The entire process of a breast reconstruction surgery is actually a series of three surgeries that can span up to about 1 year but is case specific. The following pictures show the various choices available. Consult a plastic surgeon to find out which type of reconstruction surgery may be best for you.
Types of breast reconstruction
Several types of operations can be done to reconstruct your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. (A tissue flap is a section of your own skin, fat, and in some cases muscle which is moved from your tummy, back, or other area of your body to the chest area.)
Breast Reconstruction Education and Options Brochure
Download the 2014 Educational Brochure provides a Snapshot” of the process and questions to ask your surgeons. Breast Centers and surgeons please email firstname.lastname@example.org to receive them in your office.
Types of implants
The most common implant is a saline-filled implant. It is a silicone shell filled with salt water (sterile saline).
Silicone gel-filled implants are another option for breast reconstruction. They are not 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. The FDA approved silicone implants again in 2006. Some newer types of silicone implants use a thicker gel, called cohesive gel. Some of these gels are thick enough that they may not leak much even if the implant ruptures. The thickest of these are sometimes called “gummy bear” implants, but in the United States they are only available through clinical trials.
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 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 or behind the chest muscles to 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 time (about 4 to 6 months). After the skin over the breast area has stretched enough, a second surgery is done to 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 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.
Considerations about implants
There are some important factors for you to keep in mind if you are thinking about having implants to restore the breast and/or to make the other breast match the restored one:
- Implants often do not last a lifetime. You may need more surgery to remove and/or replace your implant later. In fact, up to half of implants used for breast reconstruction have to be removed, modified, or replaced in the first 10 years.
- You can have problems with breast implants. They can break (rupture) or cause infection or pain. Scar tissue may form around the implant (capsular contracture), which can make the breast harden or change shape, so that it no longer looks or feels like it did just after surgery.
- Routine mammograms to screen for breast cancer on the remaining breast will be more difficult if you have a breast implant there — you’ll need more X-ray shots of the breast, and the compression may be more uncomfortable.
- Breast implants in the remaining breast may affect your ability to breast feed, either by reducing the amount of milk or stopping your body from making milk.
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 is 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:
- A 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 where the tissue is tunneled through.
- 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.
TRAM flap incisions The tissue used to rebuild the breast 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 is 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 is not common, some women may have weakness in their back, shoulder, or arm after this surgery.
DIEP (deep inferior epigastric artery perforator) flap
A newer type of flap procedure, 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. This requires the use of a microscope (microsurgery) 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.
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 is 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. 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. 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
These operations move sections of tissue to new places, or add fairly heavy implants, and some tissues need support to keep them in place as they heal. Doctors can use synthetic mesh, animal grafts, and other methods for this.
More recently, some doctors are using products made of donated human skin (such as AlloDerm® and DermaMatrix®). These products are regulated by the U.S. 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.
These products are fairly new in breast reconstruction. Studies that look at outcomes are still in progress, 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.
Information care of Cancer.org.
So you may fully understand the nature of what uninsured women must live with we have chosen a number of before and after pictures. While graphic in nature there really is no other way to convey the terrible situation an uninsured woman must endure, living with this disfigurement!
Be Advised, the following images show the before and after photographs of a patient and may be graphic in nature for some.