a determination will be made at that time whether they are suitable to supply a flap.
- Gluteal Artery Perforator (GAP) Flap – The GAP Flap procedure allows for reconstruction using your own body’s tissue when there is inadequate abdominal fat to restore your breast to its proper size and shape. For the woman who is thin or athletic, the breast may be reconstructed with tissue borrowed from the gluteal area. Skin and fatty tissue are collected from the buttocks/hip region without sacrificing underlying muscles. As with the DIEP procedure, the tissue is then sculpted into the new breast mound. There is a donor site scar on the buttocks.
- Transverse Upper Gracilis (TUG) Flap – The TUG Flap is taken from the upper inner-thigh area in a crescent shape. Only a small amount of the gracilis muscle is taken with the flap to ensure a reliable blood supply. There is no functional consequence to removing the gracilis muscle, which is the same muscle used to reconstruct facial paralysis or forearm injuries. This flap is coned to create a projecting breast shape, and an immediate nipple and areola reconstruction are also possible with this flap.