Breast Reconstruction Options

Today, there are new choices for breast reconstruction.

Implant procedures

The most common implant is a saline-filled implant. It’a silicone shell filled with salt water (sterile saline).

Silicone gel-filled implants are also an option for breast reconstruction. They aren’t used as often as they were in the past because of concerns that silicone leakage might cause immune system diseases. But most of the recent studies show that silicone implants do not increase the risk of immune system problems, and the FDA approved silicone implants again in 2006.

Some newer types use thicker silicone gel, called cohesive gel. The thickest ones are sometimes called “gummy bear” implants and are made of highly cohesive silicone. They are more accurately called form-stable implants, meaning that they keep their shape even if the cover is cut or broken. Form-stable implants were approved in early 2013 in the United States. Still, the FDA is requiring the company that makes them to do extra clinical trials on their safety. Some people believe that the form-stable implants won’t leak even if cut, but cases have been reported in which they have leaked into the tissues around the breast after the implant ruptured.

Also, alternative breast implants that have different shells and are filled with different materials are being studied, but you can only get them in clinical trials.

Types of Implant Surgery

One-stage immediate breast reconstruction may be done at the same time as mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant. The implant may be put in the space created when the breast tissue was removed, but extra support is often needed. Sometimes the surgeon will suture (stitch) in a special type of graft or an absorbable mesh to hold the implant in place, much like a hammock or sling. (See the section “New methods of tissue support.”) Older methods put the implant behind the chest muscles to support the implant and form the breast contour.

Two-stage reconstruction or two-stage delayed reconstruction is the type most often done if implants are used. It’s easier than the immediate operation if your skin and chest wall tissues are tight and flat. An implanted tissue expander, which is like a balloon, is put under the skin and chest muscle. Through a tiny valve under the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over a period of about 4 to 6 months. After the skin over the breast area has stretched enough, a second surgery will remove the expander and put in the permanent implant. Some expanders are left in place as the final implant.

The two-stage reconstruction is sometimes called delayed-immediate reconstruction because it allows time for other treatment options. If the surgical biopsies show that radiation is needed, the next steps may be delayed until after radiation treatment is complete. If radiation is not needed, the surgeon can start right away with the tissue expander and second surgery.

Tissue flap procedures

These procedures use tissue from your tummy, back, thighs, or buttocks to rebuild the breast. The 2 most common types of tissue flap procedures are the TRAM flap (or transverse rectus abdominis muscle flap), which uses tissue from the lower tummy area, and the latissimus dorsi flap, which uses tissue from the upper back. Other tissue flap surgeries described below are more specialized, and may not be available everywhere.

These operations leave 2 surgical sites and scars — one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but they will never go away completely. There can be donor site problems such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue’s blood supply, flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers.

In general, flap procedures behave more like the rest of your body tissue. For instance, they may enlarge or shrink as you gain or lose weight. There’s also no worry about replacement or rupture.

TRAM (transverse rectus abdominis muscle) Flap

The TRAM flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). The tissue from this area alone is often enough to shape the breast, so that an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower belly, or a “tummy tuck.”

There are 2 types of TRAM flaps:

  • pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area. This can leave an area of fullness under the skin where the tissue is tunneled.
  • In a free flap, the surgeon cuts the flap of skin, fat, blood vessels, and muscle for the implant free from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer than a pedicle flap. The free flap is not done as often as the pedicle flap, but some doctors think that it can result in a more natural shape.

Latissimus Dorsi Flap

The latissimus dorsi flap 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’s tunneled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it’s not common, some women may have weakness in their back, shoulder, or arm after this surgery.

DIEP (deep inferior epigastric artery perforator) Flap

The DIEP flap uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This results in less skin and fat in the lower belly (abdomen), or a “tummy tuck.” This method uses a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest area. Use of a microscope (microsurgery) is needed to connect the tiny vessels. The procedure takes longer than the TRAM pedicle flap discussed above, but leaves less muscle weakness and causes fewer hernias. It isn’t available in all areas.

Gluteal Free Flap

The gluteal free flap or GAP (gluteal artery perforator) flap is newer type of surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It might be an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons, but it’s not offered in many areas of the country. The method is much like the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest area. A microscope (microsurgery) is needed to connect the tiny vessels.

Inner thigh or TUG flap

A newer option for those who can’t or don’t want to use TRAM or DIEP flaps is a surgery that uses muscle and fatty tissue from along the bottom fold of the buttock extending to the inner thigh. This is called the transverse upper gracilis flap or TUG flap. Again, it’s not available everywhere. Because the skin, muscle, blood vessels are cut out and moved to the chest, a microscope is used to connect the tiny blood vessels to their new blood supply. Women with thin thighs don’t have much tissue here, so the best candidates for this type of surgery are women whose inner thighs touch and who need a smaller or medium sized breast. Sometimes there are healing problems due to the location of the donor site but they tend to be minor and easily treated.

New Methods of Tissue Support

Reconstruction operations move sections of tissue to new places, or add fairly heavy implants. Some type of support is needed as the tissues around them heal.

Many doctors now use products made of donated human skin (such as AlloDerm® and DermaMatrix®) to support implants or transplanted tissues. These products are regulated by the US Food and Drug Administration (FDA) as human tissues used for transplant. But they have had the human cells removed (are acellular), which reduces any risk that they carry diseases or the body will reject them. They are used to extend and support natural tissues and help them grow and heal. In breast reconstruction they may be used with expanders and implants. They have also been used in nipple reconstruction.

Doctors can also use synthetic mesh, animal grafts, and more recently, animal skin with the cells removed (an acellular matrix such as Strattice™), and other methods for internal support.

The acellular matrix products are fairly new in breast reconstruction. Studies that look at outcomes are still being done, but have been promising overall. There may be a higher risk of implants having to be removed after surgery when human skin is used. Some studies also suggest a higher rate of infection, fluid collecting in the surgical area, and possibly of tissue flap death (the tissue that covers the implant dies and must be removed). This skin tissue is not used by every plastic surgeon, but is becoming more widely available. Talk with your doctor about whether these materials will be used in your reconstruction and how they might affect your risk of complications.

Material resource: American Cancer Society, Inc. (revision 6/12/2013).