Breast Reconstruction

Consultation

When you meet with your breast cancer surgeon, you can ask to be referred to a plastic surgeon to discuss reconstruction.

The plastic surgeon will go over the benefits and risks of various reconstruction techniques. We encourage you to ask lots of questions. Our Patient Support Corps service can help you come up with a list of questions before your appointment.

Techniques

There is no "best" reconstruction technique, and you may not be a candidate for some of them. Your options depend on the type of mastectomy you had, your medical history, and your body shape and size.

Expander and implant reconstruction

To begin implant reconstruction, the surgeon first places a tissue expander either above or below your pectoralis (chest muscle). The expander is then gradually filled over several visits until your goal size is attained. This process requires frequent visits to the clinic but typically isn't uncomfortable.

Once the expansion stage is complete, you'll have a second surgery to remove the expander and replace it with an implant.

The care team can show you expanders and implants during your consultation.

For more information, please see our FAQ on implants.

Autologous reconstruction (free flap)

Patients may choose autologous reconstruction because:

• They don't have enough breast tissue after cancer treatment to cover and support an implant.
• The result tends to look and feel more natural than an implant.
• A successful autologous reconstruction can last a lifetime, whereas implants may need to be replaced.

When compared with implants, autologous reconstruction also has some disadvantages:

• The recovery period may be longer and more painful due to your having two surgical sites.
• Because blood flow to the transferred tissue must be monitored, you'll spend more time in the hospital. If there are concerns, another procedure may be necessary to assess blood flow.

The "donor tissue" is usually taken from the lower belly, but the back or inner thighs may also be used.

Using abdominal tissue

Several free flap reconstruction approaches use tissue from the lower abdomen. These techniques include:

• TRAM flap. The surgeon takes skin, fat, blood vessels and muscle from the lower belly to construct the breast. TRAM stands for transverse rectus abdominis muscle.
• DIEP flap. The surgeon takes skin, fat and blood vessels from the lower belly to reconstruct the breast but leaves the underlying muscle intact. However, an incision is made in the muscle to collect the vessels needed to supply blood to the transferred tissue. DIEP stands for deep inferior epigastric perforators, the blood vessels used in the procedure.

  Because the muscle is left in place, the DIEP flap is considered an improvement over the TRAM flap.

• SIEA flap. The surgeon takes skin, fat and blood vessels from the lower belly without making an incision in the underlying muscle. SIEA stands for superficial inferior epigastric artery, a vessel running just under the skin in the lower abdomen. This technique is possible only for patients with a certain anatomy.

You may not be eligible for a free flap surgery using abdominal tissue if:

• You have abdominal scarring that may have damaged important blood vessels. (C-sections are not a problem.)
• You don't have enough donor tissue (the tissue you can pinch between your belly button and pubic bone).
• You already had an autologous reconstruction procedure using abdominal tissue and it wasn't successful.

Using back tissue

This technique is called a latissimus dorsi flap for the back muscle that's used. The surgeon lifts this muscle and some skin from the patient's back and uses these tissues to support the breast skin and, in some cases, to help recreate part of the breast mound. A breast implant may also be needed. The expander, and later the implant, is placed underneath the transferred tissue.

This technique may be used for women with small- to medium-sized breasts who:

• Had a previous breast reconstruction using tissue from another body area that failed
• Had complications from radiation therapy that affected the breast skin and do not have sufficient tissue for other types of flap surgery

Using thigh tissue

In thigh-based autologous reconstruction, the surgeon uses skin, fat and a small muscle called the gracilis from the inner thigh. To create a larger breast, the flap can be combined with an implant or, less commonly, another type of flap.

Using thigh tissue may be a good option if you have small- to medium-sized breasts and using belly tissue isn't possible. The disadvantages of thigh-based flaps include:

• A higher risk of healing problems compared with free flaps taken from the lower belly.
• Potential leg swelling, although this usually goes away with time.
• If only one thigh is used for the procedure, it may look tighter and thinner than the other. Some women opt to have additional procedures to make their thighs more symmetrical.

While most surgeons try to conceal the scar in the crease near the top of the thigh, the incision is sometimes a bit lower and may be visible when you wear a bathing suit.

For more information, please see our FAQ on autologous reconstruction.

Preparation

Before your procedure, you'll have an appointment with the Prepare Program to ensure you're ready for surgery. Your care provider will also give you instructions on where to check in on the day of your procedure, plus any changes to make to your diet or medications before surgery.

To minimize your risk of complications, do not use tobacco or nicotine products for at least one to four weeks before and after surgery. By decreasing blood flow to the surgical site, they can contribute to wound healing problems, increase infection risk and even lead to the failure of your reconstruction procedure. The UCSF Fontana Tobacco Treatment Center offers resources to help people quit for good.

Recovery

To prepare for your recovery at home, we recommend having "distraction therapies," such as books, magazines and movies, on hand. Wearing comfortable button-down shirts or zip-up tops can make changing clothes easier.

Recovery times vary, with pain and fatigue resolving in anywhere from two to 12 weeks.

Infection is a risk after any surgery. Signs of infection include:

• Redness at the surgical site that gets worse over time
• Pain around the surgical site that gets worse over time
• Flu-like symptoms
• Excessive swelling

Contact your surgeon's office immediately if you notice any of these symptoms.