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Gabriel M. Kind, M.D.,
David S. Chang M.D.
45 Castro Street
Medical Office Building Suite 410
Davies Campus of California -
Pacific Medical Center
San Francisco, CA 94114
Telephone: 415-565-6884
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Breast Reconstruction Overview
It is important to be informed about each of the reconstruction options in order to determine the best possible treatment plan for each individual patient. Dr. Kind and Dr. Chang perform all of the various breast reconstruction in San Francisco procedures, and is therefore able to help each patient choose the best option.
The unique circumstances of each patient help to determine the best option for the method of reconstruction that can be used. The goals of breast reconstruction surgery are to re-create a breast which matches the opposite breast, or in bilateral cases, to reconstruct two breasts of a patients’s desired size. The nipple and areola (the pigmented area surrounding the nipple) are also reconstructed. It is ideal to consult with a plastic surgeon prior to mastectomy. This allows the surgical teams to plan the treatment that is best suited for the patient, even if the patient decides to wait to have reconstructive surgery at a later date.
Immediate breast reconstruction occurs when reconstruction is performed at the time of mastectomy. Immediate reconstruction has the advantage of usually saving the patient at least one subsequent operation, and has been shown to have a significant psychological benefit, as the patient never has to experience the total loss of a breast. All of the reconstruction options listed below can be performed at the time of mastectomy.
Delayed breast reconstruction is done at a later time. For some women, this may be advised, especially if radiation to the chest area is needed after the mastectomy. Delayed reconstruction is appropriate for these women because radiation therapy following breast reconstruction can increase complications after reconstructive surgery.
There are two main categories of breast reconstruction: Implant Reconstruction and Autogenous Reconstruction. |
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In this type of reconstruction a breast implant is placed in a pocket created on the chest wall. Implant reconstruction usually requires tissue expansion. In this process, a tissue expander is filled with saline over several weeks. The patient's body responds by stretching and creating new skin and muscle tissue. Once the desired size of the pocket is created, the tissue expander is removed and an implant is inserted. The implants used are filled with either saline or silicone gel. Another option that can avoid the use of tissue expansion is to cover an implant with muscle.
The latissimus dorsi is a large fan-shaped muscle of the back that can be rotated to the chest. In this procedure skin can also be taken if needed. More recently, foreign materials such as Alloderm (human cadaver allograft) have been used to create a sling to cover the lower portion of the tissue expander pocket. This can shorten the time needed for expansion, and in some cases, can allow for single-stage breast reconstruction, without the use of the latissimus dorsi muscle. Whenever an implant of any kind is placed in the body, a layer of scar tissue forms around the implant. This “capsule” varies in thickness, and can sometimes calcify and become hard. This is referred to as “capsular contracture”. The occurrence of capsular contracture is a concern with implant reconstruction. As a result of capsular contracture, implant reconstructions become more firm and can remain somewhat immobile, especially compared to a normal breast. If a patient has had radiation or is planning to have radiation, implant reconstruction is usually discouraged because of high rates of capsular contracture and other complications.
Another disadvantage of implants is the fact that there is a recognized leak or rupture rate. According to the implant manufacturers, the life expectancy of an implant is approximately 10 years.
Implant reconstruction procedures have the advantage of being shorter operations, and generally a rapid recovery can be expected. Since no other part of the body is used for reconstruction, there are no scars or any other damage to any other body part. |
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Autogenous breast reconstruction is the use of the body's own tissue to reconstruct a breast. The body will not reject the tissue, and it will change in volume as normal weight fluctuations occur through life. The breast is reconstructed with fat, which is similar in density to breast tissue, thus the look and feel is similar to that of a normal breast. By using a patient’s own tissues, a more natural-appearing breast is created, and the use of foreign materials is avoided.
When tissue is moved from one part of the body to another it is called a "flap". There are several different flaps that are used for breast reconstruction. During consultation, Dr. Kind or Dr. Chang will review the various flaps available and the one that would best suit his patients need. Listed below are some of the options in autogenous reconstruction.
The “deep inferior epigastric perforator” or DIEP flap is an upgraded modification of the “transverse rectus abdominis myocutaneous” flap, otherwise known as the TRAM flap.
 Once the most commonly performed flap procedure for breast reconstruction, the TRAM flap refers to the transverse (or sideways) orientation of the skin and fat taken from the lower abdomen, supplied by blood vessels that come through the rectus abdominis muscle (see figure 1). A "pedicled" TRAM flap uses skin and fat of the lower abdomen, which is elevated with the underlying rectus abdominis muscle, and transferred to the chest. The skin and fat are supplied by the "pedicle" of muscle, which carries and protects the blood vessels.
The microvascular or "free" TRAM has the advantage of a more direct blood supply, so more tissue can be safely transferred. In addition, only a part of the muscle is used, which results in less damage to the abdominal wall, and a faster return to normal activities. The major disadvantage of the free TRAM is that it requires the use of microsurgical techniques. Not all plastic surgeons are trained in microsurgery, and many who are prefer not to perform microsurgical breast reconstruction, because of the added complexity and the possibility of microsurgical complications. Microsurgical breast reconstruction requires the repair of small blood vessels. If the repair fails and the blood vessels don’t stay open, the entire flap can be lost. Although many precautions are taken to avoid this complication, according to medical literature, there is a reported risk of flap loss of 2 to 5%. Fortunately, with the use of the implantable Doppler probe and other techniques this risk is less than 1%. For a full analysis of the benefits of the miniature Doppler probe, please see Dr. Kind’s paper published in the journal Plastic and Reconstructive Surgery, “The effect of the implantable Doppler probe on the salvage of microvascular flaps”.
The main disadvantage of the TRAM flap, compared to implant reconstruction, is that it is a longer operation and typically requires a longer hospital stay. In addition, the TRAM flap requires the sacrifice of part or all of the rectus abdominis muscle. Most patients have minimal side effects from the loss of this muscle, although occasionally it can result in abdominal weakness, bulging, or (in rare cases) hernia.
 In the mid-1990's it was recognized that the TRAM flap could be harvested without the rectus abdominis muscle by dissecting the blood vessels (the perforating vessels to the skin and fat) through the muscle (see figure 2). This procedure became known as the DIEP flap. The DIEP flap uses the same skin and fat of the lower abdomen as the TRAM to reconstruct a breast. There are now many published series in medical literature that show that patients who undergo this procedure have less pain and a faster recovery than patients who undergo TRAM flap reconstruction. There is also less risk of abdominal wall weakness and herniation. Finally, since the flap is taken from the low abdomen like a TRAM flap, there is the added benefit of a "tummy-tuck", with the re-contoring of the abdomen. Most patients are pleased to have this tissue removed.
The DIEP harvest is longer and more complicated than a TRAM flap, but for most patients this is more than offset by the benefits to the abdominal wall.
Nearly every woman can opt for a DIEP reconstruction procedure, with the exception being women who lack enough abdominal fat tissue to create a breast. Younger women who are extremely athletic may fall into this category. In these patients, fat tissue can sometimes be harvested from other parts of the body, such as the inner thighs or gluteal areas, to reconstruct a breast.
In approximately 10% of patients, there are no large perforators coming through the rectus abdominis muscle. In these patients, the skin and fat of the lower abdomen are supplied by a more superficial blood vessel, the superficial inferior epigastric artery. This blood vessel is a branch of the femoral artery, and courses through the tissues of the lower abdomen without going through the rectus abdominis muscle. In these patients, breast reconstruction can be performed with a flap of fat and skin from the lower abdomen without having to dissect through the rectus abdominis muscle. This flap is called the superficial inferior epigastric artery or SIEA flap. Each time that Dr. Kind and Dr. Chang dissect a DIEP flap, they look for and preserve the superficial inferior epigastric blood vessels. If these vessels are of sufficient size, the SIEA flap can be used.
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There are other flaps that have been introduced for microsurgical breast reconstruction, although until recently these have been performed much less commonly. Gluteal flaps are flaps taken from the buttock area, supplied by the superior or inferior gluteal artery. These flaps are most commonly used for patients who have had previous abdominal surgery, or who have minimal abdominal fat, precluding the use of the TRAM flap. The major disadvantage of gluteal flaps is that the patient must be re-positioned during the surgery, adding to the length and possible complications of the case. Occasionally, a patient who needs breast reconstruction will have excess tissue of the outer or inner thigh. Microsurgical flaps (tensor fascia lata, gracilis myocutaneous) from these locations can be used for breast reconstruction. In all of these locations, care must be taken to avoid creating a deformity at the donor site.
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For women with breast cancer in one breast, the preoperative planning should always include a discussion regarding the opposite breast. Symmetry is one of the main goals of breast reconstruction. In many patients symmetry can best be accomplished by treating the opposite breast with augmentation, reduction or lifting. These procedures are covered by insurance, as mandated by law. In addition, significant breast asymmetry as a result of lumpectomy/radiation or multiple biopsies can be corrected with reconstructive surgery. |
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DIEP flap procedures typically last from 4-6 hours for a single reconstruction and 7-8 hours for a bilateral breast reconstruction. The hospital stay is generally 4-5 days for unilateral reconstruction, and five days for bilateral DIEP flap breast reconstruction. |
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Although technically more complex than other breast reconstruction techniques, the potential benefits of DIEP flap breast reconstruction can be significant.
- Compared to the TRAM Flap procedure, the DIEP option offers:
- Less post-surgical pain
- Better abdominal wall strength
- No abdominal hernia
- Abdominal wall appearance equivalent to abdominoplasty ( tummy tuck)
- Nearly every woman is a viable candidate
- All natural technique for reconstruction
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| Before Mastectomy |
After Right Mastectomy and Immediate Reconstruction With a DIEP Flap |
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| Before Mastectomy |
After Bilateral Mastectomy and Immediate Reconstruction With DIEP Flaps |
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| Before Reconstruction |
After Bilateral Reconstruction With Gracilis Flaps and Implants |
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