Breast Reconstruction Procedure Options: The Pluses and Minuses
There is a small risk of failure with any of these procedures. Some patients have a greater risk for complications. Occasionally, the treatment of complications requires additional surgery. It is important to discuss all of the potential risks and benefits with your surgeon.
EXTERNAL PROSTHESIS Women who opt to avoid additional surgery are given an external prosthesis for appearance. No additional surgery is performed and the skin lies flat across the chest.
IMPLANTS At the time of breast removal, a tissue expander is inserted under the skin. Over a period of months, the expander is inflated to create a new pocket for a breast implant. In a subsequent procedure, the expander is removed and a breast implant, made of silicone-gel or saline, is inserted in the pocket.
Advantages: Requires less scarring than other types of reconstruction. Immediate reconstruction is initiated, so the patient wakes with the beginning of a breast mound in place.
Disadvantages: More potential complications of infection, extrusion, implant hardening or leaking. Always involves at least one additional surgery to insert the synthetic breast implant. The reconstructed breast never looks completely like the unaffected breast. Implants are not recommended for women who must undergo radiation therapy.
AUTOLOGOUS RECONSTRUCTION Some women prefer to use their own tissue (autologous) for a reconstructed breast. Because the body's own tissue is more natural, the breast reconstruction can better simulate the unaffected breast. Three options are most frequently used:
Pedicled Latissimus Dorsi Flap The latissimus (a flap of muscle, fat and skin near the shoulder blade) is rotated around to the chest to form a breast mound.
Advantages: The body prefers its own tissue and, when successful, this choice has very few long-term complications. The entire procedure can be performed at the time of breast removal.
Disadvantages: Produces a scar on the back; requires more operating time than implants. Because most women do not have much fatty tissue around the muscle, an implant may be used in conjunction with the flap to provide proper size.
Pedicled TRAM Flap Instead of tissue from the back, a similar procedure is performed using the muscle, fat and skin from the lower abdomen. The procedure is called the transverse rectus abdominus myocutaneous (TRAM) flap reconstruction. The blood vessels supplying the flap stay connected to the body and are rotated into the breast pocket.
Advantages: The body prefers its own tissue, and, when successful, has very few complications. It can be performed at the time of breast removal. A woman receives a flatter abdominal contour at the same time the tissue is removed. A TRAM flap has better long-term outcomes than implant surgery. Because there is usually more fat below the naval, an implant can be avoided.
Disadvantages: Produces a scar below the naval; requires more operating time than implants. Hernias can occur if the abdominal wall is weakened. Women with pre-existing conditions usually are not candidates for this surgery. However, a TRAM flap can be 'super-charged' using an operating microscope to attach some of the blood vessels in the flap to the breast area. This is similar to the free TRAM flap (below) and provides extra blood flow to the new breast mound, but requires extra time in surgery.
Free TRAM flap After the surgeon detaches the main blood vessel supplying the TRAM flap, an operating microscope and sutures that are smaller in diameter than a human hair are used to establish blood flow to the new breast mound. Some women have pre-existing conditions (diabetes, obesity, prior abdominal surgery, or a smoking history) that mandate this type of microsurgery for breast reconstruction.
Advantages: Same as pedicled TRAM flap above. Additionally, the transferred tissue survives more completely and is more easily shaped.
Disadvantages: Same as pedicled TRAM flap above. Additionally, a free TRAM flap is a longer procedure and requires a longer post-operative stay in the hospital.