Monday, January 25, 2010

Breast Reconstruction Surgery Options After Mastectomy

Every woman has a right to breast reconstruction surgery after breast cancer. This has been a federal mandate for some time and insurance companies have to pay for breast reconstruction surgery by law. There is no age limitation for breast reconstruction and there are many different options available.

"Immediate" breast reconstruction is performed at the same time as the mastectomy. Advantages include: preserving most of the patient's breast skin, a shorter/less obvious mastectomy scar and waking up with the new breast already in place (and avoiding the experience of a flat chest). It also generally provides the best cosmetic results particularly when combined with nipple-sparing or skin-sparing mastectomy.

"Delayed" reconstruction generally takes place after the mastectomy has healed. Many times patients required to undergo radiation following their mastectomies are advised to delay reconstructive surgery in order to achieve the best results. It is common to wait several months after the last radiation therapy session before proceeding with reconstruction to allow the soft tissues to recover completely from the radiotherapy.

Tissue expander reconstruction is the most common method of breast reconstruction in the United States. Most plastic surgeons perform this as a two-stage procedure. The expander is used to stretch the skin envelope and create the size of breast the patient and plastic surgeon desire. The expander is replaced by a permanent breast implant (saline or silicone) at a separate procedure some time later.

Some patients are candidates for one-step implant reconstruction (without expanders): a permanent breast implant is inserted immediately without going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and an acellular dermal graft (like Alloderm or FlexHD). These grafts are tissue implants that provide support and increase the amount of padding over the implant.

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 procedure uses muscle (latissimus dorsi), fat and skin from the back (below the shoulder blade) that is brought around to the chest to create a new breast. Many patients also need an expander to obtain a satisfactory result. The expander is replaced by a permanent implant at a second procedure down the line. Patients typically a scar on their back that can be seen with some low-cut clothing. Women who are very active in sports may notice some strength loss with activities like golf, climbing, or tennis.

TRAM flap surgery is a common procedure that uses skin, fat and varying amounts of the sit-up muscle (rectus abdominus) from the lower abdomen. The tissue (or flap) is then relocated to the chest to create the new breast. This procedure also results in a tightening of the lower abdomen, or a "tummy tuck." Unfortunately, sacrifice of all or part of the abdominal muscle can result in bulging (or “pooching”) of the abdomen and even a hernia. Up until a few years ago, this was the gold standard in breast reconstruction.

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.

Women who do not have enough abdominal tissue for reconstruction may be eligible for the GAP (buttock) or TUG (upper inner thigh) flap procedures. The resulting scars are generally easily hidden by most underwear.

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 procedures routinely.


Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction including advanced techniques like the DIEP flap procedure. Keep up to date with the latest news in breast cancer reconstruction at The Breast Cancer Reconstruction Blog, on Facebook and on Twitter!


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