Breast Reconstruction (Reconstruction Mammoplasty)
For those women who have bee diagnosed with breast cancer, a procedure in which one or both breasts are removed (mastectomy) may mean the difference between life and death. However, for many women, this procedure can equate with feelings of lost femininity and a diminished sense of self esteem. Modern surgical techniques can help to alleviate this condition and allow the healing process to proceed in a more positive atmosphere.
Reconstruction Mammoplasty is a medical term that relates to the surgical reconstruction of the breast. This surgery is indicated when the patient has undergone a mastectomy in the treatment of cancer, serious trauma to the breast, disfigurement or in cases of gender reassignment. Breast implants can be used in conjunction with the surgery and many women choose to have an implant (saline or silicon-gel implants are used) placed in the non-reconstructed breast, as well.
The purpose of this is to achieve symmetry of both breasts. Whereby full function and sensitivity will not be obtained through reconstruction surgery, a balanced anatomy will be achieved which can directly relate to the patient’s self esteem.
There are three major types of breast reconstruction surgery:
A TRAM Flap procedure utilizes tissue, skin and muscle taken from the patient’s lower abdominal region in order to recreate the breast. The advantages of this procedure are twofold. First, the tissue that is used is the patient’s own tissue – thus eliminating the possibility of foreign tissue rejection. Secondly, the procedure has a slimming effect on the abdomen. This is why the procedure is sometimes referred to as a “tummy tuck breast reconstruction”.
The tissue that is removed from the abdomen can be complete with nerves and blood vessels attached that can be connected to the chest wall through microsurgery. This is a more complex procedure and is known as a “Free Flap TRAM Reconstruction”. Variations can include the deep inferior epigastric perforator flap (DIEP) and the superficial inferior epigastric perforator flap (SIEP). These procedures are much more time consuming and intricate than a simple TRAM Flap procedure (also known as a Pedicled TRAM flap).
The pedicled TRAM flap was the first operation to use of one of the abdominal muscles for breast reconstruction. The surgery is conducted under general anesthesia and begins with an incision from hip to hip. Then, a “flap” of skin, fat tissue and one of the patient’s abdominal muscles is tunneled under the skin to the chest to create the new breast.
The artery or vein is also kept intact in order to give the flap its’ blood supply. This is a highly invasive surgery that requires a relatively lengthy recovery time (approximately 6 weeks before normal activity may be resumed). The surgery itself will last approximately 4 hours followed by a hospital stay of, on average, 5 days.
Recovery and Possible Complications:
As a result of the surgery, the patient will have to adapt to the loss of some abdominal strength (up to 20%). As with any procedure, there is the possibility of complications including delayed healing, fat necrosis (due to poor blood supply), loss of the reconstruction altogether (rare) and abdominal complications such as bulging and/or hernia. Infection is also possible and can be treated with antibiotics.
DIEP (Deep Inferior Epigastric Artery Perforator) flap:
This version of the TRAM flap involves using fat and skin from the same abdominal area as the pedicled TRAM flap – but muscle tissue is not used to form the breast mound. This is known as a “free flap” technique since the entire tissue flap is removed from the abdominal area and transplanted to the chest area. The vessels are then attached using microsurgery.
The major advantage over the pedicled TRAM flap is that the abdominal muscles are left intact. This form of TRAM flap surgery requires specialized equipment and advanced training as compared to a pedicled TRAM flap procedure. The surgery is far more complex and lasts between 6-8 hours with a subsequent hospital stay of, on average, 5 days. Normal activity may be resumed in 6 weeks.
For those who may not have enough abdominal tissue for TRAM flap (or those who have had radiation treatment) – an LD (Latissimus Dorsi) flap may be performed. An LD flap utilizes skin tissue and muscle from the upper back as opposed to the abdomen. In this procedure, the flap is made up of of a patch of skin that rests over the flat, large muscle of the back (the latissimus dorsi) along with the muscle itself.
The flap is meandered under the skin to the front of the chest, via the armpit. In some cases, the volume of tissue that can be removed from the back can eliminate the need for an additional implant. During an LD flap, efforts are made to make the scar as minimal as possible by cloing the incision with a straight line. This effect results in most scars being able to hide beneath the strap of a woman’s bra. The surgery lasts approximately 3 hours with a hospital stay, on average, of 4 days. Normal activity is usually resumed in 4 weeks.
Complications that can arise are the same for any surgery and can include infection which can be treated with antibiotics. Some women may experience subsequent weakness in their back, shoulder or arm after this surgery (this is rare).
An ELD (Extended Latissimus Dorsi myocutaneous) flap is a version of the above mentioned LD flap that removes excess fatty tissue from the back to avoid the need for implants. This surgery is usually indicated for moderate to heavy obese patients. These patients can provide the excess fat tissue and are not usually a good candidate for implant surgery or other flap procedures.
A Gluteal Free flap utilizes fat, skin, blood vessels and muscle tissue taken from the buttocks in order to form the new breast. The free TRAM flap and the gluteal free flap are similar, but the gluteal free flap requires microsurgery to connect the vessels. This procedure can be indicated for those patients that have excess tissue located in the buttocks, but insufficient abdominal tissue.
Since the buttocks tissue is usually more firm than abdominal tissue (and thus harder to mold into the shape of a new breast), this procedure is more difficult and usually lasts approximately 8 hours. The subsequent hospital stay is 5 days with a return to normal activity in about 6 weeks.
Areola and Nipple Reconstruction:
Areola (the dark area around the nipple) and nipple reconstruction is optional with breast reconstruction and is at the discretion of the patient. This is usually done as a separate procedure, after the breast reconstruction has healed. Tissue is taken from the patient’s own body and tattooing can be done to match the color of the opposite breast pigment.