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By Dr. Jay Orringer
Today, a wide variety of breast reconstructive options exist. An understanding of the basic concepts will help greatly in the decision making process. In general terms, there are two ways to reconstruct a breast. The simpler method involves the use of a temporary adjustable-volume implant called an expander. Salt water is added to the expander until a pleasing size has been achieved. The expander is then replaced with an implant. The more involved category of reconstruction involves the use of one’s own tissues, transferred from the back, abdomen or buttocks.
Expander, followed by implant, reconstructions have the advantage of being simpler procedures and the scars are limited to the chest. However, these devices require maintenance (replacement) over the course of time. When the chest wall tissues are thin following mastectomy, edges and ripples are more visible unless the padding over the implant is improved.
One common way to improve thickness over the implant is with the use of AlloDerm. This is a sheet up to 3mm thick, derived from human skin. However, it is treated such that the cells are removed from it and the patients cells grow into it. Because the original cells have been removed from it, it tends to be well-tolerated. It becomes, in essence, another layer of one’s own tissue. This may decrease the devices’ visibility and palpability. It has gained widespread use today.
A second way to improve the appearance and thickness over an implant reconstruction is with the addition of tissue transferred from the back. This is called a latissimus flap. A scar on the outer part of the back may be traded for a less conspicuous scar on the breast. The transfer of healthy tissue over the augmentation may increase the natural quality and the durability of this method of reconstruction, but the trade-offs must be weighed in discussion with your surgeon. Implant reconstructions often do not do well long-term following prior radiation, without the addition of healthy tissue as with the latissimus flap.
Breast restoration from the abdomen and buttocks may provide enough skin and fat to make a new breast without an implant. These options avoid maintenance issues, but are much more involved procedures. A potentially more natural and permanent reconstruction may result. However, a scar at the site from where the tissue was taken results. In addition, some weakness occurs from the transfer of muscle. This is usually well tolerated in most people, but each individual has a different experience. The TRAM flap was the first transfer of skin, fat and muscle to make a new breast mound. It has been followed by muscle-sparing free TRAM flaps and DIEP flaps.
The free TRAM flap takes less abdominal muscle and usually has a better blood supply than the traditional TRAM flap. However, it requires microsurgical expertise to perform the transplant and it is not always successful. In an effort to take muscle-sparing further, the DIEP flap was developed. This flap spares more muscle, although the abdominal muscle is not totally spared of damage. The blood supply of the DIEP flap may not be as hearty as that of the muscle-sparing free TRAM flap. The traditional TRAM flap, muscle-sparing free TRAM and DIEP flap are all good options in selected patients.
The gluteal or GAP is the least commonly done and most complex option. It involves the transfer of buttock skin and fat to make the breast. It is usually done in women with little abdominal fat or in those having undergone previous tummy tuck, especially those with chest wall radiation damage. GAP flaps are currently done at limited centers. Again, in the well-selected patient, it can be a very good option.
Skin-sparing mastectomies involve removal of the nipple and underlying tissue while leaving most of the skin. Newer types of skin-sparing incisions may simulate a breast lift, avoiding the less aesthetic scar on the inner aspect of the reconstructed breast. In the appropriately selected patient, this procedure has improved greatly the cosmetic appearance of both implant and tissue reconstructions.
Whether to undergo reconstruction with expander and implant with AlloDerm or latissimus flap or whether to have a reconstruction with your own tissue without an implant is a question that must be carefully considered with your surgeon. The type of reconstruction and incision should be discussed in detail prior to the procedure. A well thought out plan will more likely produce a result that appears most aesthetic and is optimally pleasing to the patient.
About the Author: For most women in Beverly Hills, breast reconstruction is a vital part of recovery from breast cancer. Dr. Jay Orringer has more than two decades of experience performing breast reconstruction and is constantly evaluating techniques for the most natural-looking results.
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