Breast Reconstruction After Mastectomy

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Types of breast reconstruction

Several types of operations can be done to reconstruct the shape of your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of both. (A tissue flap is a section of your own skin, fat, and in some cases muscle which is moved from another area of your body to your chest.)

Implant procedures

Types of implants

Implants have a silicone shell filled with either silicone gel or salt water (saline).

Silicone gel-filled implants are one option for breast reconstruction. Most of the recent studies show that silicone implants do not increase the risk of immune system problems, and the FDA (Food and Drug Administration) has approved silicone implants since 2006.

Some newer types use thicker silicone gel, called cohesive gel. The thickest ones are sometimes called “gummy bear” implants and are made of highly cohesive silicone. They are more accurately called form-stable implants, meaning that they keep their shape even if the cover is cut or broken. Although it was first thought they wouldn’t leak even if they did break, there have been reports of ruptures with leakage. Form-stable implants were approved in early 2013 in the United States.

Alternative breast implants that have different shells and are filled with different materials are being studied, but you can only get them when they are available in clinical trials. You can learn more about clinical trials online, or call us at 1-800-227-2345.

Types of implant surgery

One-stage immediate breast reconstruction is also called direct-to-implant reconstruction. For this, the final implant is put in at the same time as the mastectomy is done. After the surgeon removes the breast tissue, a plastic surgeon places a breast implant. The implant is usually put beneath the muscle on your chest. A special type of graft or an absorbable mesh is used to hold the implant in place, much like a hammock or sling. (See the section “New methods of tissue support.”).

Two-stage reconstruction means that a short-term tissue expander is put in after the mastectomy. The expander is a balloon-like sac that’s slowly expanded to the desired size to allow the skin flaps to stretch. It’s used when the surgeon believes that the mastectomy skin flaps are not healthy enough to support a full-sized implant right away. Through a tiny valve under the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over a period of about 2 to 3 months. After the skin over the breast area has stretched enough, a second surgery will remove the expander and put in the permanent implant. Some expanders are left in place as the final implant.

The two-stage reconstruction is sometimes called delayed-immediate reconstruction because it allows time for other treatment options. If radiation therapy is needed, the final placement of the implant is put off until radiation treatment is complete. If radiation is not needed, the surgeon can start right away with the tissue expander.

Considerations about implants

Keep these important factors in mind if you are thinking about having implants to reconstruct the breast and/or to make the other breast match the reconstructed one:

  • You may need more surgery to remove and/or replace your implant later. In fact, up to half of implants used for breast reconstruction have to be removed, modified, or replaced in the first 10 years.
  • You can have problems with breast implants. They can break (rupture) or cause infection or pain. Scar tissue may form around the implant (called capsular contracture), which can make the breast harden or change shape, so that it no longer looks or feels like it did just after surgery. Most of these problems can be fixed with surgery, but others might not be reversible.
  • MRIs may be needed every few years to make sure silicone gel implants have not broken. Your health insurance may not cover this.
  • Routine mammograms to check your remaining breast for cancer will be more difficult if you have a breast implant there – you’ll need more x-rays of the breast, and the compression may be more uncomfortable.
  • An implant in the remaining breast could affect your ability to breastfeed, either by reducing the amount of milk or stopping your body from making milk.

Tissue flap procedures

These procedures use tissue from your tummy, back, thighs, or buttocks to rebuild the breast shape. The most common types of tissue flap procedures are from the lower abdomen (called TRAM [transverse rectus abdominis muscle] flap or DIEP [deep inferior epigastric perforator flap]), and the latissimus dorsi flap, which uses tissue from the upper back. Other tissue flap surgeries described below are more specialized, and may not be done everywhere.

These operations leave 2 surgical sites and scars – one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but never go away. There can be donor site problems such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts. Because healthy blood vessels are needed for the tissue’s blood supply, flap procedures can cause more problems in smokers, and in women who have uncontrolled diabetes, vascular disease (poor circulation), or connective tissue diseases.

In general, flaps require more surgery and a longer recovery. But when they work well, they look more natural and behave more like the rest of your body. For instance, they may enlarge or shrink as you gain or lose weight. There’s also no worry about implant replacement or rupture.

Abdominal flaps: TRAM and DIEP

The TRAM (transverse rectus abdominis muscle) flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). Some women, have enough tissue in this area to shape the breast, so an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower belly, or a “tummy tuck.”

There are different types of TRAM flaps:

  • A pedicle TRAM flap leaves the flap attached to its original blood supply and tunnels it under the skin to the chest. It usually requires removing most if not all of the rectus muscle on that side, which means an increased risk of bulging and/or hernia on one side of the abdomen.
  • A free TRAM moves tissue from the same part of the lower abdomen but doesn’t take very much muscle. The flap is completely disconnected and moved up to the chest. The blood vessels (arteries and veins) must then be reattached. This requires the use of a microscope (microsurgery) to connect the tiny vessels and the surgery takes longer than a pedicle TRAM flap. The blood supply to the flap is usually better than with pedicle flaps and the donor site (abdomen) often looks better. The main risk is that sometimes the blood vessels get clogged and the flap doesn’t work.

The DIEP (deep inferior epigastric perforator) flap uses fat and skin from the same area as the TRAM flap but does not use the muscle to form the breast shape. This results in less skin and fat in the lower belly (abdomen), or a “tummy tuck.” This method uses a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest. As in the free TRAM surgery, a microscope is needed to connect the tiny blood vessels. There’s less risk of a bulge or hernia because no muscle is taken.

TRAM flap incisions The tissue used to rebuild the breast shape

Donor tissue site for DIEP flap After DIEP flap

Latissimus dorsi flap

The latissimus dorsi flap tunnels muscle, fat, skin, and blood vessels from your upper back, under the skin to the front of the chest. This provides added coverage over an implant and makes a more natural-looking breast than just an implant alone. It can sometimes be used without an implant. It’s a very reliable flap and can even be used in women who smoke (smoking can delay healing). Though it’s not common, some women have weakness in their back, shoulder, or arm after this surgery.

Latissimus dorsi flap

Gluteal free flap

The gluteal free flap or GAP (gluteal artery perforator) flap is newer type of reconstruction surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape. It might be an option for women who cannot or do not wish to use the tummy sites due to thinness, incisions, failed tummy flap, or other reasons, but it’s not offered in many areas of the country. The method is much like the free TRAM flap mentioned above. The skin, fat, blood vessels, and muscle are cut out of the buttocks and then moved to the chest. Like all of the free flaps, a microscope (microsurgery) is needed to connect the tiny vessels.

Inner thigh or TUG flap

A newer option for those who can’t or don’t want to use TRAM or DIEP flaps is a surgery that uses muscle and fatty tissue from along the bottom fold of the buttock extending to the inner thigh. This is called the transverse upper gracilis flap or TUG flap, and it’s only available in some centers. Because the skin, muscle, and blood vessels are cut out and moved to the chest, a microscope is used to connect the tiny blood vessels to their new blood supply. Women with thin thighs don’t have much tissue here, so the best candidates for this type of surgery are women whose inner thighs touch and who need a smaller or medium-sized breast. Sometimes there are healing problems due to the location of the donor site but they tend to be minor and easily treated.

New methods of tissue support

Tissue support is sometimes needed, especially when implants are used for breast reconstruction. This tissue can provide added coverage, support the implant, or position the muscle where it needs to be. There are many different products that use donated human skin (such as AlloDerm® and DermaMatrix®) to support implants or transplanted tissues. These products are regulated by the FDA (Food and Drug Administration) as human tissues used for transplant. But they’ve had the human cells removed (are acellular), which reduces any risk that they carry diseases or the body will reject them. They are used to extend and support natural tissues and help them grow and heal. In breast reconstruction they may be used with expanders and implants. They have also been used in nipple reconstruction.

Doctors can also use synthetic mesh, animal grafts, and more recently, animal skin with the cells removed (an acellular matrix such as Strattice), and other methods for internal support.

The acellular matrix products are newer in breast reconstruction. Studies that look at outcomes are still being done, but have been promising overall. This skin tissue is not used by every plastic surgeon, but is becoming more widely available. Talk with your doctor about whether these materials will be used in your reconstruction and how they might affect your possible risk of complications or their possible benefit in making a better reconstruction.

Last Medical Review: 12/05/2014
Last Revised: 03/12/2015