Breast reconstruction is the use of autologous tissue or prosthetic material to construct a natural-looking breast, e.g. after a mastectomy or to correct deformities. Often this includes the reformation of a natural-looking areola and nipple. The primary part of the procedure can often be carried out immediately following the mastectomy.

Techniques

Tissue expander - breast implants

This is the most common technique used worldwide. The surgeon inserts a tissue expander, a temporary silastic implant, beneath a pocket under the pectoralis major and serratus anterior muscles of the chest wall. The pectoral muscles may be released along its inferior edge to allow a larger, more supple pocket for the expander at the expense of thinner lower pole soft tissue coverage. The use of acellular human or animal dermal grafts have been prescribed as an onlay patch to increase coverage of the implant when the pectoral muscle is released, which purports to improve both functional and aesthetic outcomes.

In a process that can take weeks or months, a saline solution is percutaneously injected to progressively expand the overlaying tissue. Once the expander has reached an acceptable size, it may be removed and replaced with a more permanent implant. Reconstruction of the areola and nipple are performed in a separate operation after the skin has stretched to its final size.

Flap reconstruction

This procedure uses tissue from other parts of the patients body. This procedure may be performed by leaving the donor tissue connected to the original site to retain its blood supply (the vessels are tunnelled beneath the skin surface to the new site) or it may be cut off and new blood supply may be connected.

The latissimus dorsi muscle flap is tissue from the back. It is a large flat muscle which can be employed without significant loss of function. It can be moved into the breast defect still attached to its blood supply under the arm pit (axilla). A latissimus flap is usually used to recruit soft-tissue coverage over an underlying implant. Enough volume can be recruited occasionally to reconstruct small breasts without an implant.

The abdominal flap is abdominal tissue between the umbilicus and the pubis. It requires advanced microsurgical technique and are less common as a result. The contour of the lower abdomen is reliably improved by these procedures which remove the same tissue as a tummy tuck. This procedure may weaken the abdominal muscles, but are usually tolerated well in most patients. To prevent muscle weakness and incisional hernias, the portion of abdominal wall exposed by reflection of the rectus abdominis muscle may be strengthened by a piece of surgical mesh placed over the defect and sutured in place.

Other total autologous tissue breast reconstruction donor sites include thebuttocks.

Reconstruction of the nipple-areolar complex

This is usually delayed until after the breast mound reconstruction is completed so that the positioning can be planned precisely.

Nipple-Areolar Composite Graft (Sharing) - if the contralateral breast has not been reconstructed and the nipple and areolar are sufficiently large, tissue may be harvested and used to recreate the nipple-areolar complex on the reconstructed side.

Local tissue flaps creates a nipple by raising a small flap in the target area and producing a raised mound of skin. To create an areola, a circular incision may be made around the new nipple and sutured back again. The nipple and areolar region may then be tattooed to produce a realistic colour match with the contralateral breast.

Local tissue flaps with the use of AlloDerm is the same as above, but a nipple is created by raising a small flap in the target area and producing a raised mound of skin. AlloDerm (cadaveric dermis) can then be inserted into the core of the new nipple acting like a "strut" which may help maintain the projection of the nipple for a longer period of time. The nipple and areolar region may then be tattooed later.

Other considerations

1 of the challenges in breast reconstruction is to match the reconstructed breast to the breast on the other side. This often requires a lift, reduction or augmentation of the other breast.

Patients with comorbidities (high blood pressure, obesity, diabetes) and smokers are higher-risk candidates. Surgeons may choose to perform delayed reconstruction to decrease this risk. Patients expected to receive external beam radiation as part of their adjuvant treatment are also commonly considered for delayed autologous reconstruction due to significantly higher complication rates with tissue expander-implant techniques in those patients.

Breast reconstruction is a large undertaking that usually takes multiple operations. Sometimes these follow-up surgeries are spread out over weeks or months. If an implant is used, the individual runs the same risks and complications as those who use them for breast augmentation but has higher rates of capsular contracture (tightening or hardening of the scar tissue around the implant) and revisional surgeries.

In in the United States, the Womens Health and Cancer Rights Act mandates insurance coverage for the surgery of the affected breast and also the contralateral side for purposes of symmetry.

Follow-up and Recovery

Recovery from implant-based reconstruction is faster than with flap-based reconstructions. Both take at least 3 to 6 weeks to recover and both require follow-up surgeries in order to construct a new areola and nipple. All recipients of these operations should refrain from strenuous sports, overhead lifting and sexual activity during the recovery period.


This page has been updated on the 2017-12-18.