Breast reconstruction is one of the most rewarding surgical procedures available for women today. Modern techniques make it possible for plastic surgeons to create a breast that may be very close to a natural breast in appearance and feel. Most women are candidates for breast reconstruction, which is usually possible at the time of mastectomy. This allows the patient to avoid the displeasure of seeing herself without a breast. For some women, there are legitimate reasons to wait. Many women have a difficult time weighing their options while struggling to cope with their recent cancer diagnosis. Some patients decide not to have more surgery than is absolutely necessary. Other patients are advised by their surgeons to wait, particularly if there are significant health risks. Still other women have already had breast removal without being aware that reconstruction was and still is available to them. At the Partnership for Breast Care our plastic surgeons have expertise in performing state of the art breast reconstruction.

A patient may begin to consider reconstructive plastic surgery as early as being diagnosed with breast cancer. It is often a member of the Partnership for Breast Care such as the general surgeon or medical oncologist who refers the patient to a plastic surgeon to learn about breast reconstruction. Most patients are scheduled for an office consultation within just a few days. At the initial consultation, the plastic surgeon will review the patient’s medical history, examine the patient and review all reconstructive options, focusing on those most appropriate to the individual. This is both an educational process, covering in detail the history and the state of the art of breast reconstruction as well as an opportunity to establish timing and goals of reconstruction. The plastic surgeon will also arrange expeditious follow-up office visits to answer any further questions and settle unresolved issues while agreeing upon the selected method of breast reconstruction.

Types of Reconstruction

Breast reconstruction typically involves more than one operation. For patients awaiting mastectomy, the first stage may be coupled with the mastectomy. This is referred to as immediate reconstruction. In patients who have already undergone breast removal, all stages come after the mastectomy and chemotherapy or radiation therapy as deemed necessary. This is known as delayed reconstruction. Regardless of the timing of breast reconstruction, there are various types of breast reconstruction that apply to all women, including those anticipating immediate or delayed reconstruction. These include skin or tissue expansion, flap reconstruction, or a combination of both. These techniques are described below for immediate reconstruction but apply equally well for delayed reconstruction. All types of reconstruction may also apply for removal and reconstruction of one or both breasts.

Implant Reconstruction

The most common form of breast reconstruction involves expansion of the breast skin and insertion of a breast implant. This is a two-staged procedure. The first stage begins immediately following mastectomy, with a deflated or partially inflated temporary breast implant, known as the tissue expander being placed beneath the skin and chest muscle. Most patients are discharged from the hospital within one or two days of surgery (Figure 1). Within a few weeks, tissue or skin expansion may begin. The plastic surgeon will periodically inject the tissue expander with a salt-water solution known as saline solution as a brief office procedure on a weekly basis to gradually fill the expander (Figure 2). This will allow the skin to stretch enough to ultimately allow removal of the tissue expander and replacement with a permanent saline or silicone gel-filled implant as a second surgical procedure (Figure 3). For this and all other techniques of breast reconstruction, the nipple-areola complex may also be reconstructed in a subsequent surgical procedure.

Figure 1

Figure 2

Figure 3

Flap Reconstruction

For some women, one or both breasts may be reconstructed using the patient’s own tissues. This is known as flap reconstruction. This technique involves creation of a skin, fat and muscle flap using tissue taken from other parts of the body. The most popular donor site for this flap is abdomen. Breast reconstruction with this tissue is known as the TRAM Flap, which is an acronym for “transverse rectus abdominus musculocutaneous” flap. This is the anatomical description of the flap (Figure 4).

Figure 4

This flap has also been referred to as the Tummy Tuck Flap, which alludes to the added benefit obtained with this type of reconstruction. The tissue remains attached to its original site to maintain blood supply, but is tunneled beneath the skin to the chest, creating a new breast mound, with the patient’s natural tissues and often without the need for a breast implant (Figure 5). Closure of the abdominal wound or donor site may provide a dramatic cosmetic improvement of the abdomen (Figure 6).

Figure 5

Figure 6

Another added benefit of this type of breast reconstruction is that it is very useful for women who will have had radiation therapy. Radiation increases post-operative risks of complications for women who have undergone or are anticipating breast reconstruction with implants alone. Flap reconstruction may improve the patient’s ability to heal the reconstructed breast without complications. TRAM Flap surgery is however a more demanding form of breast reconstruction and requires a longer hospital stay and post-operative recovery for those patients eligible for this type of breast reconstruction.

Combination Implant/Flap Reconstruction

Another form of breast reconstruction involves both implant and flap tissues. For some women, the abdominal tissues used for TRAM Flap surgery may not be appropriate for use in breast reconstruction. If there is too little abdominal skin and fat or if previous abdominal surgery and the resulting scars make this option very risky, an alternative approach involves using back tissues. The LATS Flap involves use of the latissimus dorsi muscle and its overlying back skin and fat (Figure 7). The LATS Flap is tunneled to the front of the chest wall where it provides added healthy tissue coverage for an implant (Figure 8).

Figure 7

Figure 8

Follow Up Procedures

Following the initial procedure, additional surgeries may be necessary to complete the reconstructive process. For implant reconstructions, once the skin expansion has been completed, the tissue expander will need to be replaced with a permanent breast implant. For any type of reconstruction, the nipple and the darker surrounding skin, known as the areola, may be reconstructed as a subsequent procedure. The nipple/areola complex is recreated using a patient’s own tissues. The plastic surgeon may also recommend additional surgical procedures to enlarge, reduce, or lift the opposite breast to achieve better symmetry with the reconstructed breast. These procedures are often completed as a second or third surgery, frequently as outpatient surgery or at most involve an overnight hospital stay with far less post-operative recovery. These procedures, as all operations toward breast reconstruction, remain optional attempts to achieve a more natural final result and do not interfere with the treatment of the underlying breast cancer, physical appearance and quality of life following mastectomy.

The plastic surgeons involved in the Partnership For Breast Care would like to extend their gratitude to the American Society of Plastic Surgeons for providing the above images with the goal of educating our patients with regards to breast reconstruction. At the Partnership For Breast Care, all of our plastic surgeons are either board certified or board eligible for certification by the American Board of Plastic Surgery.