Breast Reconstruction

Breast reconstruction is generally done following mastectomy for cancer, but may also be used for congenital and post-traumatic breast deformity.

The amount of breast tissue missing depends on the type of tumor excision done. Lumpectomy removes the tumor and a portion of the breast. A total mastectomy removes all of the breast tissue, a modified radical mastectomy generally refers to a total mastectomy with removal of the lymph nodes from the armpit, and a radical mastectomy removes all of these tissues and the underlying muscle as well. The type of cancer excision done will affect the type of reconstruction needed.

Reconstruction can be done during the same operation as the mastectomy ("immediate") or at a later date ("delayed"). Immediate reconstruction has the benefit of being done when the remaining tissues are pliable and not distorted by scar tissue, reduces the number of operations, and in many cases can allow the patient to wake up with a reconstructed breast. Delayed reconstruction may facilitate the use of other cancer treatments such as radiation and chemotherapy prior to beginning the reconstructive process.

Reconstruction can be done with the patient's own tissues ("autologous") or with implants ("prosthetic"). The decision regarding which type of reconstruction to do depends on many factors, including the body shape of the patient, scars from earlier abdominal surgeries, surgical risk factors, and patient preference.

Autologous reconstruction is most often done with a TRAM (transverse rectus abdominus myocutaneous) flap, which brings abdominal skin, fat, and muscle up to the breast based on blood supply from one of the abdominal muscles. Less tissue is available through the latissimus myocutaneous flap, which often also requires an implant for sufficient breast size. Other sites such as the hip, thigh, and buttocks may be used in selected patients. These three flaps and some TRAM flaps need to be completely separated from their blood supply and reattached to new blood vessels ("free flap").

Prosthetic reconstruction generally requires two operations. A tissue expander is placed at the first operation and then gradually inflated with saline injections in the office until stretching the overlying tissue sufficiently. At the second operation the expander is removed and a permanent implant is placed. A combined permanent expander/implant may be used in selected patients.

Reconstruction of the nipple/areola is usually done several months later, after healing has occurred from the breast reconstruction. The areola is usually reconstructed through tattooing or skin grafting, and the nipple is reconstructed with small folds of skin.

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