Breast reconstruction is usually performed for breast cancer patients who have had a mastectomy. In addition, there are patients who require breast reconstruction for other reasons such as for Poland’s Syndrome, some breast asymmetries, and for deformities secondary to previous breast implant complications. In addition, patients that have inherited the gene for breast cancer (BRCA1 or BRCA2) may desire breast reconstruction. The lifetime risk of developing breast cancer with this genetic predisposition has been reported to be anywhere from 35%-85%. Some of these patients request prophylactic mastectomies to avoid the likelihood of developing breast cancer in the future. Patients who are undergoing treatment for breast cancer should seek consultation with a plastic surgeon in conjunction with their general breast surgeon. Many times it is easier to perform the mastectomy and reconstruction during the same operative setting. Sometimes, the breast reconstruction is performed as a delayed procedure (at a later time). As with all surgery that plastic surgeons perform, patients should avoid smoking because of the inherent risks and significant complications that can develop from its use.
Mastectomies can be performed in a traditional fashion in which an island of skin is removed along with the nipple areola complex and the underlying breast tissue, or with a skin-sparing incision, in which only the minimum amount of skin is removed along with the nipple areola complex and the underlying breast tissue. The skin-sparing incision leaves the most amount of skin and often will allow for a more natural breast shape following reconstruction. In addition, some individuals can have a nipple-sparing procedure which leaves all the skin as well as the nipple areola complex intact and removes only the breast tissue.
- Autologous Breast Reconstruction
- Pedicled Breast Reconstruction
- Free Flap Breast Reconstruction
- Non-autologous Breast Reconstruction
Autologous Breast Reconstruction
Reconstructive options include autologous tissue procedures or non-autologous procedures. Dr. Wallach prefers to use autologous tissue for breast reconstruction. These are operations that use your own tissue for the reconstruction; this includes: pedicled flap reconstruction such as with the latissimus dorsi (LD) muscle flap (tissue from your back) with/without an implant, or the pedicled transverse rectus abdominis myocutaneous (TRAM) flap (muscle and tissue from your abdominal region). There are also free flap breast reconstruction options (tissue moved on its own blood supply from another area of the body). The common free flaps for breast reconstruction include: the deep inferior epigastric artery perforator (DIEP) flap, the intercostal artery perforator (ICAP) flap, the inferior gluteal artery perforator (IGAP) flap, the superficial inferior epigastric artery (SIEA) flap, the superior gluteal artery perforator (SGAP) flap, the free TRAM, or the thoracodorsal artery perforator (TDAP) flap, to name a few.
The procedure chosen is tailored specifically for each patient. The pedicled procedures will often take between two and five hours with the average hospital stay of about two to three days. The free flap surgery is often six to twelve hours long, with the majority of patients staying in the hospital for a minimum of three to five days. Recuperation can vary from two to three weeks depending upon the procedure performed. As with all the procedures, if the nipple areola complex is removed during the mastectomy, then this will need to be reconstructed at a later time.
Pedicled Breast Reconstruction
Latissimus Dorsi (LD) Muscle Flap
The LD muscle is located on the back, and is often the muscle palpated just posterior to the native breast. In some women who have excess tissue in this area, the muscle along with its overlying skin and some surrounding subcutaneous fatty tissue can be rotated into the chest to reconstruct the breast. This is a pedicled muscle flap; that is, it is a muscle flap that is still attached to its native blood supply but is rotated into a new position. This specific flap is sometimes referred to as an extended latissimus dorsi flap, and can often be used for a single stage reconstruction. If a patient is very thin, then a latissimus dorsi muscle flap may not provide adequate amounts of tissue to reconstruct the breast, and this may require an immediate implant placement with the LD flap, or a staged reconstruction with a tissue expander and then a delayed implant placement. (See section on non-autologous breast reconstruction) Patients may stay in the hospital for one or two days after this procedure. In addition, drains are also placed and usually are removed within the first week after surgery.
Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
The TRAM flap is an excellent option for breast reconstruction in the appropriate patient. This flap is created from the lower abdominal skin and subcutaneous tissue (tissue often discarded in a “tummy tuck”) along with either one or both of the rectus abdominis muscles and then rotated into the chest defect that is usually left after a mastectomy. This is a pedicled muscle flap; that is, it is still attached to its native blood supply but is rotated into a new position. This tissue is then contoured to look like a breast. It can feel very natural because it is the patient’s own tissue.
Patients that have had a previous tummy tuck or do not have adequate lower abdominal skin and fat are not candidates for this procedure. In addition, patients that have had major abdominal surgery or even liposuction of their abdomen may not be good candidates either. The latter two procedures may have jeopardized the blood supply to the lower abdominal tissue, and thus potentially using this tissue for reconstruction may be fraught with too many potential complications. One additional benefit of this procedure, is that a modified “tummy tuck” is accomplished at the same time.
Patients usually stay in the hospital for several days after this procedure. In addition, drains are also placed and usually are removed within the first week after surgery. One disadvantage of this procedure is that sometimes there is not enough tissue in the lower abdomen to support creating a breast of equal size to the opposite breast. On the other hand, many patients opt to have a breast lift on the opposite side to match the less ptotic (droopy) breast that has been reconstructed. Furthermore, because one or both of the rectus abdominis muscles is used, the patient will not have the same strength in the abdominal musculature. This may limit the ability to perform sit-ups.
Free Flap Breast Reconstruction
Free flap breast reconstruction is another option for treatment. A free flap is a mound of tissue that is removed from its donor site along with its main arterial and venous blood supply and “plugged in” to a new location. This is a very time consuming surgery, often taking several hours more than most of the other forms of reconstruction, but many times providing a better result. While a pedicled breast reconstruction such as a TRAM pedicle flap can also create a very natural and excellent result, a free flap often can provide more tissue for reconstruction. Furthermore, when the lower abdominal tissue is not available to be used, there are several alternative free flaps to choose from for breast reconstruction. These surgeries are very labor intensive and often require two surgeons to facilitate the procedure. In addition, patients often require several days stay in the hospital for monitoring of the flap.
“I don’t think I have one favorite thing about plastic surgery. I enjoy practicing plastic surgery because I find it very creative since there are many ways to approach an individual’s treatment. In other words, each day brings a new adventure. It allows me to challenge my artistic side. I also enjoy the many different people that walk through my office doors and become part of my practice. I treat everyone as if they are a part of my family, and I have made many new friends that way.”
Deep Inferior Epigastric Perforator (DIEP) Flap
DIEP flap is derived from the tissue of the lower abdomen. This is the same tissue that is used in a transverse rectus abdominis myocutaneous (TRAM) pedicled flap except that the DIEP flap preserves the underlying rectus muscle. The vessels supplying the flap are harvested from within the muscle. The muscle is not removed. This helps reduce the risk of a postoperative lower abdominal bulge. The patient also has the same added benefit of using this tissue by producing a modified tummy tuck as well. Patients that are not good candidates for a DIEP flap are similar to those considering a pedicled TRAM flap(SEE PEDICLED TRAM FLAP ABOVE). The DIEP flap can often provide more tissue for breast reconstruction than a pedicled TRAM flap, because its blood supply is usually better. In addition, it is thought that these patients have less discomfort from the surgery than either pedicled TRAM flaps or free TRAM flap patients.
Intercostal Artery Perforator (ICAP) Flap
The ICAP flap is derived from soft tissue along the lateral aspect of the breast in line with the rib cage vessels. This flap can either be used as a pedicled flap or a free flap. Most commonly it is used as a pedicled flap. This is often used to fill small defects that are left from breast excisions.
Inferior Gluteal Artery Perforator (IGAP) Flap
The IGAP is a free flap derived from tissue from the lower border of the buttock region. This can be performed in the lower buttock crease, or just above the fold. This is a great alternative for patients that need a free flap but can not have a flap created from the abdominal tissue (either a DIEP or SIEA flap). The beauty of this flap is that the incision can often be hidden in the underwear line.
Superior Gluteal Artery Perforator (SGAP) Flap
The SGAP is a free flap derived from tissues from the upper buttock region. This flap includes portions of the upper buttock and some of the lateral hip roll. The scar usually hides very well in many forms of under garments. This is a great alternative for patients that need a free flap but can not have it created from the abdominal tissue. The decision to use an IGAP or SGAP depends upon the amount of available tissue in each area and of course patient preference.
Superficial Inferior Epigastric Artery (SIEA) Flap
The SIEA flap is a free flap that is derived from the lower abdominal tissue. Unlike the DIEP flap, it is not necessary to harvest the vessels through the rectus muscle. The vessels of this flap are superficial and do not go through the rectus muscle. This ensures that the rectus muscle is not weakened by the dissection. However, many times the vessels that supply this flap are not adequate for transfer, and an alternative such as a DIEP flap is more appropriate.
Free Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
The Free TRAM is a variation of the pedicled TRAM described earlier. The main difference is that the dominant vascular pedicle is divided and reattached in the chest. This can provide more tissue for breast reconstruction than a pedicled TRAM flap. In addition, if a DIEP flap is attempted, sometimes a small cuff of rectus abdominis muscle is included in the flap to improve the success of the flap. This is considered a free TRAM flap or a muscle-sparing free TRAM flap, depending upon how much muscle is taken with the flap.
Thoracodorsal Artery Perforator (TDAP) Flap
The TDAP flap is a variation of the latissimus dorsi (LD) pedicle flap. The LD is a muscle along the flank of the upper back. (see pedicled breast reconstruction section) Many times the LD muscle is used for coverage of breast implants for patients that have undergone a mastectomy. The TDAP flap consists of the skin and subcutaneous fat that lies over the LD muscle, but includes a perforating vessel that is attached to the thoracodorsal artery. This vessel is dissected away from the LD muscle so that the muscle can be left intact and can remain functional. This flap is often used as a pedicled flap and not as a free flap.
Non-autologous Breast Reconstruction
Non-autologous breast reconstruction refers to breast reconstruction performed with tissue expanders and breast implants. This is sometimes combined with local muscle flaps, usually the LD flap, so that there is adequate skin and soft tissue coverage of the implant. Of course, as with all the other procedures, if the nipple-areola complex was removed with the mastectomy, this would need to be reconstructed at a later time. Patients usually stay in the hospital for a few days after the initial procedure. The second stage for exchange of the expander to an implant can usually be performed as an outpatient.
Tissue Expanders and Implants
After a mastectomy, there is often less skin coverage on the chest. Sometimes, a tissue expander is placed underneath the remaining breast skin flaps for later expansion of the skin. The tissue expanders are like balloons, and act to expand the skin. Usually these expanders are not inflated until about three weeks after surgery. Then, the expander is inflated on a weekly basis in the office until the expander is inflated to an adequate size. After the expander is fully inflated or even over-expanded, the patient then undergoes another surgical procedure to exchange the expander for either a saline or silicone filled breast implant. If the patient originally had a skin-sparing mastectomy (a mastectomy that just removed the areola and a very small portion of skin with the breast tissue) then the initial treatment with an expander may not be necessary, and a saline or silicone gel implant can be placed in a single stage.
Latissimus Dorsi (LD) Muscle Flap and Implant
Sometimes after a mastectomy or even for salvage of a previous reconstruction (radiation damaged tissue), a LD flap can be rotated into the chest with a small skin paddle to treat the skin defect that was caused by the mastectomy. In many cases, this will avoid the need to use a tissue expander. A saline or silicone gel breast implant can sometimes be placed underneath the LD flap during a single stage to reconstruct the breast. The LD flap provides adequate soft tissue coverage over the implant to protect it from possible exposure during the healing process.
Acellular Dermal Matrix (ADM)
ADM’s have changed the way we do breast reconstruction, specifically for tissue expander and implant reconstructions as well as correcting secondary cosmetic breast deformities. ADM’s are derived from dermis or skin elements that are treated to remove all antigenic material. They can be derived from pig or human skin. The most popular human-derived one is Alloderm®(LifeCell, Branchburg, NJ), but there are several others including FlexHD® (Ethicon, Somerville, NJ); Neoform™ (Mentor, Santa Barbara, CA), and DermaMatrix™ (Synthes, West Chester, PA); and porcine-derived Permacol™ (Covidien, Boulder, CO) and Strattice® (LifeCell). These products are used to provide full coverage of the tissue expander during reconstruction. They provide a scaffold for tissue regeneration and incorporation. They provide for support of the tissue expander or implant in the lower pole of the breast pocket and they may contribute to a lower risk of capsular contracture formation. In cosmetic breast surgery, they may be used for better coverage and camouflage for rippling, and provide further support in procedures to reconstruct the pocket, as in a capsulorrhaphy (capsule repair) procedure or bottoming out correction.
Direct to Implant Reconstruction
Direct to implant reconstruction is performed in patients that undergo mastectomy but do not need a significant skin resection or a lift procedure. This can be done for patients undergoing a nipple sparing mastectomy or a skin-sparing mastectomy. The pectoralis muscle is elevated and an implant is placed underneath. An ADM covers the implants lower half. The ADM is secured along this lower pole to the pectoralis muscle above and the inframammary soft tissue below.
If you would like more information about Dr. Wallach and his success with New York City Breast Reconstruction procedures, we hope that you will not hesitate to contact our Manhattan offices at (212) 257-3263 or by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028; or using our contact form to request additional details.
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