Types of Reconstruction
There are a wide range of different techniques for breast reconstruction, some that involve artificial implants and others that utilize your own tissue. While this can be overwhelming, knowing all of your options allows you to find the technique that works best with your body type, post-surgery status and lifestyle. This could mean combining techniques and using both implants and your own tissue to reconstruct your breast.
Significant factors to consider include what breast cancer surgery was or will be performed, whether or not radiation treatment is needed, and other personal preferences. As with all surgical procedures, different surgical centers and teams may have quite different approaches to breast reconstruction.
Breast cancer treatment is not complete until after reconstruction.
Several types of operations can be done to reconstruct your breast. Traditionally, women have had the options of newly shaped breast(s) with the use of
tissue expanders
and
breast implants
,
autologous reconstruction
using a flap of their own tissue, or a combination of the two. Today, women may choose a newer type of surgery, which uses their own fat tissue enriched with their own regenerative cells (
cell-enriched reconstruction, such as the RESTORE procedure
). The procedure may be used to fill small volume defects or in combination with breast implants.
Implant Procedures
Implants, whether they are filled with saline or with silicone, are frequently used in breast reconstruction. Today, there are more implant options than ever before and they can vary greatly in contour, texture, and in the placement of the incision. Saline implants are a silicone rubber shell filled with a sterile, saline solution and can have either a fixed volume or can be adjusted after implantation. Silicone implants also use an outer silicone shell but are filled with silicone gel which has a consistency more similar to human fat tissue.
In order to create sufficient space beneath the skin for the implant, many women who have undergone breast surgery may require the surgical insertion of a tissue expander. Once a tissue expander, which is a silicone balloon, is inserted below the skin, it is gradually filled with a saline solution over a period of weeks, stretching the skin to create a pocket for the implant. After the expander is in place, the periodic filling of the expander with saline is a minimally invasive, outpatient procedure. The expander is later replaced with a more permanent implant once the desired volume has been achieved.
In cases where enough skin has been spared (if a lumpectomy candidate elects to undergo a full mastectomy or if a preventative mastectomy is performed on a non-cancerous breast) an implant may be used without a tissue expander.
If you have had a full mastectomy, an implant can restore the volume and shape to your breast. Implants involve fewer surgeries and a shorter recovery time than tissue flap procedures. However, breast implants may not last for a full lifetime—in many cases, implants need to be replaced or removed if a contracture or scar forms around the implant.
In addition, some patients choose to undergo augmentation or reduction in the other breast to make the overall result more symmetrical.
Breast implants are generally not an option for women who have undergone a lumpectomy or a partial mastectomy because implants often do not come in these shapes or sizes.
Tissue Flap Procedures (Autologous Breast Reconstruction)
Tissue flap procedures use tissue (muscle, skin and fat) from your stomach, back, or buttocks to rebuild the breast. The two most common types of tissue flap surgeries are the
TRAM flap
(or transverse rectus abdominis muscle flap), which uses tissue from your stomach area, and the
latissimus dorsi flap
, which uses tissue from your upper back.
Since flap procedures use tissue taken from your own body, your body will not reject the tissue. A flap reconstructed breast will feel very much like a natural breast, warm and soft. Furthermore, you do not need to worry about replacement or rupture as you may after an implant reconstruction. However, flap procedures require more time in surgery and recovery than implant placement. In addition, flaps surgery may be complicated by insufficient blood supply to the tissue, possibly leading to tissue loss.
TRAM (
T
ransverse
R
ectus
A
bdominis
M
uscle) Flap
During a TRAM flap reconstruction, skin, fat, and muscle will be moved from your stomach up to your chest and used to create a new breast mound post breast cancer removal surgery. This procedure takes its name from the transverse rectus abdominus muscle in your stomach. Most women have enough tissue in their stomach area to create a new breast. If there is not enough tissue, a small implant can be placed to add to the size of the new breast.
There are two ways to perform a TRAM flap, as a free (detached) tissue flap and as a pedicle (attached and tunneled) tissue flap. When performing a free flap, the surgeon cuts the flap of skin, fat, blood vessels, and muscle free from its original location in your abdomen. This section will be relocated to the breast area and reconnected to the blood supply using microsurgery.
In a pedicle flap, the surgeon leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area. Newer types of free flap are the DIEP (
D
eep
I
nferior
E
pigastric Artery
P
erforator) flap, which uses fat and skin from the same area as in the TRAM flap, but does not use the muscle to form the breast mound, and the SGAP (
S
uperior
G
luteal
A
rtery
P
erforator) flap, which uses tissue from the buttocks, including the gluteal muscle, to create the breast shape.
Latissimus Dorsi Flap
During the latissimus dorsi flap procedure, the surgeon moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunneled under the skin to the breast area to reconstruct the breast. Often times, an implant is used in conjunction with this tissue flap.
Autologous Fat Grafting Procedures
Fat grafting, or transferring fat from one area to another, has a long history and is a commonly performed procedure in the practice of reconstructive surgery. Your own fat tissue may be used to reconstruct your breast following breast conserving surgery or with an implant following a full mastectomy. Fat is removed from your stomach, hips, or thighs and is carefully re-injected into the breast, either in the defect area or around an implant.
Fat has many advantages over other materials: it is your own tissue (autologous), biocompatible, easily accessible and available, and can produce aesthetically pleasing and natural-looking results. However, in traditional fat grafting procedures, the grafts have shown a tendency to re-absorb back into the body, making the increase in volume temporary.
Cell-Enriched Breast Reconstruction: The RESTORE Procedure
RESTORE uses your own fat that has been enriched with your naturally occurring stem and regenerative cells, improving the survival of the transplanted graft. When your breast is reconstructed with cell-enriched fat the look and feel is similar to that of a normal breast. The use of fat results in a reconstructed breast that is soft and changes with your body with weight changes and/or aging. Not only can you expect a more natural-appearing breast, but the recovery time is often shorter as compared to other methods of breast reconstruction. In addition, the use of foreign materials is entirely avoided.
Cell-enriched fat grafting enables surgeons to enrich the graft with their patient’s own adipose-derived stem and regenerative cells (ADRCs). These cells are believed to promote fat graft survival by providing necessary oxygen and nutrients. While no results can be 100% guaranteed, RESTORE can be an option for women who seek a natural, less invasive way to reconstruct their breasts.
This technique may be used:
As a natural filler for defects after undergoing breast-conserving surgery
In implant reconstruction to cover the implant with fat for a more natural appearance
To correct contour deformities after a flap reconstruction
In small breasts, to reconstruct the breast following breast-conserving surgery, without the need for large scars and prolonged recovery
To improve skin quality and soft tissue coverage after mastectomy and radiotherapy
As a total breast reconstruction
Areola/Nipple Reconstruction
Although not a required part of breast reconstruction, reconstructing the nipple may provide a finishing touch to the aesthetic look of your breast. There are several different techniques used for areola and nipple reconstruction, including simple tattooing. A tattoo re-creates the look of a healthy areola through a simple outpatient procedure. For a more realistic texture and feel including a nipple and areola, local flaps of skin or an artificial graft may be used to reconstruct the nipple mound. The areola color can be added through a nipple tattoo.