Effective reconstruction is possible for virtually any post mastectomy condition. Having breast reconstruction is a complicated decision that involves you, your family, and your health care team. Breast reconstruction can help promote a sense of wellness or wholeness after traumatic illness.
Insurance carriers are required by law to cover the costs of breast reconstruction. This not only includes the breast that is affected by cancer but also adjustment of the opposite breast to achieve symmetry. If a woman does undergo mastectomy on one side for breast cancer and has reconstruction, the remaining normal breast might benefit from breast lift or breast reduction to achieve the best possible symmetry.
Some women opt for bilateral mastectomies to help reduce the risk for possible recurrence of breast cancer. This may offer some advantages for reconstruction because in this situation the same procedure can be performed for each breast, increasing the potential for a symmetrical surgical result.
Breast reconstruction can be accomplished with different techniques including use of breast implants or use of the patient's own tissues. Reconstruction is typically performed in two stages with the first stage being creation of the breast mound or mounds. The second stage is the adjustment of the breast shape and nipple reconstruction.
Breast Implant Technique:
If an implant is used, a tissue expander is put in place first. This expander is placed underneath the muscles of the chest wall and is gradually inflated to recreate the appearance of the breast mound. After the expander has been fully inflated and has been left in place for a short while, it is removed at the second operation and a permanent breast implant is placed. This may consist of a saline implant or a silicone gel implant.
At the second operation, the nipple is also reconstructed, usually from the skin present on the breast mound. Tattooing is later performed to re-create the image of the areola margin and also to add color to the reconstructed nipple.
Patient Tissue Technique:
Use of the patient's own tissues can also be utilized for breast reconstruction. This is an effective technique for a unilateral reconstruction and provides a better match for a normal remaining opposite breast. The technique also works very nicely for bilateral reconstructions if there is sufficient tissue present. The most common donor site for the tissue to be transferred is the abdominal area. This provides skin, fatty tissue, and muscle and generally creates a breast mound that has a very normal shape and texture.
The transfer tissue from the abdominal area is usually left attached to the rectus muscles which provide the blood supply to the tissue. The flap of skin, muscle, and fat is tunneled underneath the skin to the chest area and shaped into a breast mound. Sometimes the tissues are fully removed and reattached with the blood supply being re-established using micro-vascular surgical techniques.
The tissue that is obtained from the abdominal area is called a TRAM flap (transverse rectus abdominus muscle flap). Most patients will have some degree of excess skin and fatty tissue of the abdominal area and this can be utilized for the breast reconstruction as described above. The abdominal donor site is closed with a long transverse incision that is similar to an abdominoplasty, though is placed somewhat higher on the lower abdominal area. Sometimes a breast implant may be combined with use of the TRAM flap, particularly for bilateral reconstructions.
Another method for using the patient's own tissues is the latissimus dorsi flap or LD flap. This procedure relocates part of the latissimus dorsi muscle of the back with overlying skin and fatty tissue to the breast area. The procedure generally does not provide enough tissue to fully recreate the breast and thus a small implant is usually also necessary.
Sometimes an expander is placed underneath the LD flap, gradually inflated, and later replaced with a permanent prostheses. The donor site of the back is less optimal as compared to an abdominal donor site for a TRAM flap. There is generally a more noticeable scar with some loss of the natural thickness of the skin of the back and asymmetry compared to the opposite back area.