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What You Need to Know if You Choose Breast Reconstruction

by Karen M. Horton, MD, MSC, FRCSC

Breast reconstruction involves recreating a breast form following cancer. Women facing breast cancer should be reassured that reconstruction of the breast can be a positive experience. Restoration of a breast form and creating symmetry helps to restore a woman’s body image, self-esteem, and sense of femininity and wholeness.

Recent advances allow for options in reconstruction that were not available a few years ago. These exciting, state-of-the-art techniques are increasingly being offered. Women who are facing the challenge of a breast cancer diagnosis, and who are making difficult decisions about cancer surgery, can benefit from these new techniques.

Timing of Reconstruction
Immediate reconstruction refers to a procedure that reconstructs the breast at the same time as the mastectomy, with most or all of the breast skin being preserved. Delayed reconstruction implies a period of time between breast removal and reconstruction, and can be done at any time – typically six weeks after completing chemotherapy or six months following radiation.

A recent advance in breast reconstruction is the nipple-sparing mastectomy.

Options for Breast Reconstruction
Reconstruction can use either breast implants or the body’s own tissue. Advantages of implant reconstruction include a shorter operation time, shorter recovery, and usually a single scar on the breast. Disadvantages include the risks of capsular contracture (hardening of scar tissue around the implant), infection, and a less natural shape to the breast, particularly if only one breast is reconstructed. Use of implants following radiation increases the risk of complications.

The use of the body’s own tissue is called flap reconstruction, or autogenous tissue reconstruction. Advantages include a warm, soft, living tissue reconstruction that is permanent. Disadvantages include the creation of a donor site (the area of the body where the tissue is taken from), additional scars, a longer surgery, and slightly longer recovery time. However, once recovery from surgery is complete, the reconstruction lasts forever.

A recent advance in breast reconstruction is the nipple-sparing mastectomy. Some women with breast cancer may be candidates for this procedure, which preserves all skin of the breast including the areola and the nipple. Candidates include women with non-invasive cancer, those with small tumors at least two centimeters away from the nipple, and women with relatively small breasts.

Types of Microsurgical Breast Reconstruction
The latest flap reconstructions do not sacrifice major muscles of the body. Free flaps transfer tissue from elsewhere on the body to the breast area using microsurgery, which detaches and then reattaches blood vessels under the operating microscope.

DIEP Flap The Deep Inferior Epigastric artery Perforator flap uses the skin and the fat from the lower abdomen but does not include any muscle. DIEP flap reconstruction can look and feel almost exactly like a breast. It is recommended following radiation therapy because it brings with it a new and robust blood supply to the area. The abdominal scar is usually hidden by undergarments or a bathing suit, and closure of the donor site results in the bonus of a tummy tuck.

SIEA Flap The Superficial Inferior Epigastric Artery flap uses the superficial blood supply to the skin and the fat of the abdomen, whereas the DIEP flap uses the deep blood supply. Only approximately 30 percent of women have the SIEA blood vessel; this cannot be determined until surgery. The cosmetic outcome is the same as the DIEP flap, with possibly slightly less down time.

TUG Flap The Transverse Upper Gracilis flap is taken from the upper inner thigh area, in the same distribution as a cosmetic inner thigh lift. Advantages include a soft, shapely breast, immediate nipple and areola reconstruction, and the added benefit of an inner thigh lift. This flap is another choice for women seeking flap reconstruction.

Finishing Touches
A nipple prominence and an areolar circle are reconstructed during an outpatient procedure done three to six months after breast reconstruction. Skin and fat are rotated from the breast to make a nipple prominence, and a medical tattoo is used to create an areola. Usually, a balancing procedure is performed on the other breast to match the reconstructed one. This may involve a breast reduction, a lift, or occasionally an implant to match the reconstructed side. This is often done at the same time as the initial reconstruction.

Reconstruction of the breast is an individualized procedure. The options, desires, and anatomy of each person differ greatly. The best reconstructive option takes into account a woman’s goals, the way she uses her body, and her unique situation.

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