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Breast Reconstruction:

Exploring the Options, Procedures and Perceptions


Every woman has a right to breast reconstruction. This has now actually become a federal mandate and insurance companies have to cover all types of breast reconstruction by law.

Breast reconstruction is not a form of cosmetic surgery. Breast reconstruction restores something that nature has provided but cancer has taken away.

There is no age limitation for breast reconstruction and there are multiple reconstructive options available. There is no single procedure that is best for everyone; the best option will become clear following lengthy discussion between the surgeon and patient.

Tissue Expanders/Implant Reconstruction

The most common method of reconstructive breast surgery in the United States is using expanders and implants. Most surgeons perform this is a two-stage procedure. The expander can be placed at the same time as the mastectomy ("immediate reconstruction") or after the mastectomy has healed ("delayed reconstruction"). Immediate reconstruction generally provides better results. The expander is used to stretch the skin envelope and recreate the size of breast the patient wants. The expander is ultimately replaced by a permanent implant (saline or silicone) at a separate procedure several months later.

Some patients are candidates for one-step implant reconstruction whereby a permanent implant 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 Alloderm (an acellular dermal graft). Two types of implants are available to patients: Saline and Silicone. There are many opinions regarding both types of implants and it is advised that you speak with your surgeons as to which implant would be best for you. Patients who undergo Implant Reconstruction should be aware that their implants may need to be replaced at a future date.

Implant reconstruction can be the best option for some patients. However, expanders and implants can be fraught with complications long-term, particularly if the patient has had or is going to have radiation therapy as part of her cancer treatments. For these reasons, many surgeons and patients prefer autologous reconstruction, i.e. reconstruction using the patient's own tissue taken from another part of the body.

Latissimus Dorsi Flap

The Latissimus procedure uses muscle from the back of the shoulder blade which is brought around to the breast mound to help create a new breast. During the procedure a section of skin, fat and muscle is detached from the back and brought to the breast area. A majority of patients who undergo the Latissimus Flap procedure also require an expander in order to obtain a satisfactory result. The expander is replaced by a permanent implant at a second procedure down the line. Patients will have a scar on their back shoulder region that can sometimes be seen through a tank-top, swimsuit or sundress. The upper back can be numb or sore for a few following this procedure until the nerves grow back and your incisions are completely healed. Women who are very active in sports should know that this procedure can reduce your ability to participate in such activities like golf, climbing, swimming, or tennis.

TRAM Flap (Transverse Rectus Abdominis Myocutaneous)


There are 3 main forms of TRAM flap reconstruction that are commonly used:

  • The PEDICLED TRAM flap: this was the first procedure to describe use of one of the rectus abdominis muscles (sit-up muscle) for breast reconstruction. This procedure begins with an incision from hip to hip. Then, a "flap" of skin, fat and one of the patient's abdominal muscles is tunneled under the skin to the chest to create a new breast. Recovery from the pedicled TRAM flap procedure is difficult and painful. Long-term, the patient has to adapt to the loss of some of their abdominal strength (20%). As with any procedure there is the possibility of complications including delayed healing, fat necrosis (part of the tissue turns hard due to poor blood supply), loss of the reconstruction altogether (rare), and abdominal complications such as bulging and/or hernia.
  • The FREE TRAM flap: this procedure involves disconnecting the flap from the patient's body, transplanting it to the chest, and reconnecting it to the body using microsurgery. Advantages over the pedicled TRAM include: improved blood supply (and therefore less risk of healing problems and fat necrosis), and less muscle sacrifice (so the abdominal recovery is a little easier, potentially more strength is maintained long-term, and the risk of bulging and hernia formation is lower). Since the tissue is disconnected and transplanted to the chest, there is also no tunneling under the skin as there is with the pedicled TRAM and no subsequent bulge in the upper abdomen (which is typically seen with tunneling).
  • The MUSCLE-SPARING FREE TRAM flap: similar to the free TRAM except the amount of muscle taken is typically very minimal (postage-stamp size). This procedure is associated with all the benefits of the free TRAM but with significantly fewer abdominal side effects and complications (pain, bulging, hernia, strength loss) because such a small amount of muscle is sacrificed. The PRMA surgeons perform this procedure if the patient's anatomy does not allow for a DIEP or SIEA flap.

DIEP Flap (Deep Inferior Epigastric Perforator)

The DIEP breast reconstruction has replaced the TRAM as today's gold standard in breast reconstruction. This is the most common type of breast reconstruction performed by Dr. Chrysopoulo with over 250 DIEP breast reconstructions performed at PRMA every year.

The DIEP flap was first described in the early 1990s but has remained less popular than the TRAM flap, presumably because of the increased complexity and difficulty of the procedure compared to the TRAM. The DIEP Flap procedure is similar to the free TRAM flap but only requires the removal of skin and fat. NO MUSCLE is sacrificed. The blood vessels required to keep the tissue alive lay just beneath the abdominal muscle. Therefore, a small incision is made in the abdominal muscle in order to dissect the vessels and microsurgery is required to reattach the blood vessels to the chest area. Even though an incision is made in the abdominal muscle NO abdominal muscle is removed or transferred to the breast in the DIEP Flap procedure. As a result, patients do not have to sacrifice their abdominal strength and experience less pain and a much quicker recovery. The risk of abdominal bulging and hernia is also very small.

So the advantages of the DIEP flap are multiple: it recreates a breast that often looks and feels like a normal breast; abdominal strength is not affected; the risk of bulging or hernias is significantly reduced; and, like the TRAM flap, the patient benefits from a simultaneous tummy tuck. The DIEP flap is a very technically demanding operation but the benefits are tremendous for the patient, especially when performed at the same time as a skin-sparing mastectomy.

Dr. Peter LeDoux, Dr. Steven Pisano, Dr. Chet Nastala and Dr. Minas Chrysopoulo are the only physicians in San Antonio who perform the DEIP (Deep Inferior Epigastric Perforator) microsurgery procedures. Collectively they performed 1387 flaps between 2002-2007. Of the 1387 flaps performed there have only been a loss of 1.73%.

SIEA Flap (Superficial Inferior Epigastric Artery)




The SIEA Flap procedure is very similar to the DIEP Flap procedure. The main difference between the SIEA and DIEP is the artery used for blood flow supply to the reconstructed breast. The SIEA arteries are generally found in the fatty tissue just below skin. As in the DIEP the SIEA flap reconstruction does not sacrifice the abdominal muscle and only uses the patient's skin and fat to reconstruct the breast. While the SIEA flap procedure is similar to the DIEP it is used less frequently since the arteries required are generally too small to sustain the flap in most patients. Only about 20% of patients have the anatomy required to allow this procedure.

 

GAP Flap (Gluteal Artery Perforator)

Women who do not have an adequate amount of abdominal tissue for reconstruction may be eligible for the GAP Flap. This procedure uses excess skin and fat from the gluteal or buttock region. The procedure is much like the DIEP Flap, which spares the muscle. With the GAP flap procedure your surgeon can take fat and tissue from either your superior (upper buttock) region or inferior (lower buttock) region. Our surgeons prefer to use the upper buttock region (known as the sGAP). Both incisions can be easily hidden with underwear. If the GAP procedure is performed as an immediate form of reconstruction the patient will first undergo the mastectomy as usual. Following the mastectomy the patient will then be gently turned onto her stomach and the gluteal flap harvested. The patient is then turned back onto her back and the microsurgical reconstruction is performed and the breast is shaped. If a patient wants bilateral reconstruction with GAP flaps most surgeons prefer to only perform one side at a time. It is important to discuss this possibility with your surgeon. Advantages of the GAP flap include: a scar that is generally hidden with underwear or swimsuits, and no loss of muscle function or strength. As with any surgery there can be complications and patients often require multiple surgeries for the optimal cosmetic result.

To schedule an appointment with Dr. Chrysopoulo to discuss all your breast reconstruction options, please call 210-692-1181.

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