Breast Reconstruction

Breast Reconstruction Options

Each reconstruction patient is different. Factors such as the severity of the cancer, the patient’s breasts before surgery, and the amount of tissue available after a mastectomy or lumpectomy determine the breast reconstruction techniques that will be performed.² The first goal of breast surgery is to cure the cancer if present, and this need directs the recommended reconstructive option.

There are various methods of breast reconstruction, including implant-based, tissue expander, or flap procedures such as the TRAM flap, DIEP Flap (deep inferior epigastric), and latissimus dorsi flap plus an implant or expander using perforator tissue. Adjunctive procedures include fat transfer, use of ADM, and nipple-areolar reconstruction.

Direct-to-Implant

A patient who has good skin laxity and who has enough preserved tissue after mastectomy surgery can often have an anatomically shaped implant inserted immediately following mastectomy. Patients who do not have enough lax breast tissue for reconstruction or who want to be significantly larger postoperatively will require a delayed reconstruction with tissue expanders to make room before breast implants can be inserted to achieve the desired size.

For the patient with a genetic risk (BRCA 1, BRCA 2, CHEK2 gene, or familial high-risk breast), a nipple-sparing mastectomy with direct-to-implant reconstruction with an anatomical implant, immediate fat grafting, and mastopexy as warranted can create a visually beautiful enhancement of the preoperative breast. These technical advances enable a mostly ’one-step’ approach to breast reconstruction and are cosmetically indistinguishable from pure aesthetic breast augmentation. A secondary minor procedure to refine the mastopexy or graft additional fat may be desirable for both patient and surgeon.

In some cases, a pre-pectoral, minimally invasive approach can be used to avoid any donor site deformity and undesirable animation effect postoperatively.

These sophisticated techniques are often extended to patients with smaller breast cancers away from the nipple-areolar complex deemed suitable candidates by their breast oncological surgeons.

Flap Reconstruction

Flap reconstruction involves autologous tissue only (no implants), usually harvested from the lower abdomen (DIEP, Free TRAM, Pedicle TRAM). The advantage of this approach is the ability to avoid breast implants; this is also the disadvantage, as implants add significant aesthetic power to the end result. This type of reconstruction is ideal for the patient with excess lower abdominal tissues and more than adequate extra tissue and blood supply to fill the mastectomy defect. None of these procedures should be confused with tummy tucks as they all weaken the abdominal wall to some degree, particularly in bilateral reconstruction, have a longer recovery than other techniques for breast reconstruction, a higher failure rate, and can result in abdominal bulges and (rarely) hernias, especially with advancing age and weight gain.

In some instances, the breast can be reconstructed using liposuction fat only as donor material. This has the advantage of building a breast completely out of body tissues while avoiding the potential complications traditionally associated with tissue flaps. It generally requires the use of an external tissue expansion device for a period of 2 to 3 weeks prior to fat transfer and requires multiple rounds of (2 to 3) treatment. The big advantage is the body sculpting which is combined with breast reconstruction that avoids the use of implants.

Hybrid Reconstruction Procedures

Some patients may benefit from a hybrid reconstruction using tissue from the upper back (latissimus flap) and an implant or tissue expander. These patients can expect a complete return of function with appropriate [postoperative physical therapy to regain strength and flexibility. Most return to preoperative competitive tennis and golf. Latissimus flap and implant reconstruction are ideal for patients requiring skin-sparing mastectomies or who have a history of prior breast radiation. They can be very useful in salvaging a poor result. Latissimus flap breast reconstruction, when combined with anatomically shaped implants and fat grafting, results in aesthetically beautiful breasts and can yield long-lasting excellent results, frequently surpassing the preoperative appearance of the breasts.

Areolar Reconstruction

For some patients, the finishing step involves nipple-areolar reconstruction. Modern technology allows surgeons to recreate a natural-looking nipple by using a nipple mound flap. However, patients can also opt for a cosmetically tattooed areola and nipple applied by a tattoo procedure makeup technician.

Patients who have breast reconstruction elsewhere and have step-off deformities of the upper chest and cleavage areas due to a lack of soft tissue fill are usually candidates for fat transfer procedures to soften, fill in defects, and refine their results. Excess fat is removed from other areas by liposuction, purified, and re-injected into the breast area and chest to add volume, correct contour deformities, and soften the tissues.