Breast reconstruction is not a cosmetic procedure. It’s a right every woman has when faced with mastectomy after breast cancer. Fortunately, there are several reconstructive options.

Breast reconstruction performed at the same time as the mastectomy is known as “immediate reconstruction”. Immediate reconstruction is generally associated with the best cosmetic results but, more importantly, the patient avoids the psychological trauma of waking up from surgery with a flat chest.

In some instances immediate reconstruction is not recommended or is not possible and the reconstruction is performed several months after the mastectomy. This is called “delayed” reconstruction. Women with more advanced disease are usually not candidates for immediate reconstruction because of the need for radiation therapy after the mastectomy. While some plastic surgeons still perform immediate reconstruction in these cases, most prefer to delay the reconstruction until a later date to allow the tissues to recover.

Tissue expander reconstruction is the most common method of breast reconstruction in the United States. Most plastic surgeons perform this as a two-stage procedure. The expander is used to stretch the skin envelope and create the size of breast the patient and plastic surgeon desire. The expander is replaced by a permanent breast implant (saline or silicone) at a separate procedure some time later. Some patients are candidates for one-step implant reconstruction (without expanders): a permanent breast implant is inserted immediately without going through the whole expansion process. In the one-step implant reconstruction the implant is completely covered by the pectoralis muscle and an acellular dermal graft (like Alloderm or FlexHD). These grafts are cadaveric tissue implants that provide support and increase the amount of padding over the implant.

Breast reconstruction with implants can provide excellent cosmetic results. However, the long term risk of complications is much higher than in women who have cosmetic breast enhancement with implants. The most common risks include contracture (hardening of the new breast), and implant ripples that can be felt and seen through the breast skin. These risks are increased if the patient has to undergo radiation as part of the cancer treatment.

The Latissimus procedure uses muscle (latissimus dorsi), fat and skin from the back (below the shoulder blade) that is brought around to the chest to create a new breast. Many patients also need an expander or implant to obtain a satisfactory result in terms of size. Patients typically have a scar on their back that can be seen with some low-cut clothing. Women who are very active in sports may notice some strength loss with activities like golf, climbing, or tennis.

A more attractive option for many women is the TRAM flap procedure. This uses tissue from the lower tummy, rather like a “tummy tuck”. Skin, fat and part of the sit-up (rectus) muscle is transferred to the chest to recreate the breast mound. Advantages include a natural reconstruction along with an improved abdominal contour. Disadvantages include loss of abdominal strength and a risk of abdominal bulging (“pooching”) or hernia.

The DIEP flap is the latest evolution of the TRAM flap. It provides all the advantages of the TRAM while decreasing the risks. Like the TRAM, it provides a very natural breast reconstruction which is warm and soft and ages with the patient. However, the DIEP preserves all the abdominal musculature so is associated with a lower rate of abdominal bulging and hernia. Since the muscle are preserved, recovery is also easier and abdominal strength is maintained long term.

There are a handful of other tissue options available for women who are not candidates or prefer to avoid using their abdominal tissue. These include the inner, upper thigh (TUG flap), lower buttock crease (IGAP), and upper buttock (SGAP). The best tissue option will depend on a number of factors, primarily the patient’s body habitus.

Microsurgical breast reconstruction procedures like the DIEP, TUG and GAP flaps are not offered routinely by many American plastic surgeons. There are many reasons for this, primarily the complexity of the surgery and the need for additional training. Unfortunately most patients seeking one of these breast reconstruction options after mastectomy will be forced to travel to specialized centers for their surgery.

Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction, particularly DIEP flap breast reconstruction. In-network for most US insurance plans. PRMA Plastic Surgery, San Antonio, Texas. (800) 692-5565.