Reconstruction Options

What are the Different Types of Breast Reconstruction?

There is not one type of breast reconstruction that is best for all women. Each technique has its pros and cons that a woman must weigh, depending upon her unique circumstances. Poor outcomes can result from the most advanced techniques, when performed by a surgeon inexperienced in that form of breast reconstruction. On the other hand, any type of breast reconstruction, in the right hands and under the right conditions, can produce outstanding results perhaps more beautiful than your original breasts.  What  outcome you are able to achieve is wholly dependent on your understanding of the options and your obtaining a surgeon highly skilled in the specific procedure you choose.

Implants or your own tissue?

There are two major categories of breast reconstruction: those that use implants and those that use your own tissue (called “autologous”).

Implant Reconstruction

Breast implants were originally developed for breast augmentation rather than for reconstructive purposes. In breast augmentation, the implant is placed beneath the breast tissue and on top of the pectoris muscle. The fat of the breast is a cushioning layer over the implant. Because the conditions are quite different when using implants for breast reconstruction (the implant is placed beneath the muscle and there is no fat padding on top of it) there are some undesirable side-effects associated with implant reconstruction that you need to factor into your decision-making.

Silicone or Saline?

With implant reconstruction, you will be asked to choose between implants filled with saline and those filled with silicone. Saline implants result in a firmer breast, while silicone implants have a bouncier feel.

Some women have health concerns about using silicone implants They were outlawed, for a time, for breast augmentation, though they continued to be available for use in breast reconstruction after cancer. Earlier implants sometimes developed leaks, resulting in loose silicone within the breast pocket and even elsewhere. Some women developed health problems they felt certain were silicone-related. Later studies seemed to indicate that silicone was not the cause.

In any event, advances have been made in the construction of and the consistency of the silicone in breast implants, making rupture and leakage less likely, but still possible. For this reason, women with silicone implants are monitored periodically and implants replaced if problems arise. Women wanting to avoid worrying about this issue may choose saline implants, as leakage of saline into the body is harmless.

Traditional Implant Process

Implant reconstruction requires a surgery to place the expanders (which are a kind of implant that can be filled, over time, within your body) behind the pectoris muscles and then another surgery to remove the expanders and replace them with the final implants. In the interim period, you will need to see your doctor for periodic fills. This involves the gradual introduction of more fluid into the expanders over a period of weeks or months in order to gradually stretch your chest muscles and skin to increase the size of the pocket to accommodate the implants. Following your surgery for placement of the implant(s), you will require surgical drains for a few days. These are tubes placed to drain off fluid that otherwise will pool within your body, leading to possible complications such as swelling and infection.

Pros and Cons of Traditional Implant Reconstruction:

Pro:

• ·No additional body scarring, as occurs at donor sites when using your own tissue.
• ·Surgery time is shorter than more complicated autologous procedures.
• ·More surgeons are available who are trained in this technique.
• ·Recovery time is less than autologous reconstruction procedures. Surgical drain time is less.

Con:

• ·Expander process and/or implants themselves may cause discomfort and pain.
• ·Long process to restore breast mounds.
• ·Ripples in the implants may be visible beneath the breast skin and may move unnaturally when the chest muscle is flexed.
• ·Breasts may feel cold in winter climates.
• ·If reconstruction is on one side only (unilateral), it may be more difficult to attain symmetry.
• ·Requires exchange surgery- second surgery to exchange expanders for final implants and address symmetry issues.
• ·Need to monitor implants over time.
• ·Implant reconstruction carries the unique risk of capsular contraction, which is excess scar tissue that forms around the implant. This can result in hardness, pain and deformity of the reconstructed breast, which may be able to be addressed with corrective surgery.
• ·Implants can lead to infection.
• ·Incidence of complications for implant reconstruction after radiation is quite high.

One-Step Alloderm Implant Reconstruction

In One-Step Alloderm reconstruction, the upper section of the implant is set beneath the pectoralis muscle, and the lower is covered with Alloderm, which is a type of collagen sheeting. The Alloderm also acts as a sling to help hold the implant. One-Step Implant Reconstruction can provide very good results for appropriate candidates. Women requiring radiation therapy, those having thin skin, or smokers are not good candidates. It is best performed in conjunction with a skin-sparing mastectomy where the skin envelope is preserved.

Pros and Cons of One-Step Alloderm Implant Reconstruction (in addition to those listed for Implant Reconstruction):

Pro:

• ·Procedure requires only one surgery.

Con:

• ·Far fewer surgeons are trained in this procedure than traditional implant reconstruction.

Flap Reconstruction (“autologous” reconstruction)

Advances in surgical technique and knowledge have lead to a different type of  breast reconstruction using a woman’s own tissue to reconstruct her breast(s) after mastectomy. This has taken the field to a whole new level. Because the breast is built using your own fat, it feels more like a breast, moves and bounces naturally, is warm, soft, and living, and even gains and loses weight along with the rest of your body.

There are many types of flap reconstruction based upon where on your body the donor tissue comes from and whether muscle is impacted or used, as part of the flap. All involve transplanting fat, skin, and blood vessels (perforators) from one part of your body to your chest to recreate your breast(s). Which type of flap reconstruction you undergo depends upon many factors, including where on your body you carry your excess fat. Surgeons experienced in multiple types of flap procedures determine this by physical examination.

Don’t be discouraged if you think you’re too thin or your plastic surgeon says your fatty tissue is insufficient. This is often more a commentary on the skill of that surgeon rather than whether you are a candidate for flap reconstruction. There are top surgeons in the field who can usually manage to find donor sites, even stacking fat from different areas, if necessary.

Before describing the subcategories of this type of reconstruction – each carrying its own additional pros and cons – there are some advantage and disadvantages that generally apply to all flap reconstructions.

Pros and Cons of Flap Reconstruction:

Pro:

• ·Flap looks, feels, and behaves more like a real breast.
• ·Easier to attain symmetry, possibly making surgery on the other breast unnecessary.
• ·Unlike implants, flap doesn’t have to be replaced.
• ·No chance of capsular contraction.
• ·New skin can be used to replace radiated skin that may have prevented implant reconstruction.

Con:

• ·Causes significant scarring at the donor site (may be visible beyond bikini line), though scars fade a great deal over time.
• ·Causes numbness at the donor site, which may lessen over time but never resolves totally.
• ·Surgery time is very long, increasing the possibility of post-surgical complications.
• ·Requires a second surgery to revise donor site and address symmetry issues, if needed.
• ·Recovery time is longer than with implant surgery.
• ·Surgical drains to siphon fluid from donor and breast recipient sites must be managed for days to weeks (vs. only breast drain for implants).
• ·There is a small possibility of flap failure after surgery.
• ·Fewer surgeons are proficient in this type of surgery, possibly requiring patient to travel.

Types of Flap Reconstruction

DIEP (Deep Inferior Epigastric Perforator) Flap and SIEA (Superficial Inferior Epigastric Artery) Flap Reconstruction

Of all the types of flap reconstruction methods, the DIEP flap is perhaps the most preferred, one reason (from the patient’s perspective) being that the fat comes from your abdomen, thus resulting in a tummy tuck (one of the few perks of breast cancer. There are other flap methods that use your abdominal tissue, but this is the only one that does not involve the removal of any abdominal muscle, thus preserving the functional integrity of the muscle that helps you sit up, among other things. For active women, this is an important consideration. It also results in less post-operative discomfort and a shorter recovery time.

For some women, a SIEA flap is a better choice, if the blood vessels in the fatty tissue closer to the surface supply stronger blood flow to the flap rather than the deeper DIEP vessels. Other than the vessel choice, everything else is similar between the SIEA and DIEP flap procedures.

There are relatively few doctors who are trained in these surgeries, although the number is increasing. Hopefully, as more women gain knowledge of their reconstructive options, the increasing demand for this procedure will lead to more surgeons in more locales who have the training and can offer this option. This lack of surgeons is due to the fact that the DIEP and SIEA procedures require a high degree of skill in microsurgery, which not all plastic surgeons possess. As with any surgery, you want a doctor who has a great deal of experience in the particular procedure you will be undergoing, lessening the chance of complications or flap failure.

Pros and Cons of DIEP and SIEA Flap Reconstruction (in addition to those listed for flap reconstruction):

Pro:

• ·Maintains functional integrity of abdominal muscles.
• ·Tummy tuck.
• ·Easier recovery than from TRAM reconstruction.

Con:

• ·Pain, swelling, and tightness in abdomen can persist for months.

TRAM (Transverse Rectus Abdominus Myocutaneous) Flap Reconstruction (Pedicled Tram and Free Tram)

The pedicled TRAM is an older breast reconstruction surgery, but it can still produce aesthetically beautiful results, carrying many of the advantages of the DIEP flap, but with some down-sides — the main being that it does utilize abdominal muscle. The procedure involves the same abdominal donor site, but the flap remains attached by a pedicle (a strip of tissue containing a blood supply and muscle) to the abdomen, and then is tunneled up under the skin to the chest to recreate the breast at the mastectomy site. The more robust deep inferior epigastric vessels that supply the DIEP and free TRAM flaps are cut in the pedicled procedure. Instead, the blood must travel a long distance to reach the transplanted flap, reversing its natural direction through choke vessels or small vessels that choke off some of the power of the blood flow.

The Free Tram utilizes the same donor site as the TRAM and DIEP, but the flap is detached along with muscle and blood vessels, then is re-attached to the chest to create the new breast.

Pros and Cons of TRAM Flap Reconstruction (in addition to those listed for flap reconstruction)

Pro:

• ·There are more surgeons capable of doing this surgery, though still fewer than implant reconstruction.

 Con:

• ·Pedicled TRAM has higher chance of partial flap failure than DIEP or free TRAM, as blood flow is poorer.
• ·Compromise of the abdominal muscle, which can lead to loss of muscle strength and function.
• ·Increased risk of hernia.
• ·Recovery is more difficult due to muscle loss.

A Note about DIEP and TRAM Flap Surgeons: Because of the additional time and skill required to excise the perforator artery from the donor site without taking muscle along with it, and because arterial configurations may differ between women, some surgeons will not be able to guarantee that a surgery started as a DIEP will end up a DIEP. Rather, it may turn into a Free Tram, mid-surgery. You may be told they might have to take a little bit of muscle. The muscle from which the “little bit” is taken, however, is only the size of a postage stamp. If you are convinced you want the DIEP procedure, and not a Free Tram, be sure to choose a surgeon who can guarantee that result. Surgeons most experienced in the DIEP flap will never find it necessary to switch techniques mid-operation, no matter how small the blood vessels. If, however, the surgeon you choose does require that you agree to the possibility of switching procedures once you get into surgery, that option is better than if he/she were to continue in an endeavor for which they lack the skill. A surgeon without micro-surgical skills will have better success with a TRAM.   

GAP (Gluteal Artery Perforator) Flap Reconstruction

With GAP flap reconstruction, the breast is recreated using tissue from your derriere. There are two subcategories of this method, one that harvests the fat, skin, and blood vessels from the upper part of your buttocks, called S-GAP (Superior Gluteal Artery Perforator) and the I-GAP (Inferior Gluteal Artery Perforator), where the donor site is the lower hip and buttock. Each carries its own advantages and disadvantages, some of which have led certain surgeons to no longer perform the I-GAP.

If you are a woman who a qualified surgeon deems to have too little abdominal tissue for a DIEP, or if you have previously had DIEP reconstruction on the other breast, you may choose to undergo a GAP procedure.

Usually, you will have one breast reconstructed in one surgery, and if you need both breasts reconstructed, you will need a second surgery. There are surgeons who work as teams, however, each working on a different breast at the same time. This cuts surgical time in half and allows this part of the  procedure to be completed in one surgery, instead of two.

Pros and Cons of  GAP Flap Reconstruction (in addition to those listed for flap reconstruction):

Pro:

• ·Pain and discomfort less than from DIEP.
• ·Scar hidden when wearing a swimsuit.
• ·Provides an alternative for women who have previously had DIEP reconstruction on the other breast.

 Con:

• ·Surgical time longer than DIEP. Depending on surgeon, this could mean 2 surgeries.
• ·Surgical drains in place longer than for DIEP.  
• ·Need to address symmetry of buttocks for unilateral breast reconstruction.

Pros and Cons of S-GAP vs. I-GAP Reconstruction (in addition to those listed for flap reconstruction):

S-GAP Pro:

• ·Donor site is on upper derriere, thus causing little pain upon sitting down during healing.

S-GAP Con:

• ·Scar more visible when naked.

I-GAP Pro:

• ·Scar is less visible in crease under buttocks.
• ·Easier surgery to perform than S-GAP.

I-GAP Con:

• ·Scar may be visible on thigh.
• ·Results in squarer buttock shape.
• ·Some surgeons are concerned that without the fat pad, as you age and skin thins, sitting on that pressure point may become painful or cause nerve damage, though there is no published longitudinal information available yet.

Hip Flap Reconstruction or LAP (Lumbar Artery Perforator) Flaps

The Hip flap uses fat from the waistline in the lower back, upper buttock area and back of the hips. It is also sometimes referred to as a Lumbar flap, but the area is probably best known to women as their “love handles.”

Pros and Cons of Hip Flaps (in addition to those for flap reconstruction):

Pro:

• ·Provides another donor location for flap reconstruction in thinner women.
• ·Results in buttock lift.
• ·Works well when stacking with flaps from other areas.

Con:

• ·Very few surgeons knowledgeable in using this type of flap.
• ·When stacked with DIEP, scar essentially encircles entire torso.

Stacked (Chimeric) Flap Reconstruction

Another step in the evolution of flap reconstruction is the ability to stack flaps from different parts of the body in order to rebuild a breast. The number of surgeons using this technique is even fewer than those doing DIEP flaps. Stacked flaps make flap reconstruction possible for a woman who may have been told by other plastic surgeons that she has too little extra fat for a DIEP. There are various combinations of flaps that can be stacked, including a stacked DIEP for unilateral reconstruction, stacked DIEP with GAP flaps, and stacked DIEP with hip flaps.

Pros and Cons of Stacked Flaps (in addition to those listed for flap reconstruction:

Pro:

• ·Allows flap reconstruction for thinner women.
• ·Increases size possibilities for flap-reconstructed breasts.
• ·Provides an alternative for women who have previously undergone DIEP for the other breast.

Con:

• ·Few surgeons capable of performing these procedures.
• ·Requires twice the operative time as a single flap.
• ·More donor sites equal more post-operative drains and areas for complications.

 Types of Flap Reconstruction that use muscle (besides TRAM):

Latissimus Dorsi Flap Reconstruction

The Latissimus Dorsi Flap was first used when radical mastectomies were still routinely  performed. Since that procedure involved removal of the pectoralis muscle, this left only  skin to cover the breast implants, rather than muscle and skin as is used today. Aesthetically, this left much to be desired. So surgeons developed a new technique, stretching the large latissimus dorsi muscle and accompanying skin and fat from below the shoulder blade area and tunneling it around to the front in order to better cover the breast implant, though in some cases, an implant was unnecessary. Generally, when an implant is used, the woman must undergo the same expander process as with traditional implant reconstruction, necessitating a second exchange surgery. The development of the TRAM flap, which needs no implants, largely replaced the latissimus dorsi flap as a breast reconstruction method.

Pros and Cons of Latissimus Dorsi Flaps:

Pro:

• ·Back-up procedure, usually of last resort.

Con:

• ·Usually requires an implant, with its associated difficulties.
• ·Back muscle weakness when arm is raised.
• ·Some women experience weakness in arm or shoulder.
• ·Tight feeling across back and chest.
• ·Ten to 15 cm. (4-6 inch) diagonal back scar following line of one of the ribs.
• · 

TUG flap (transverse upper gracilis) Reconstruction

The TUG flap uses the tissue of the inner and upper thigh (just beneath groin crease), an area that usually provides less fat than other donor sites. It also uses gracilis muscle, which is one of the muscles used in moving and flexing your thigh, though some surgeons claim its use results in no noticeable functional impairment.

Pros and Cons of TUG flap Reconstruction:

Pro:

• ·Results in inner thigh lift.
• ·Avoids abdominal or gluteal scar.

Con:

• ·Uses leg muscle.
• ·Muscle in flap shrinks as it heals.
• ·Leaves visible scars and possible thigh deformity.
• ·Provides less volume.