What Is Breast Reconstruction?

By Peter Henderson, MD

Breast reconstruction surgery can be performed on patients who have had either a mastectomy or a lumpectomy due to breast cancer.  Breast reconstruction is best thought of as a process, as opposed to a single procedure, because in most cases it takes more than one operation in order to achieve the look, shape, and feel that best meets each woman’s goals.  There are several different approaches to breast reconstruction: some women choose to receive breast implants made of silicone or saline, some choose to use a piece of tissue from their body (most commonly the fat and skin from the lower abdomen, which is similar to the tissue removed during a “tummy tuck” procedure).

Breast Reconstruction diagram

It is possible to have breast reconstruction immediately after treatment for breast cancer (immediate reconstruction). Alternately, it might occur a few months or even years later (delayed reconstruction). Depending on the circumstances, women can choose to have breast removal and reconstruction procedures on one or both of breasts.

What are the kinds of breast reconstruction surgeries that may be done?

Following a mastectomy, women often have three main options for breast reconstruction surgery.

Types of breast reconstruction surgeries

#1. No reconstruction (sometimes referred to as “aesthetic flat closure”)

Whether to undergo breast reconstruction after mastectomy is a very personal decision, and in some situations women choose to not undergo any reconstruction at all.  This is a perfectly reasonable decision, and if a woman at first chooses to not undergo breast reconstruction, she can still undergo one of multiple types of breast reconstruction at a later time.

#2. Implant-based reconstruction

In implant-based reconstruction, reconstructive plastic surgeon use implants filled with either silicone or saline in order to recreate the breast shape.  There are multiple variables for how implant-based breast reconstruction can be performed:

Depth of implant placement:  In some cases, the implant is placed under the chest muscle (“subpectoral”).  In this form of implant-based reconstruction the main chest muscle (pectoralis major) is elevated, and the implant is put underneath it.  Alternatively, the implant can be placed on top of the chest muscle (“prepectoral”).  Because your chest muscle has not been disrupted, women usually recover faster.  Additionally, there is less likelihood of scar tissue forming between the muscle and the skin (a situation that can lead to “animation deformity”).

Type of implant:  In some cases, the permanent implant can be placed at the time of the mastectomy (“direct-to-implant” reconstruction).  This has the advantage of a shorter overall reconstruction sequence, and avoiding the staged tissue expansion process.  If the permanent implant cannot be safely placed at the time of the mastectomy, then a temporary implant (“tissue expander”) can be placed instead.  A few weeks after the operation, expansion of the expander can be performed by gently injecting fluid into the port underneath the skin.  The soft tissue of the chest gradually stretches, and once it has reached the size that best meets the patient’s goals, a separate small operation is performed where the expander is removed and it is replaced with a permanent implant.

#3. Tissue-based (“flap,” or “autologous”) reconstruction

In tissue-based reconstruction, the reconstructive plastic surgeon uses a patient’s own tissue (autologous tissue) to make a new breast. Most of the time, the tissue is collected from the lower abdomen, but it can also be collected from the thigh, buttocks, or back.  The medical term for this piece of tissue is a “flap.” Sometimes, a flap is moved from a nearby area and remains at least partially connected at all times (“pedicled” flap).  Otherwise, the flap tissue is momentarily completely disconnected from the body before the blood vessels are subsequently reconnected.  This technique is called a “free flap,” and it affords much more flexibility and creativity because tissue can be collected from anywhere on the body.

The different kinds of flap reconstruction are:

DIEP flap:  The current “gold standard” for tissue-based breast reconstruction, it uses fat and skin from the lower abdomen, but leaves the muscles intact and unaffected.

TRAM flap:  This older technique uses the same skin and fat from the lower abdomen, but does remove some or all of your abdominal wall muscles, and therefore is more likely to affect a woman’s long-term core muscle strength.  For this reason, the DIEP flap is much preferred compared to the TRAM flap.

SIEA flap:  Similar tissue is used as in the DIEP or TRAM flaps, but different blood vessels are used.  It is not as reliable as the DIEP or TRAM, and is therefore used less commonly.

PAP flap: skin and fat (without any muscle) is moved from the inner thigh and back of the thigh as a free flap

TUG flap: skin and fat from the inner thigh is collected at the same time as a portion of one of the muscles from the inner thigh. 

Latissimus dorsi (LD) flap: Tissue is moved from the patient’s back, and remains connected as a pedicled flap as it swings underneath the axilla (armpit).  In most cases a tissue expander or permanent implant is placed underneath the latissimus flap in order to provide sufficient shape and projection.

SGAP/IGAP flaps: tissue is moved form the buttock as a free flap.  It does not involve use of any muscle.

Oncoplastic reconstruction after lumpectomy

If a woman has been deemed a good candidate for a lumpectomy (“partial mastectomy”) oncoplastic reconstruction may be a good fit.  In oncoplastic reconstruction, the lumpectomy is done simultaneously as a breast lift or a breast reduction (or at most two weeks later). The breast reduction or breast lift helps to fix the shape of the breasts and fills in the hole left by the lumpectomy.

Can a nipple be reconstructed?

Some types of mastectomy keep the nipple and areola (dark skin around the nipple) in place.  If the nipple and areaola need to be removed  (nipple-sparing mastectomy), then the reconstructive plastic surgeon can create a new one. This is done by one of three options:

Tattoo only: in some cases, women choose to use tattoo only in order to create the appearance of a nipple-areola complex.  Because this is in fact “flat” and not three-dimensional, this is best done by a trained specialist who is able to use shading in order to create the appearance of texture and dimensionality.

Surgery + tattoo: in this approach, the skin on the breast is used in order to create a three-dimensional nipple, followed by tattoo to provide pigment to the nipple and surrounding skin to approximate the appearance of an areola.

Nipple sharing + tattoo: if the other nipple is still in place, and if it is very large and would benefit from being reduced, half of that nipple can be removed and placed at the ideal site on the reconstructed breast.  This “nipple graft” takes root at the new site, and then tattooing can be performed at a later time in order to give appearance of an areola.

Peter Henderson

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