Women who want breast reconstruction after mastectomy have several options with respect to timing, type of procedure, and materials used. Here, plastic surgeon , reviews the options and discusses considerations relevant to each procedure.
Breast cancer remains a key women's health issue. When presented with the diagnosis of breast cancer women face the choice of lumpectomy (usually accompanied by breast radiation) versus mastectomy. And while lumpectomy rates remain high, . This is driven in part by several distinct subsets of women: those seeking to avoid radiation therapy, those looking to reduce their risk for disease recurrence, and by a dramatic increase in women seeking prophylactic mastectomy.
Prophylactic mastectomy may be performed in the contralateral breast or prophylactically in both breasts to help prevent the development of breast cancer (especially among those patients with one of the genetic mutations predisposing women to breast cancer, such as the BRCA gene mutations).
The majority of patients choosing mastectomy are candidates for immediate reconstruction at the time of mastectomy. This allows them to avoid additional surgeries and recovery times. It provides by allowing women to feel "whole," with reduced incidences of depression, anxiety and low self-esteem. Importantly, immediate surgery improves the aesthetic result of the reconstruction by preserving the breast skin envelope to reduce the extent of scarring and to maintain the natural breast shape. This allows the breast reconstruction to replace only the missing breast tissue under the preserved breast skin.
Breast reconstruction falls into one of three types; breast reconstruction, , and combination techniques that use an implant and some natural tissue as well. Patients and their physicians should know which type or types of reconstruction procedures a plastic surgeon can perform.
Natural/autologous breast reconstruction offers several distinct advantages over implants:
- It looks and feels more natural
- It will age more naturally as compared with an implant
- It can more readily be designed with an aesthetic and natural shape
- It can be used to replace missing skin resulting from mastectomy or radiation therapy
- The donor site can be tailored to improve the contour/shape of the waistline, buttocks, or thighs
Natural/autologous breast reconstruction consists of moving skin and fat from areas of the body with excess to the deficient breast after the mastectomy (often referred to as flap). Flaps have gone through several distinct evolutionary advancements over the years. The original/older flaps were "," left intact with its blood supply. The flap was brought under a tunnel of skin and fat and into the defect following the mastectomy. The two most common examples of these procedures are the flap (which requires an implant for adequate volume replacement) and the TRAM () flap.
The TRAM flap was improved by converting it to a microvascular free-TRAM, wherein the blood vessels were cut and reconnected to blood vessels in the area where the breast tissue was removed. This evolution improved the blood supply to the skin and limited the amount of muscle sacrificed. However, free-TRAM flaps still require significant muscle cutting, which can lead to abdominal weakness, bulges/hernias, and pain.
The next evolutionary jump was to leave the muscle behind by means of perforator flaps (blood vessels "perforate" the muscle before reaching the skin). The mainstay of perforator flaps is the DIEP () flap, which consists of abdominal skin and fat.
By means of general anesthesia, the flap is dissected and then transplanted by suturing the blood vessels in the flap to vessels in the chest. For many women the DIEP flap offers an ideal volume match for the missing breast. There is often enough tissue to construct two flaps, one for each breast.
The procedure continues to evolve as plastic surgeons continue to investigate ways improve the blood supply to the DIEP, particularly rearranging and augmenting the vascular connections without sacrificing any abdominal muscle (the APEX flap).
Women who do not have enough abdominal skin and fat have other options for natural reconstruction. Many of these women will have adequate fat deposits in the upper buttock/hip areas. Hip/GAP () flaps are taken from the upper buttock in a fashion similar to DIEP flaps. The skin and fat are harvested without cutting muscle and then transplanted to the breast. Flaps harvested from the upper portion of the buttock can effectively lift and shape the buttocks.
Other options for natural breast reconstruction include less-utilized flaps from the inner thigh such as the TUG () and the PAP () from the posterior thigh.
M. Whitten Wise, MD, is a plastic surgeon at the Center for Restorative Breast Surgery in New Orleans and an adviser to .
Disclosures
Wise is a plastic surgeon at the Center for Breast Restorative Surgery in New Orleans, whose services include breast reconstruction after mastectomy.
Primary Source
JAMA. Journal of the American Medical Association
Kurian AW, et al "Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011" JAMA 2014; 312(9): 902-914.
Secondary Source
Clinical Breast Cancer
Rozen WM et al "Defining the role for autologous breast reconstruction after mastectomy: social and oncologic implications" Clin Breast Cancer 2008; 8(2): 134-142.