Breast Reconstruction

Immediate versus delayed reconstruction. When breast cancer reconstruction is performed at the same time as the mastectomy, this is referred to as immediate breast reconstruction. If a mastectomy is performed, but no reconstruction is performed at that time, breast cancer reconstruction can be started months or even years later; this is referred to as delayed breast reconstruction.

Tissue expander/implant reconstruction versus tissue or flap reconstruction. The breast can be recreated with breast implants or by moving tissue from another part of the body into the breast. The former is referred to as implant or tissue expander breast reconstruction; the latter, as flap or tissue breast cancer reconstruction.

Tissue expander. Once a mastectomy is performed, the breast skin shrinks (contracts) and has reduced blood flow, so an implant big enough to reconstruct the breast will not initially fit. So a surgical balloon called a tissue expander is first placed to stretch the tissues.

Flap. The term “flap” is used in plastic surgery to describe tissue that is taken from one area of the body, moved, reshaped, and used to rebuild another area where tissue has been lost due to trauma, cancer treatment, or other causes.

TRAM flap. TRAM is the acronym for the Transverse Rectus Abdominus Myocutaneous flap. Transverse refers to the horizontal orientation of the football-shaped area of skin used for this flap; the skin of the lower belly. The rectus abdominus is the wash-board muscle on the front of the belly (abdomen), which also makes up the flap, along with the overlying skin and fat. Myocutaneous denotes the presence of muscle (myo, from latin) and skin (cutaneous, from latin) in the flap. Obviously, it easier just to say TRAM flap. The TRAM is the most commonly used flap in breast reconstruction after cancer.

The pedicled TRAM flap, free TRAM flap, and DIEP flap. (This is particularly technical; feel free to read it twice.) The TRAM flap has three basic variations. The pedicled TRAM flap is lifted off the belly and left attached (pedicled) to the top (origin) of the rectus abdominus muscle at the lower border of the rib cage. The flap is tunneled under the skin into the breast pocket created by the mastectomy.

The free TRAM is actually taken out of the abdomen completely (not tunneled) and is therefore temporarily free of the body (hence the name). The main artery and vein (the deep inferior epigastric artery and vein) going into the flap are then connected to recipient vessels in the armpit or chest (which must be exposed by the surgeon). A microscope is generally used to assist with reconnecting the vessels.

DIEP is the acronym for deep inferior epigastric perforator flap. The deep inferior epigastric vessels, as mentioned, are the main artery and vein going into the TRAM flap. They travel through the rectus abdominus muscle prior to entering the fat and skin. The vessels can be dissected out of the muscle and into the skin, so that the muscle can be left in the abdomen. As with the free TRAM, the DIEP requires that the vessels be disconnected from the body and reconnected in the chest or armpit; otherwise, the tissue would not reach the breast.

Latissimus flap. This flap uses the latissimus muscle (the large muscle on the side of the back) and overlying skin and fat to reconstruct the breast after cancer. Generally, this flap must be used with a breast implant because it is not large enough to restore adequate breast volume in most patients.

Patient preference or preconceptions;

Surgeon preference and experience;

The patient’s health, including factors like smoking history, diabetes, and obesity;

The size and shape of the breasts;

The type and stage of cancer and whether radiation or chemotherapy will be used;

Other factors, like prior surgery and body habitus or shape;

Flap breast cancer reconstruction is more involved initially than tissue expander reconstruction, but the expansion process (including office visit for expansion and a second stage to replace the expander with a permanent implant) takes longer to complete.

If a flap is used, surgery takes longer, sometimes several hours. Recovery is also harder than implant reconstruction because the patient’s belly or back have to heal. There are also scars at the donor sites. But once the flap is healed, the patient usually does not have any other surgery over her lifetime for breast cancer reconstruction, except nipple reconstruction.

If tissue expanders are used, surgery usually takes less than an hour following the mastectomy, and recovery is basically the same as for a mastectomy alone, but the patient will then have saline injected into the expander in the office every week or so for approximately 2 to 4 months. The expansion sessions are quick, but emotionally it is difficult for some patients to undergo a reconstructive process that takes a few months.

Flaps involve one major surgery. Expanders require a second anesthetic to replace the expander with a permanent implant.

Nipple reconstruction is a minor procedure performed 3 months or so after flap or permanent implant placement.

Tattooing of the nipple is performed in the office 3 months or so after nipple reconstruction with local anesthetic. The reconstructive process taken out through tattooing therefore takes several months.

Patients who have had previous radiation are at higher risk of complications. If a mastectomy and radiation have already been performed, tissue expansion generally cannot safely stretch the skin and is not a good option. Some breasts that have had previous lumpectomy and radiation and now require mastectomy may be able to undergo expansion safely.

The TRAM flap breast cancer reconstruction is generally not a safe option for heavy smokers, diabetics, and obese patients.

For reconstruction of one breast, Dr. Goldman uses implants and the TRAM flap about equally. In general, he is more likely to use the TRAM flap in younger patients and patients who are more concerned with the appearance of the breast than with donor site issues like weakening of the belly or recovery time.

Dr. Goldman prefers silicone to saline implants for most breast cancer reconstruction patients, but believes the distinction between the two are often over-emphasized since both types of implants can produce excellent results.

The main benefit of the DIEP versus the TRAM flap is preservation of the rectus abdominus muscle and therefore of abdominal wall strength. The main disadvantages of the DIEP is longer operating room time and a higher incidence of fat necrosis (hardening of areas of fat within the flap). For reconstruction of one breast, the pedicled TRAM flap is by far the most commonly performed flap based on its track record of reliability, excellent aesthetics, natural feel, and ease of use. The pedicled TRAM usually takes about 4 hours to perform; the DIEP usually takes 6 to 12 hours. Most patients do not notice weakening of the abdominal wall unless they are athletes, with certain tasks like sit-ups. So for unilateral (single breast) reconstruction, Dr. Goldman feels that the pedicled TRAM remains the standard.

For reconstruction of both breasts, Dr. Goldman feels that implants or DIEP flaps are preferable to the using two TRAM flaps (one for each breast), since using two TRAM flaps sacrifices both rectus abdominus muscles, and this weakens the abdominal wall significantly. Of note, many surgeons still do use two TRAM flaps in this situation. The choice between implants and the DIEP flaps in this situation is mainly based on patient preference in considering implants versus a long surgery. The DIEP’s often take 12 to 24 hours to complete. The tissue expanders take an hour or less of additional O.R. time but, as mentioned, will require tissue expansion in the office, expander-implant exchange in the operating room, and there are long term implant-related issues like leak and capsular constracture.

The overall failure rate (due to infection or similar problems) of implant breast cancer reconstruction is about 10% in studies of large numbers of patients; the risk is probably less in healthier patients.

Nipple reconstruction is generally performed under monitored sedation and takes about an hour to perform. It is performed about 3 months after a flap or permanent implant placement, once we are sure that the breast has settled into its permanent shape. Tattooing of the reconstructed nipple and areola constitutes the last step in breast reconstruction after cancer and is typically performed 3 months after the nipple reconstruction. Nipple tattooing is performed using local anesthesia as an office procedure.

Matching procedures are often necessary to allow the reconstructed breast on one side have optimal symmetry with the natural breast on the other side. It may be necessary to perform a breast reduction, breast lift, or augmentation with a cosmetic implant on the natural breast. These procedures are covered by insurance as part of the breast cancer reconstruction.

Risks. For any surgery, risks include bleeding, infection, and anesthetic or medical complications. Longer operating times are associated with higher infection rates, and patients who undergo mastectomy and breast cancer reconstruction are more likely to require transfusion than those undergoing mastectomy alone. Tissue expander and implant breast reconstruction after cancer carry the additional risks of implant infection or exposure, which require removal of the implant. The breast has to be allowed to heal completely, generally for 3 to 6 months before expansion can be reattempted, if appropriate. Implants may leak (at a rate of about 1% per year), become distorted by hardening scar tissue (capsular contracture, which is more likely in patients with a history of radiation), shift, or develop rippling. Flaps may experience blood flow problems, which can cause all or part of the flap to die. The TRAM flap has an approximately 5% rate of weakening of the abdominal wall (hernia formation), that may require repair with mesh. The latissimus flap can cause winging of the scapula (the shoulder blade). All these procedures may require revisions to modify their size, shape, or position after the initial reconstruction. Scarring is unpredictable in general and can compromise the reconstructed breast or donor sites of the flaps.