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Breast reconstruction is not a cosmetic procedure. It’s a right every woman has when faced with mastectomy after breast cancer. Fortunately, there are several reconstructive options.

When the breast reconstruction is performed at the same setting as the mastectomy it is referred to as “immediate” reconstruction. The biggest advantage of immediate reconstruction is that the patient wakes up from the surgery still “whole” and completely avoids having to live without a breast. Other advantages include shorter scars and, generally speaking, a better cosmetic result.

Some patients do not have access to a reconstructive surgeon at the time of the mastectomy. Other patients are advised to avoid immediate reconstruction because radiation therapy is likely after the mastectomy. In these cases, the reconstruction can be performed some time after the mastectomy. This is known as “delayed reconstruction”.

The most common breast reconstruction procedure performed by American plastic surgeons utilizes implants to restore the breast shape and form. These can be either saline or silicone. Implant reconstruction is typically performed as two separate surgeries. The first involves placing a tissue expander (temporary implant) under the skin and pectoral muscle. This is used to expand the skin to the required size. The expander is later replaced by the permanent implant at a second surgery. A few surgeons prefer using a one-stage approach and place the permanent implant at the same time as the mastectomy. While not all patients are candidates, this is a very attractive option for many women because they avoid the entire tissue expander phase of the reconstruction.

Breast reconstruction with implants can provide excellent cosmetic results. However, the long term risk of complications is much higher than in women who have cosmetic breast enhancement with implants. The most common risks include contracture (hardening of the new breast), and implant ripples that can be felt and seen through the breast skin. These risks are increased if the patient has to undergo radiation as part of the cancer treatment.

The Latissimus procedure uses muscle (latissimus dorsi), fat and skin from the back (below the shoulder blade) that is brought around to the chest to create a new breast. Many patients also need an expander or implant to obtain a satisfactory result in terms of size. Patients typically have a scar on their back that can be seen with some low-cut clothing. Women who are very active in sports may notice some strength loss with activities like golf, climbing, or tennis.

TRAM flap surgery is a common procedure that uses skin, fat and varying amounts of the sit-up muscle (rectus abdominis) from the lower abdomen. The tissue (or flap) is then relocated to the chest to create the new breast. This procedure also results in a tightening of the lower abdomen, or a “tummy tuck”. Unfortunately, sacrifice of all or part of the abdominal muscle can result in bulging (or “pooching”) of the abdomen and even a hernia.

The DIEP flap is the latest evolution of the TRAM flap. It provides all the advantages of the TRAM while decreasing the risks. Like the TRAM, it provides a very natural breast reconstruction which is warm and soft and ages with the patient. However, the DIEP preserves all the abdominal musculature so is associated with a lower rate of abdominal bulging and hernia. Since the muscle are preserved, recovery is also easier and abdominal strength is maintained long term.

There are a handful of other tissue options available for women who are not candidates or prefer to avoid using their abdominal tissue. These include the inner, upper thigh (TUG flap), lower buttock crease (IGAP), and upper buttock (SGAP). The best tissue option will depend on a number of factors, primarily the patient’s body habitus.

Microsurgical breast reconstruction procedures like the DIEP, TUG and GAP flaps are not offered routinely by many American plastic surgeons. There are many reasons for this, primarily the complexity of the surgery and the need for additional training. Unfortunately most patients seeking one of these advanced breast reconstruction options after mastectomy will be forced to travel to highly specialized centers for their surgery.

Dr Chrysopoulo is a board certified plastic surgeon specializing in advanced breast reconstruction, particularly DIEP flap breast reconstruction. Over 500 DIEP flaps per year. In-Network for most US insurance plans. (800) 692-5565. Are you a Facebook fan? Connect with others touched by breast cancer in our FB breast cancer reconstruction community!