Breast Reconstruction Options After Mastectomy
Any woman facing mastectomy because of breast cancer has the right to have breast reconstruction. Breast reconstruction is not a cosmetic surgery procedure and is covered by insurance plans as long as the mastectomy is covered. There are many reconstructive options to choose from.
Breast reconstruction performed at the same time as the mastectomy is known as “immediate reconstruction”. Immediate reconstruction is generally associated with the best cosmetic results but, more importantly, the patient avoids the psychological trauma of waking up from surgery with a flat chest.
Some patients do not have access to a reconstructive surgeon at the time of the mastectomy. Other patients are advised to avoid immediate reconstruction because radiation therapy is likely after the mastectomy. In these cases, the reconstruction can be performed some time after the mastectomy. This is known as “delayed reconstruction”.
The most common reconstructive procedure in the US is implant reconstruction. This is typically performed as a two-stage process. The first surgery involves placement of a temporary implant (tissue expander) which is used to obtain the desired breast size. Tissue expanders can be placed at the same time as mastectomy or at a later date. Several weeks after the desired size is achieved, the expander is replaced by the permanent implant at another surgery. Some surgeons perform implant reconstruction as a single stage surgery placing the permanent implant at the same time as the mastectomy. This is known as the “one-step” procedure. Not all women are candidates for this.
Implant reconstruction can be the best option for some patients. However, reconstruction with expanders and breast implants are associated with more complications than cosmetic breast augmentation. Complications following radiation therapy are also higher with implants compared to reconstructions using the patient’s own tissue.
The Latissimus flap is one of the most common tissue reconstructions performed in this country. It uses the skin, fat and muscle (latissimus dorsi muscle) from the mid-back. This tissue is tunneled under the armpit skin and onto the chest to recreate the breast mound. Some women will also require an implant under this tissue for additional breast volume. The loss of function from moving the latissimus muscle is generally very well tolerated in all but the most active women.
A more attractive option for many women is the TRAM flap procedure. This uses tissue from the lower tummy, rather like a “tummy tuck”. Skin, fat and part of the sit-up (rectus) muscle is transferred to the chest to recreate the breast mound. Advantages include a natural reconstruction along with an improved abdominal contour. Disadvantages include loss of abdominal strength and a risk of abdominal bulging (“pooching”) or hernia.
DIEP flap breast reconstruction has replaced the TRAM flap as today’s gold standard in breast reconstruction. The DIEP flap uses only skin and fat. This is disconnected from the lower abdomen and reconnected to the chest area using microsurgery to create a new breast. Since all the abdominal muscles are saved, patients do not have to sacrifice their abdominal strength. They also experience less pain and have a quicker recovery than TRAM patients. The risk of abdominal bulging and hernia is also very small. The SIEA flap is a variation of the DIEP flap. It is associated with an even easier recovery and a 0% hernia risk but requires specific anatomy which not all patients have. Like the TRAM, the DIEP and SIEA procedures also provide a simultaneous tummy tuck.
There are a handful of other tissue options available for women who are not candidates or prefer to avoid using their abdominal tissue. These include the inner, upper thigh (TUG flap), lower buttock crease (IGAP), and upper buttock (SGAP). The best tissue option will depend on a number of factors, primarily the patient’s body habitus.
Like the DIEP flap, the GAP and TUG flap procedures are unfortunately not offered by most plastic surgeons as they require advanced training in microsurgery and reimbursement is very low. Only about 40 surgeons in the US perform these advanced breast reconstruction procedures routinely.
Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction after mastectomy, particularly DIEP breast reconstruction. In-network for most US insurance plans. PRMA Plastic Surgery, San Antonio, Texas. (800) 692-5565.