Methods of Breast Reconstruction

 

Breast reconstruction can utilise your own tissues, implants of some kind or a combination of the two. A comparison of the different types of breast reconstruction in terms of the size of the operation, hospital stay and recovery periods is shown below. The main methods of breast reconstruction are:

• Abdominal Flaps (TRAM, DIEP, SIEA)

• Latissimus Dorsi Flaps (with implants or without implants)

• Expanders and Implants (temporary, permanent, fixed volume, strattice-assisted)

• Uncommon techniques: Gluteal Flaps (SGAP, IGAP), Thigh Flaps (TUG, ALT)

 

Parameter	Expanders	LD flap	TRAM/DIEP/GAP
Duration	1 - 2 hours	2 - 4 hours	6 - 8 hours
Hospital stay	3 nights	5 nights	5 - 7 nights
Driving	4 weeks	6 weeks	8 weeks
Work	4 - 6 weeks	4 - 8 weeks	6 - 12 weeks
Strenuous activities	1 1/2 months	2 months	3 - 4 months

 

Methods of Breast Reconstruction 1

Breast Reconstruction with DIEP/TRAM/SIEA Flaps

The deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flaps make use of any excess skin and fat from your lower abdomen to create a new breast mound. This abdominal flap technique is indicated when the reconstructed breast needs to be large or droopy enough to match the opposite side. It permits the formation of a more naturally shaped, fuller and larger breast than any other method of reconstruction, and in the way the new breast looks, feels and moves. It is also the procedure of choice in patients who will require postoperative radiotherapy. This procedure also results in a "bonus" tummy tuck thus giving you a slimmer abdomen. The reconstructed breast is completely made of your own tissue.

We endeavour not to harvest any rectus muscle with the flap (DIEP flap) thus practically eliminating weakness, bulging or herniation of the abdominal wall. Consequently no mesh is required to repair the abdomen. Rarely a small piece of muscle around the blood vessels is harvested with the skin and fat of flap (muscle-sparing free TRAM flap). Although Professor Malata is trained in all the numerous techniques of breast reconstruction utilizing the excess soft tissues of the abdomen, he does not use pedicled TRAM flap because of their inferior blood supply and suboptimal cosmesis compared to DIEP flaps and free TRAM flaps. Theoretically a pedicled TRAM might be used if during surgery the blood vessels in the rectus muscle were found not suitable for microsurgery.

DIEP breast reconstruction is, however, a major surgical operation with a number of risks and a prolonged recovery period. It can be performed at the same time as the mastectomy (immediate or years later (delayed).

To view the before and after photos in some of Professor Malata’s publications on abdominal flap breast reconstruction (DIEP, TRAM, SIEA flaps) please click here:

• Influence of neoadjuvant chemotherapy on outcomes of immediate breast reconstruction;

• An algorithmic approach to abdominal flap breast reconstruction in patients with pre-existing scars results from a single surgeon’s experience;

• Experience with the Wise mammaplasty skin resection pattern in skin-sparing mastectomy and immediate breast reconstruction for large breast volumes;

• Tips for successful microvascular abdominal free flap breast reconstruction utilising the total rib preservation technique

• Cowden syndrome and reconstructive breast surgery - Case reports & review of the literature;

• Previous multiple abdominal surgery: A valid contraindication for abdominal flap breast reconstruction?

 

All operations carry risks as well as benefits. As in any surgery, there are benefits, risks and the final results are not guaranteed. The chance of complications following a DIEP or free TRAM flap depends on the type of operation and other factors such as your general health. Professor Malata will explain how the risks apply to you. Detailed postoperative instructions will be discussed during consultation and a procedure-specific handout given to you by Professor Malata.

 

Some risks of TRAM/ DIEP flaps:

• Bleeding and hematoma: uncommon

• Infection: rare

• Delayed healing and wound breakdown: common in smokers and the overweight

• Seroma: very common

• Numbness of abdominal wall: universal and partially permanent

• Residual asymmetry of scars, umbilicus, upper abdominal fullness, dog ears

• Long scars hypertrophic/ keloidal scars

• Fat necrosis (with high BMI, or little abdominal tissue): oily fluid leakage & hard lumps

• Abdominal: weakness, bulging, herniation - rare

• Tightness of abdomen & getting full quickly when eating

• General complications: chest infection, blood clots (DVT, PE)

 

Flap Related (The reconstructed breast)

• Bleeding and hematoma: uncommon

• Re-Exploration: rare (5-8%)

• Delayed healing & wound breakdown: especially big breasts, axillary dissection, skin reduction

• Total flap loss: extremely rare (2-5%)

• Total numbness of new breast

• Residual asymmetry

• Fat necrosis

• Flap shrinkage with radiotherapy: pedicled flaps and DIEPs

• Fluid collection in arm pit (if axillary dissection performed)

 

Alternatives to Abdominal Flap Breast Reconstruction

• Latissimus dorsi flap with or without implant

• Expander/ Implant +/- strattice or alloderm

• Buttock flaps: IGAP, SGAP

 

Methods of Breast Reconstruction 2

Breast Reconstruction with Latissimus Dorsi Flaps

Latissimus dorsi flap breast reconstruction creates a new breast mound using the back muscle, fat and skin, often with an implant or expander. It is used when the new breast needs to be large or droopy enough to match the opposite side and the patient does not want or is not suitable for the abdominal (TRAM/ DIEP) flap operation. The additional tissue brought from the back to the front of the chest wall permits the formation of a more naturally shaped, fuller and larger breast (than could be created by simple implant placement or tissue expansion alone). This extra tissue also enables breast reconstruction in patients with a tight chest wall, for instance, after radiotherapy.

In terms of size this operation is intermediate between expander-implant reconstruction and the use of the abdominal flap (see comparative table above). It creates a new scar on the back (whose length depends on whether this is a delayed or immediate breast reconstruction). It creates an extra scar on the breast only in delayed breast reconstruction. The scar on the back measures 12-13cm (5 – 6 inches) on average and is designed so that it is hidden in the bra strap..LD flap breast reconstruction can be performed at the same time as the mastectomy (immediate) or years later (delayed). It is also suited for reconstructing partial mastectomy defects.

Because the skin and muscle from your back are usually quite thin, this method is often (90% of the time) used along with a breast implant or expander to give a fuller more natural shape. In suitably built patients it can be used without an implant (totally autologous LD or Extended LD).

During LD flap breast reconstruction, a section of your skin and muscle is removed from your back, tunnelled through the axilla and brought to the front of the chest through the mastectomy defect where it is reconstruct the breast.

 

To view the before and after photos in some of Professor Malata’s publications on latissimus dorsi breast reconstruction please click below:

• Early experience with an anatomical soft cohesive silicone gel prosthesis in cosmetic and reconstructive breast implant surgery;

• Experience with Mentor Contour Profile Becker-35 expanders in reconstructive breast surgery;

• Influence of neoadjuvant chemotherapy on outcomes of immediate breast reconstruction;

• Principles of Reconstructive Breast Surgery.Book Chapter in Early Breast Cancer - From Screening to Multidisciplinary Management.

 

Some risks of latissimus dorsi flap breast reconstruction:

All operations carry risks as well as benefits. As in any surgery, there are benefits, risks and the final results are not guaranteed. The chance of complications following latissimus dorsi breast reconstruction depends on the type of operation and other factors such as your general health. Professor Malata will explain how the risks apply to you. Detailed postoperative instructions will be discussed during consultation and a procedure-specific handout given to you by Professor Malata.

• Bleeding and blood accumulation (haematoma): unusual: early

• Seroma (fluid collection in the back): common: - if uncomfortable syringe aspiration

• Shoulder stiffness – common: Interference with swimming, gymnastics, tennis, golf

• Infection is rare (antibiotics lessen this chance)

• Some patients complain that it is difficult to keep shoulder erect: exercise

• Scar capsular contracture around the implant/ expander: requires revisional surgery

• Contraction of the new breast with arm movements (“winking”)

• Delayed donor site healing: usually minor but common if total autologous technique used.

• Blood circulation problems to the flap (<2%): usually previous radiation or axillary clearance.

• Flap loss (< 1%): due to poor blood supply or accidental damage to the pedicle, or haematoma

• Need for revisional surgery: contractures, dog ears, scars, persistent asymmetry, malposition

• Differences in the size, shape, & position of the 2 breasts: the new breast cannot be identical to a natural breast.

• General complications of surgery: blood clots (DVT, PE’s), chest infection, wound infections, etc.

• Flap Related (The Reconstructed Breast)

• Bleeding and haematoma: uncommon

• Delayed healing & wound breakdown: especially smokers, big breasts, axillary dissection, skin reduction

• Total flap loss: extremely rare (0-1%)

• Total numbness of new breast

• Residual asymmetry

• Fat necrosis

• Flap shrinkage with radiotherapy: LD fat resists radiotherapy shrinkage better than pedicled flaps and DIEPs.

• Fluid collection in arm pit (if axillary dissection performed)

 

Alternatives to LD Flap Breast Reconstruction

• Abdominal Flaps: DIEP, TRAM

• Expander/ Implant +/- strattice or alloderm

• Buttock flaps: IGAP, SGAP

 

 

Methods of Breast Reconstruction 3

Breast Reconstruction with Expanders or Implants

Breast reconstruction with expanders or implants is also known as prosthetic breast reconstruction or implant-based breast reconstruction. In this technique a breast mound is created by inserting an implant, a temporary expander, or permanent expander (expandable-implant) under the front chest wall muscle (the pectoralis major muscle). Breast reconstruction with prostheses can be performed at the time of the mastectomy (immediate) or later (delayed).

The scar from this type of operation is identical to that after a mastectomy alone and is horizontal and located in the centre of the reconstructed breast.

Implant breast reconstruction is mainly used for small to moderate sized breasts (usually a C cup or less). It cannot easily create a large and/ or droopy breast & is not used if postoperative radiotherapy is planned or highly likely.

Where a temporary expander is used a 2^nd operation is necessary to replace it with the definitive breast implant (or fixed-volume breast implant). This implant is made of or filled with “liquid” silicone gel, saline or cohesive silicone gel depending on your preference. Permanent expanders (also called expandable-implants) do not need to be exchanged as they serve both as expanders and implants. Most often (90%) implant reconstruction requires a period of tissue expansion. The expander or expandable implant is gradually inflated in Professor Malata’s outpatient clinic with saline starting 2 – 3 weeks following surgery. The expansion process lasts a few months. After a 3 month waiting period for maturation of the capsule, the expander is then replaced with a permanent breast implant at a 2^nd operation. Rarely a “direct-to-implant” breast reconstruction is possible but only for very small breasts (A or B cup) unless strattice, alloderm or matriderm is used. These dermal matrix equivalents improve the aesthetics and the safety of prosthetic breast reconstruction and also extend the range or size of breasts that the implant-based reconstructions can be applied to.

During the mastectomy, the surgeon removes skin and breast tissue, leaving the breast tissues flat and tight. Before a permanent implant can be inserted the skin of the breast needs to be stretched to make a space for the implant. This process is called tissue expansion and is performed in one or two stages.

 

Two-Stage Implant-Breast Reconstruction (Classical Expander/ Implant)

This is a very popular option especially in North America. The surgery can be performed as a delayed or immediate procedure. A temporary tissue expander (usually breast shaped) is placed underneath the pectoralis major muscle. Over a period of weeks the expander is filled with saline causing the skin to gradually stretch and grow to make room for the implant as it expands. Once the right size has been reached the expander is then replaced with a permanent silicone implant in a second operation; usually after a 3-month wait.

 

Single-Stage Implant Breast Reconstruction

The surgery occurs initially in the same way as the two-stage procedure. However, the implant used is a permanent silicone implant with an expander facility. Professor Malata prefers to use the tear-drop or breast shaped type of expandable-implants namely the Mentor Becker 35 expander or the McGhan style 150 device). These devices has a small fill tube and dome that is placed under the skin a short distance away from the implant. Over a period of weeks or months the expander is inflated with saline. When the desired size is reached the fill tube and port can be removed while leaving the implant in place or can be left in situ indefinitely.

To view the before and after photos in some of Professor Malata’s publications on implant-based breast reconstruction please click below.

• Early experience with an anatomical soft cohesive silicone gel prosthesis in cosmetic and reconstructive breast implant surgery;

• Experience with Mentor Contour Profile Becker-35 expanders in reconstructive breast surgery;

• Indications for extra full projection anatomical cohesive silicone gel implants in cosmetic and reconstructive breast surgery

• Cowden syndrome and reconstructive breast surgery - Case reports & review of the literature;

• Principles of Reconstructive Breast Surgery.Book Chapter in Early Breast Cancer - From Screening to Multidisciplinary Management.

 

Some Risks of Implant-based breast reconstruction:

All operations carry risks as well as benefits. As in any surgery, there are benefits, risks and the final results are not guaranteed. The chance of complications following implant-based breast reconstruction depends on the type of operation and other factors such as your general health. Professor Malata will explain how the risks apply to you. Detailed postoperative instructions will be discussed during consultation and a procedure-specific handout given to you by Professor Malata.

• Bruising and swelling

• Bleeding and haematoma – uncommon

• Numbness & tingling

• Infection: very rare

• Wound breakdown & exposure: rare

• Failure to expand: infrequent, port flicked over

• Perforation of the prosthesis during expansion: rare

• Capsular contracture: very common

• Poor projection and poor ptosis: common

• Need for revisional surgery: common:

• Alteration of breast shape as you tense your chest muscle

• Palpable or visible folds or ripples or implant outline

• Malposition of the prosthesis – infrequent, often appears fuller in upper part

• as with other technics the reconstructed breast feels relatively numb to touch

• Asymmetry: differences in the size, shape, and position of the 2 breasts

• New breast does not move or droop or feel as a normal one or that made with your own tissues

 

Alternatives to Implant Breast Reconstruction

• Abdominal Flaps: DIEP, TRAM

• Total autologous LD

• Latissimus dorsi flap  implants or expanders

• Other tissues: Buttock flaps (IGAP, SGAP), Thigh flaps (TUG).

• No reconstruction: external prosthesis either bra mounted or adherent to skin.

 

Methods of Breast Reconstruction 4

Uncommon techniques: Gluteal Flaps and Thigh Flaps

For patients who do not have enough tissues on their abdomen or back Professor Malata sometimes used the lower or upper buttock tissue (gluteal perforator flaps or GAP flaps) or rarely used the upper inner (TUG) or upper outer thigh (LTTF) flaps. These operations are performed as free tissue transfers and in terms of size and complexity are similar to the use of abdominal free flaps (see comparative table above). The buttock flaps can be harvested from the lower part (inferior gluteal perforator flap) or the upper part (superior gluteal perforator flap). Professor Malata prefers to use the lower part as it has more advantages.

To view a GAP flap in Professor Malata’s publications please click here (Perforator flaps in Breast Reconstruction).