Author’s Note: Breast reconstruction is an extremely complex topic. The overview that follows is meant to briefly introduce the various methods of reconstruction that are available today. Various aspects may not apply to each individual. We encourage women to consult with a Board Certified Plastic Surgeon who specializes in breast reconstruction to discuss the specifics of her individual situation.
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Breast Reconstruction:
An Overview

Historically, breast reconstruction was only performed after the loss of a breast due to cancer treatment. However, with the availability of genetic testing, many women who are at very high risk of developing breast cancer are now considering “prophylactic” or “risk-reducing mastectomy” as a course of treatment and prevention. In these cases, both breasts are removed before cancer has a chance to develop. The following is a general introduction to breast reconstruction methods, and applies to all patients undergoing breast reconstruction.

The purpose of breast reconstruction is to restore the breast form and in doing so, help to improve the patient’s body image. Most women can wear revealing styles of clothing with confidence after their breast reconstruction and it is usually difficult, if not impossible, to tell which side was reconstructed side while dressed. The need for an external prosthesis is eliminated by surgical reconstruction of the breast.

Although there are several options in breast reconstruction, all methods ultimately involve the use of an implant or the patient’s own tissue. No method of breast reconstruction will precisely duplicate a normal breast. It is not possible, for example, to restore normal sensation or restore the ability to breastfeed. Despite these shortcomings, the vast majority of women are very pleased with the results achieved by breast reconstruction.

Breast reconstruction, by whatever method, is usually a staged effort (typically two or three stages) directed towards achieving an attractive, symmetrical outcome. The first stage is a “rough draft” reconstruction where the breast mound is recreated. The second stage is aimed at improving breast symmetry and fine-tuning the reconstructed breast in terms of size, shape, and position. During the second or third stage, minor revisions of the reconstructed breast may be performed. If the nipple was removed during the mastectomy, nipple reconstruction may be performed at this time. Later, a “tattoo” of the nipple areola is performed to obtain reasonable color match and help camouflage scars.

Implant Breast Reconstruction

A common form of breast reconstruction utilizes an implant to recreate the breast mound. This method works well for women with moderate sized breasts and minimal skin laxity (looseness) or drooping (ptosis). This surgery may not work as well for women who have larger or very lax breasts, those who are substantially overweight or have had previous radiation to the breast.

The first stage procedure follows the mastectomy; a pocket is created behind the chest muscle and a temporary implant called a tissue expander is inserted. The expander is similar to the final implant, however it contains a magnetic valve, which allows fluid to be added after surgery. Two or three weeks after surgery, the expander is gradually filled with salt water (saline), stretching the skin and muscle, and creating room for the final implant. The expansion process requires weekly office visits for a few weeks.

The second stage procedure is performed 1-3 months after final inflation. During this outpatient procedure, the expander is removed and a final implant is placed. The final implant is made of a thin silicone shell and filled with either saline or silicone gel. The choice of implant is made by the patient and surgeon before the procedure. Implants are not guaranteed to last forever and have a limited lifespan (typically more than 10 years) so they may need to be replaced at some time. Additional fine tuning of the breast, as well as nipple reconstruction, may also be performed during this procedure.

In some selected cases, the expansion process may be omitted and a permanent implant placed at the time of the mastectomy as a one-step procedure. This procedure involves inserting the final implant, rather than a tissue expander, under the chest muscle at the time of the mastectomy. This avoids the need for the expansion process after the initial procedure and may avoid the need for a second procedure. The ability to offer this procedure depends on each woman’s breast size and the amount of skin remaining after the mastectomy.

Reconstruction with Your Own Tissues

Breast reconstruction with your own tissue is an excellent option for those women who wish to avoid the use of man-made materials. With this method, a breast mound may be created by borrowing tissue from another body area, such as the abdomen or back. Following are descriptions of some of the more common methods:

Latissimus Dorsi Flap

The latissimus dorsi muscle (LDM) reconstruction uses the skin, fat and muscle from the back to replace the skin that is removed during a mastectomy. The LDM may be used for reconstruction of both breasts, either at the same time or at different times, and is usually combined with placement of a breast implant), to achieve adequate breast volume. The LDM flap does not require microsurgery.

TRAM Flap

TRAM stands for Transverse Rectus Abdominus Myocutaneous flap. With this technique, excess abdominal skin and fat is used to reconstruct the breast. The TRAM can be performed immediately or as a delayed reconstruction. There are three basic types of TRAM flaps.

Pedicled TRAM
The abdominal tissue remains connected to the rectus abdominus muscle and is tunneled under the skin of the upper abdomen into the breast. Removing the rectus muscle may lead to abdominal weakness or hernia formation. This technique is successful in 98-99% of cases. Rarely, a portion of the flap may be lost due to inadequate blood circulation.

Free TRAM
While similar to the pedicled TRAM, the abdominal tissue in the free TRAM is disconnected and reattached in the breast using microsurgery to reconnect the blood vessels. Less muscle is used in this operation than the pedicled TRAM, thereby maintaining abdominal strength. This flap has better circulation allowing more tissue to be used. This technique is successful about 97% of the time.

DIEP or SIEA flaps
These are specialized microsurgical versions of the free TRAM flap in which abdominal tissue is used without using any of the abdominal muscle. The DIEP and SIEA flap procedures carry a slightly higher overall risk than the pedicled or free TRAM, however, these flaps have the added benefit of preserving abdominal muscle function and reducing abdominal hernia formation.

The TRAM, DIEP, and SIEA flaps can be used for reconstruction of both breasts simultaneously. However, once they have been used to reconstruct a single breast, it cannot be used again in the future for the other breast.

Which Breast Reconstruction Option is Right for You?

Since each option and technique has its advantages and disadvantages, and each patient has her unique goals, expectations and individual body type, there is no one choice that is best for all patients. Other factors such as radiation therapy, medical condition and if one or both breasts are being reconstructed will influence which options should be considered. Your plastic surgeon should offer you recommendations based on these variables after examining you and learning about your specific situation.

Summary

Breast reconstruction is considered to be a highly successful procedure. That said, it must be cautioned that there are no guarantees of success regardless of the method selected. In most cases, however, patients are quite satisfied with their results and, in retrospect, would chose to undergo the procedure again.

For further information and diagrams of the various procedures, as well as patient photographs, please see www.plasticsurgery.org.

About the Authors:
Dr. Michael Howard and Dr. Karol Gutowski are Board Certified Plastic Surgeons and faculty members at the University of Chicago Pritzker School of Medicine.

Frequently Asked Questions about Breast Reconstruction

Author’s Note:
This list of questions and answers was compiled from a list of our answers to the most common questions we receive from patients and their family members regarding breast reconstruction. While other plastic surgeons may have slightly different answers to these questions, we recommend these as a great starting point for discussion during consultation with a plastic surgeon.
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What are my options for breast reconstruction?
There are three commonly used techniques for breast reconstruction:

A breast implant may be used to reconstruct a breast. In most cases, a tissue expander (a device similar to an implant) is placed at the time of mastectomy. Then, the expander is enlarged by injecting salt water during weekly clinic visits. As the expander stretches out the remaining skin on the breast, a pocket is created to allow for placement of a breast implant at a second surgery.

A second option is the use of your own tissue from your back (latissimus dorsi muscle flap). This tissue is used to cover a breast implant and often eliminates the need for tissue expansion but still requires the use of an implant.

The third option is the use of the tissue from your abdomen (TRAM flap) and usually does not require an implant.

There are other options available but they are used less commonly and typically reserved for patients where these choices are not possible.

Which option is best for me?
Each option has its advantages and disadvantages. Not all patients will be candidates for each reconstruction. The best option will depend on your wishes and expectations, your overall health, breast and body shape, and if you have any risk factors for reconstruction such as smoking, obesity or radiation treatment. The choice of reconstruction will be decided by both you and your plastic surgeon after examining you and reviewing your health history.

Is breast reconstruction covered by insurance?
Yes, in most cases all procedures associated with breast reconstruction are covered as required by federal law.

How many surgeries are necessary?
The use of a tissue expander is a two-stage process and will require a second surgery 4 to 6 months later to exchange it for a breast implant. Breasts can be reconstructed in one stage by using a latissimus dorsi muscle flap to cover an implant or by using a TRAM flap. After the breast is reconstructed, most patients desire nipple reconstruction. This minor procedure is usually done 4 to 6 months later. At that time, minor revisions may be done to the reconstructed breast. After the nipple is reconstructed, the areola (pigmented skin around the nipple) may be reproduced with a tattoo. Some patients desire surgery on the opposite breast to have better symmetry with the reconstructed breast. This may involve a breast enlargement, breast reduction, or breast lift. If breast implants are used, you may need another surgery to replace them at some time. These additional procedures are typically covered by insurance as part of the breast reconstruction.

Will I need any more visits before surgery?
Although it is not necessary, you may meet with your plastic surgeon before your surgery to answer any questions and review the procedure. You will also need to have a “History & Physical Exam” a few weeks before surgery, typically by your own primary care physician.

Where will the procedure be done?
Depending on scheduling availability and the length of your surgery, the procedures may be done at a hospital or at a surgery center.

What kind of anesthesia will I have?
For the initial procedure, general anesthesia is used and you are completely asleep. However, in many second stage procedures, the operation can be done using “twilight” or sedation anesthesia, which allows for faster recovery.

How long does the procedure take?
Placement of a tissue expander or breast implant takes about 1-2 hours. Reconstruction with a latissimus flap or TRAM flap takes 3 to 5 hours. More time may be needed if both breasts are being reconstructed.

Will I need a blood transfusion?
It is very unlikely to need a blood transfusion for such cases.

How long will I stay in the hospital?
After reconstruction with only an expander or implant, most patients are able to go home the next day. Patients with a with a latissimus flap spend 2 to 3 days in the hospital while those with a TRAM flap reconstruction spend 3 to 5 days.

Will I have any drains after surgery?
Yes, the drains are usually removed 5 to 10 days after surgery.

What medications will I need after surgery?
You will receive a prescription for a pill containing a narcotic and acetaminophen (Tylenol) combination. The day after your surgery, you may also start using ibuprofen (Motrin) or naproxen (Aleve) which can be obtained before your procedure without a prescription. Most patients stop using the narcotic pills after 2 to 5 days and change over to acetaminophen alone or in combination with ibuprofen or naproxen. You may also receive a muscle relaxant called diazepam (Valium) to use for a few days as some pain may be due to muscle spasm. You may want to take an over the counter stool softener (ie: Colace) while taking narcotic pain medications to avoid constipation. In some cases, an antibiotic may be given also.

Will I need any special bras?
No, but if needed, you will be given a surgical bra or breast band after surgery.

How often will I need to come back after surgery?
Typically, your plastic surgeon or his/her assistant will see you in 3 to 7 days after surgery and again after 1 to 2 weeks, 4 to 6 weeks, and after 3 to 4 months.

Will there be any sutures to remove after surgery?
In most cases, there are no sutures to remove except for those associated with drains.

What are my restrictions after surgery?
After reconstruction with only an expander or implant, you may shower the second day after surgery but be very gentle with your breasts for the next 2 weeks. Patients with a with a latissimus dorsi muscle flap reconstruction or TRAM flap reconstruction may shower 2 days after surgery. Light regular activity is allowed during the first week but should be limited if it causes discomfort. Avoid heavy straining or lifting more than 10 pounds (about the weight of a gallon of milk). You should sleep on your back for the first 1 to 2 weeks. Do not drive if you are using narcotic pain medications. After reconstruction with only an expander or implant, you may resume regular activity as tolerated after 2 weeks. After latissimus dorsi muscle flap reconstruction or TRAM flap reconstruction, you may resume regular activity in 4 to 6 weeks.

How long before I can return to work?
This depends on the type of work you do. Those who perform mostly desk work will be able to return sooner than those who require heavy activity at work. After reconstruction with only an expander or implant, most patients are able to return to work in 1 to 2 weeks. Patients with a with a latissimus dorsi muscle flap reconstruction may return to work in 2 to 3 weeks while those with a TRAM flap reconstruction may need 4 to 6 weeks before returning to work.

Will I need any therapy after surgery?
No, just be sure to move your arms in a full range of motion 3 times a day in a slow and gentle manner after surgery to prevent stiffness. Start this 3 days after surgery.

What can I do to minimize scars after surgery?
Silicone gel sheets and scar gels have been shown to improve scar appearance after surgery.