In the past ten years, major achievements have been made in breast reconstruction following mastectomy surgery. No longer do women need to face long, jagged scars that impact their self image. Instead, advanced techniques have given plastic surgeons the tools to rebuild a woman’s breast in such a way that her silhouette is once again whole.

Women with breast cancer have two main considerations when considering reconstructive breast surgery—when to have surgery and what type of surgery to have. All of the options below are available to patients who are good candidates and healthy enough for surgery.

Tissue Expander – Silicone Implants based Breast Reconstruction

A common breast reconstruction technique is tissue expansion, which involves expansion of the breast skin and muscle using a temporary tissue expander. A few months later, the expander is removed and the patient receives either microvascular flap reconstruction, or the insertion of a permanent breast implant. This type of breast reconstruction requires two separate operations.

Chemotherapy or radiation may be recommended to you by your surgical oncologist following your mastectomy. If you choose to have these treatments it will delay the tissue expansion process by approximately four to eight weeks.

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Pic1. Tissue expander is placed under the chest wall muscle and filled with normal saline

Pros: The recovery from the initial expander placement surgery and from the permanent implant placement surgery is usually quicker than flap surgery. It may be easier to control the final size of the reconstructed breast with implant reconstruction. There are no additional scars on the patient’s body other than those on the breasts. For patients without excess fatty tissue and who do not require radiation treatment, implants are a good choice and yield good final results.

Cons: With this implant most patients require placement of an expander first, followed by replacement of the expander with an implant. This type of reconstruction almost always requires at least two surgical stages and multiple visits to the plastic surgeon’s office between these stages for tissue expansion. it is important to realize that for patients who are having a unilateral (one-sided) mastectomy, matching the other natural breast with an implant can be difficult. The shape and “feel” of an implant is not exactly like that of a natural breast.

In the short term, implants can become infected or mal-positioned and require surgery to correct these problems.

mplant-based reconstruction is not generally recommended if patients require radiation, due to the risk of complications. In the longer term, implants can develop capsular contracture (tightening of the soft tissues around the implant), implant mal-position, and implant rupture. If there are complications, secondary procedures may be required.

Breast reconstruction with abdominal (DIEP) Flap

The DIEP flap is the technique where skin and tissue (no muscle) is taken from the abdomen in order to recreate the breast. This is the most common procedure performed at our Breast Center as women generally have excess skin and fat along the lower portion of their abdomen; plus, patients like the “tummy tuck” it gives. This flap may be preferable to the older TRAM procedure, where women are prohibited from lifting anything weighing more than 25 lbs., because of the risk of a hernia.

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Pic3. Preoperative planning of DIEP flap in patient with right side mastectomy and previously failed breast reconstruction attempt with expander and implant

Pros: Since the reconstruction involves using the patient’s own tissues, the risks of implant reconstruction are avoided, particularly in the case of radiation. Most patients have less postoperative pain than after a TRAM flap and are therefore able to leave the hospital sooner, and return to normal activities quicker than after a TRAM flap. Because the abdominal muscle is not removed as in the TRAM flap, patients have much less risk of developing hernias, bulges and core weakness at the site where the flap is removed than patients who have had a TRAM flap. This advantage is much greater in bilateral (both sides) reconstruction. It is typically easier to match the contralateral natural breast with the patient’s own tissue when compared to implant reconstruction. Patients essentially end up with a “tummy tuck,” “bottom lift” or other cosmetic benefits at the same time as the breast reconstruction.

Cons: DIEP/SIEA/SGAP flap reconstruction generally requires a longer and more challenging surgery at the first stage when compared with implants or TRAM flaps. Patients will have a scar across the lower abdomen or the upper part of the buttock where the flap is obtained. However, this does not differ from the TRAM flap as the abdominal scars are equivalent.

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Pic4. Before and after breast reconstruction with DIEP Flap

Small revision surgeries or matching procedures on the opposing breast or donor site may be required. Patients who smoke, are obese or have diabetes are not ideal candidates for this type of surgery.In the short term, implants can become infected or mal-positioned and require surgery to correct these problems. Implant-based reconstruction is not generally recommended if patients require radiation, due to the risk of complications. In the longer term, implants can develop capsular contracture (tightening of the soft tissues around the implant), implant mal-position, and implant rupture. If there are complications, secondary procedures may be required.

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