Breast reconstruction is a broad field involving the treatment of many different kinds of breast problems, including congenital or developmental problems with the breast, asymmetry between the breasts, trauma and breast cancer.
The most common type of reconstructive breast surgery performed is surgery to restore the breast after surgery for breast cancer. In breast cancer treatment, a portion or all of the breast must be removed to remove the cancer. Sometimes radiation is used to control the cancer also. Ideally, you should discuss your cancer treatment and resection with the surgeon who will be doing your reconstruction afterwards. This way you can understand how your treatment options will affect your reconstruction options. Also, if involved early, your surgeon may be able to begin your reconstruction process at the same time as your initial breast cancer surgery is done.
Breast reconstruction after cancer falls into three main categories.
1) Reconstruction using an implant
2) Reconstruction using your own body tissues
3) Reconstruction using a combination of an implant and your own body tissues
With implant reconstruction a silicone implant is used to replace the breast tissue that were removed. Usually, but not always, this is not an option if radiation is used to treat the breast cancer.
If a mastectomy has been performed, often the implant reconstruction can be started at the same time as the mastectomy. After the surgeon performing the mastectomy has removed the breast tissue, the reconstructive surgeon will place a tissue expander within the breast cavity. The tissue expander can help preserve the shape of the skin envelope of the breast while you are healing. The expander can be used to increase the size of the skin envelope if needed post-operatively. This is done by inflating the expander with saline as an office procedure. Once the implant is at the right size, a permanent implant can be selected and the tissue expander can be replaced with a permanent implant.
Native tissue Reconstruction:
Another option for reconstruction is to transfer tissue from one area of your body to your chest to recreate the breast mound. A common way to do this is to use the lower abdominal skin and fat. This can be brought up to the chest in one of two ways. The first way is to use the rectus muscle as a bridge or pedicle, to provide blood flow to the lower abdominal skin and fat. The tissues are then transferred to the chest with the muscle and it’s blood vessels acting as it’s blood supply. This is called a pedicled Transverse Rectus Abdominus Musculocutaneous Flap, which is generally shortened to pedicled TRAM flap.
Another way to move these tissues is to disconnect them from the body, while preserving the artery and veins, to move the tissues to the chest and then reattach the artery and vein to blood vessels in the chest to provide blood flow. If a portion of the muscle is taken, this is called a Free TRAM flap. The word free indicates it was disconnected from the body, before reconnecting it again. Sometimes the surgeon carefully dissects the perforating blood vessels and can leave all the muscle behind. This is called a Free Deep Inferior Epigastric Perforator Flap, or free DIEP flap.
There are many types of flaps that can be taken from different areas of the body. Some are pedicled (remain attached to the original blood supply) and some are free flaps (are released from the original blood supply, and reattached elsewhere).
Sometimes the patient has a contraindication to breast reconstruction with an implant alone, but does not have enough native tissue to make a breast of the desired size. In this situation a combination of native tissue and an implant may be used. A common way to do this is with a Pedicled Latissimus flap. The Latissimus muscle and some skin from the back is transferred to the chest, and a small implant is placed underneath it to give the breast the volume desired.
Risks of Surgery:
Breast surgery, as with any surgery, carries with it some risks. The risk of complication is low, but it is something you need to understand and discuss with your surgeon thoroughly before having surgery. In addition to the normal risks of bleeding, infection and scarring, there are some risks that are specific to breast surgery. For example, your ability to breast feed may be affected by surgery.
Another example is asymmetry. A person’s breast are almost never exactly the same to start with. After breast surgery, this may be changed but it is unlikely that they will be identical. The amount of asymmetry you can expect depends on how much was present before surgery, and what kind of surgery you are having. You should discuss this with your surgeon before having surgery.
Another risk of breast surgery is changes to nipple areolar complex. The worst complication would be if the blood supply to the nipple compromised, which could cause death to a portion or even all of the nipple. Thankfully, this is a very rare complication. More common would be changes to the sensation, and function of your nipples. Depending on the type of surgery you have, your sensation will be the same (most cases) but may also be increased or decreased. Likewise, the degree of contractility (how easily they become erect) of your Nipples can be changed by surgery. This type of change occurs in about 2-3% of cases.