Breast reconstruction

ALSO KNOWN AS: Breast implants; deep inferior epigastric perforator (DIEP) flap; free flap; gluteal flap; latissimus dorsi flap; pedicle flap; saline breast implants; silicone breast implants; transverse rectus abdominis muscle (TRAM) flap

DEFINITION: Breast reconstruction is a complex procedure performed by a plastic surgeon that restores the appearance of a breast after mastectomy to treat breast cancer.

Cancers treated:Breast cancer

Why performed: Breast reconstruction is performed to reconstruct the size and shape of the breast in a patient who has had a mastectomy. Most women who have had a mastectomy can have breast reconstruction, which may be done either at the time of mastectomy or at a later date. Breast reconstruction may improve the self-esteem and body image of a woman who has had a mastectomy.

Patient preparation: A patient facing a mastectomy who is interested in breast reconstruction will likely be advised to consult with a plastic surgeon experienced in breast reconstruction prior to the mastectomy. Ideally, the breast surgeon and the plastic surgeon work together to develop the best surgical and breast reconstruction strategy for each patient, even if the reconstructive surgery will be done later. Two or more operations probably will be needed to achieve a satisfactory result.

A patient will be given specific instructions prior to surgery. Since smoking can decrease a patient’s blood circulation, which is critical to the survival of transplanted tissue, a patient who is a smoker will be given instructions and tips to quit smoking prior to reconstruction procedures that involve the use of transplanted tissue.

Steps of the procedure: There are two basic types of breast reconstruction, implant procedures and tissue flap procedures. A combination of these procedures may also be used. Either type of procedure may be begun either at the same time as the mastectomy (immediate reconstruction) or at a later time (delayed reconstruction).

Saline-filled implants are the most common type of breast implant used and consist of external silicone shells filled with sterile saline. The use of silicone gel-filled implants has decreased because of concerns of possible health risks if silicone leaks from the implant.

Sometimes a one-stage procedure is possible, where the implant is placed behind the pectoral muscle in the chest in the first surgery. For most patients, a two-stage procedure is used in which a tissue expander, like a balloon, is implanted beneath the skin and chest muscle. Over a period of several months, the surgeon injects a saline solution at regular intervals to fill the expander and stretch the chest pocket. At the appropriate time, the expander is removed in a second operation and the permanent implant is put into place.

Tissue flap procedures involve autologous tissue reconstruction and are the more surgically complex option for breast reconstruction. Tissue from the abdomen or back (more commonly), or buttocks or thighs (less commonly), is used. Two types of methods, pedicle flap and free flap, are used. In a pedicle flap procedure, some of the blood vessels feeding the tissue to be transferred are cut and some are kept intact. The tissue is tunneled beneath the skin to the chest area, where a new breast mound or pocket for an implant is created. In a free flap procedure, the flap of skin, fat, blood vessels, and muscle tissue is disconnected from its blood supply completely and removed from its original location, and intricate microsurgical techniques are used to reattach the tissue flap to new blood vessels near the chest. This procedure typically takes longer to complete than a pedicle flap procedure.

Four main tissue flap procedures are performed: the TRAM (transverse rectus abdominis muscle) flap, the DIEP (deep inferior epigastric perforator) flap, the latissimus dorsi flap, and the gluteal flap.

The TRAM flap procedure uses tissue and muscle from the lower abdominal wall, which may be transferred as a free flap or a pedicle flap. This procedure also results in a tightening of the lower abdomen, or a “tummy tuck.” Variations on this procedure use different amounts of abdominal muscle. The use of less muscle for reconstruction may help the patient retain abdominal strength after surgery.

The newer DIEP flap procedure uses skin, fat, and minimal abdominal muscle tissue, and it uses a free flap approach. Patients generally retain more abdominal strength with this type of breast reconstruction.

The latissimus dorsi flap procedure transfers skin, fat, muscle, and blood vessels from the upper back as a pedicle flap, tunneling the tissue under the skin to the front of the chest. The amount of skin and other tissue used in this procedure is generally less than in a TRAM flap surgery, making it useful for reconstructing small and medium-sized breasts or for creating a pocket for a breast implant.

The gluteal flap is a free flap procedure that uses skin, fat, blood vessels, and gluteal muscle tissue from the buttocks to create the breast shape. This procedure is an option for women who cannot use the abdominal site due to thinness or incisions, or for patient preference.

Nipple and areola reconstruction is optional and, if done, is performed as a last step after the patient has healed from the first surgeries. The nipple is reconstructed using tissue from the breast itself or from another part of the patient’s body, such as the inner thigh. The areola may be created by tattooing the skin to make it match the natural nipple and areola. Saving the nipple from the breast with cancer that is removed (called nipple saving or nipple banking) is sometimes done, but there are risk factors associated with this procedure because the nipple tissue might contain cancer cells.

After the procedure: A patient will likely feel tired and sore for a week or two after implant reconstruction, and longer, perhaps months, after tissue flap reconstruction. The patient will probably be discharged from the hospital with a surgical drain in place to allow excess fluids to drain from the surgical site. Stitches will be in place after the surgery, but they will most likely be absorbable sutures that will not have to be removed. Scars will fade over time but never go away entirely. It takes about six to eight weeks for the patient to return to normal, depending on the type of procedure performed. A patient will be advised to take it easy during this period and avoid overhead lifting and strenuous physical activity.

Risks: Some risks of breast reconstructive surgery are bleeding, fluid collection, swelling and pain, excessive scar tissue, infection, the death of all or part of the flap, problems at the donor site, fatigue, changes in the affected arm, and the need for additional surgeries to correct problems.

If an infection develops after the implant surgery, then the implant may need to be removed until the infection clears. If an infection develops after flap surgery, then surgical cleaning of the wound may be necessary.

Sometimes local complications occur with breast implants. The most common of these is capsular contracture, which can occur if the scar or capsule around the implant begins to tighten and squeeze down on the soft implant, making the breast feel hard. More surgery may be needed to remove the scar tissue, or the implant may need to be removed or replaced. Rarely, rupture of the implant may occur. Implants may not last a lifetime, so additional surgeries may be needed to replace them.

Textured implants, both silicone and saline, have been linked to cases of anaplastic large cell lymphoma (BIA-ALCL). Though the cancer is found in the breast, it is not breast cancer. Instead, it is a rare form of T-cell lymphoma that develops in the scar tissue surrounding the implant. Though rare, this type of cancer can metastasize if not found. As of 2023, the American Society of Plastic Surgeons reported a total of 1,352 cases of BIA‗ALCL.

Breast reconstruction has no known effect on the recurrence of breast cancer, and neither implant nor flap procedures decrease the likelihood of detection of a recurrence of breast cancer.

Results: Breast reconstruction after a mastectomy can improve a woman’s appearance and self-confidence. Although the surgeon will try to create a breast shape that matches the other breast closely, a perfect match is not possible, and a reconstructed breast does not have natural sensations. In some cases, surgery on the other breast is performed to improve the match.

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