Mastectomy: options for breast reconstruction

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There are several options for breast reconstruction after mastectomy. It is important to consult with a board certified plastic and reconstructive surgeon about options that are available to you based on your body type and size, your personal preference, and medical condition. It is also important to determine whether or not you would like to have breast reconstruction at the time of your mastectomy, or have the procedure done at a later date. Usually, both options are open for most women.

Options for breast reconstruction after mastectomy include:

Latissimus dorsi flap procedure: This procedure uses muscle and skin from your upper back to reconstruct your breast. The surgeon removes a section of muscle and skin and tunnels it under your arm to your chest to create a breast. By moving the muscle and skin in this manner, a blood supply is maintained to the tissue, which increases the chance that the flap will succeed.

TRAM flap procedure: This procedure uses muscle and skin tissue from your abdomen, which the surgeon will tunnel to your chest wall to form a breast. It is also possible to have this procedure done as a “free flap” where the muscle and skin are removed from your abdomen and reattached to a blood supply in your chest. (The effect on your abdomen in either case is similar to a tummy tuck.) This option might not be available to you if you have back problems, smoke or do not have enough fat in your abdominal area.

Gluteal flap procedure: This procedure uses skin and muscle from your buttocks to create a breast mound. This procedure is only done as a “free flap” where the surgeon removes the buttocks tissue and attaches it to a blood supply in your chest.

It is important to note that these flap procedures require several hours of surgery to complete (up to 8 hours in some cases). Many women require some type of physical therapy to learn to adjust to a missing muscle in the back or abdomen.

In addition, some women may require an implant in addition to their own tissue to construct a breast mound. The cosmetic results from these procedures are very pleasing to women, as their reconstructed breast feels natural and looks very much like the opposite breast. It is possible to have breast reconstruction using a saline or silicone implant, although the FDA has severely restricted access to silicone implants.

Breast reconstruction using an implant may first require a tissue expander (depending on the size that the reconstructed breast will become; women who desire small breasts do not need an expander). The expander is inserted first, and there is a tube that extends from the healed incision. Over a period of weeks, the physician will inject saline (salt water) into the tube to slowly inflate the expander and stretch the skin and muscle. In some cases, the expander will be inflated slightly larger than the true breast size; this is to ensure that the skin is loosened enough to insert the implant.

The plastic surgeon will remove the expander in surgery, and insert a silicone or saline implant. Some women prefer a silicone implant for reconstructive purposes, as it creates a more natural feeling breast in their opinion. Other women feel saline implants are natural and they are more comfortable with that option.

Surgery to insert an implant is much shorter than a flap procedure, although many women feel that having an expander is difficult. Some women feel pressure and pain while their expander is being inflated, and it can be difficult at the time when the expander is slightly bigger than the opposite breast. In addition, it can be awkward after surgery when it takes some time for the implant to “sag” into place (it can appear to be higher on your chest than your opposite breast). After the implant shifts down slightly, it makes the breast shape appear more natural looking.

It is necessary to enroll in a clinical trial with a participating surgeon in order to receive a silicone implant. The trial is designed to look at the rate of complications, and to monitor women who have silicone implants.

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