William Callaghan. MD (Breast-Reconstruction Surgery)
The importance of the breast as a symbol of femininity is well documented; therefore, breast reconstruction is one of the most important procedures for women if they are unfortunate enough to have a diagnosis of breast cancer.
Several types of operations are available for reconstruction. They are selected on many factors. Reconstruction can be in the form of an implant, one’s own tissue, or a combination of both. (A tissueflap is a section of your own skin, fat, and in some cases muscle which is moved from your tummy, back, or other area of your body to the chest area.). Also, fat grafting can be done, though usually it is performed in multiple stages.
Most commonly, a patient undergoes a mastectomy and a tissue expander, or in some cases a permanent implant (one stage reconstruction), is then placed. The tissue expander is slowly expanded withsaline. Once it has achieved the desired size, it is then exchanged for a permanent implant (most often a silicone gel implant.
Advantages of implants are their relative simplicity. That is the recovery time is not as long as with flap reconstruction (see below). However, all implants will eventually rupture and also, the exact appearance, or feel, of a “normal” breast may not be able to be reproduced using implants. Also, MRI done every 10 years is recommended when using a silicone gel implant.
Another potential disadvantage is that the results may be affected adversely follow radiation therapy.
Tissue flap Reconstruction
Tissue flaps are procedures that use tissue from your tummy, back, thighs, or buttocks to rebuild the breast. These can be in the form of a pedicle flap (flaps where the blood vessels are still connected and the flap is moved to the new site) or a free flap (flaps where the tissue and its blood supply is completely removed and then re-attached to the recipient’s blood vessels).
These operations have two sites of procedures: the donor site and the recipient site. One, where the tissue was taken, and the other on the reconstructed breast.There can be donor site problems such as abdominal hernias and muscle damage or weakness.
Choosing which type of flap depends on the availability of tissue, patient preference, and health, or habits, of the patient
TRAM (transverse rectus abdominis muscle) Flap
The TRAM flap procedure uses tissue and muscle from the lower abdominal wall. The tissue from this area alone is often enough to shape the breast, so that an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries (such as cholecystectomy). The procedure also results in a tightening of the lower belly, or a “tummy tuck.”
There are 2 types of TRAM flaps:
- • A pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area.
- • In a free flap, the skin, fat, blood vessels, and muscle are removed from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope. This is a microsurgical procedure.to connect the tiny vessels and takes longer than a pedicle flap. The free flap is not done as often as the pedicle flap, but some doctors think that it can result in a more natural shape.
TRAM flap incisions The tissue used to rebuild the breast shape
Latissimus dorsi Flap
The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It’s tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed.
Latissimus dorsi flap
DIEP (deep inferior epigastric artery perforator) Flap
The DIEP flap uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This method uses a free flap, meaning that the tissue is completely cut free from the abdomen and then moved to the chest area. Use of a microscope (microsurgery) is needed to connect the tiny vessels. The advantage of this technique is less muscle weakness and causes fewer hernias.
Donor tissue site for DIEP flap After DIEP flap
Gluteal Free Flap
The gluteal free flap orGAP (gluteal artery perforator) flap uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It might be an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons. The method is much like the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest area. A microscope (microsurgery) is needed to connect the tiny vessels.
Inner thigh or TUG flap
Another option for those who can’t or don’t want to use TRAM or DIEP flaps is a surgery that uses muscle and fatty tissue from along the bottom fold of the buttock extending to the inner thigh. This is called the transverse upper gracilis flap or TUG flap. Because the skin, muscle, blood vessels are cut out and moved to the chest, a microscope is used to connect the tiny blood vessels to their new blood supply. Women with thin thighs don’t have much tissue here, so the best candidates for this type of surgery are women whose inner thighs touch and who need a smaller or medium sized breast. Sometimes there are healing problems due to the location of the donor site but they tend to be minor and easily treated.
Fat Transfer (Graft)
The newest way to perform breast reconstruction is using fat harvested by liposuction and re-injecting them into the new breast. This method often requires an external device to “create space” for the fat. This device is a form of an external bra which creates suction of the soft tissue of the chest resulting in edema. The new “space” can then be utilized to store fat. This method of reconstruction often requires multiple stages to achieve a proper breast mound.
The advantages are profound though the disadvantages are that multiple operations are required to achieve the desired shape and appearance.