Understanding Options for Breast Reconstruction

By Rita Malobabich,
Senior Market Executive, Strategic Supplier Partnerships, aptitude

Breast cancer remains one of the four most common cancers worldwide, with nearly 240,000 cases diagnosed in U.S. women each year, according to the Centers for Disease Control. More than 100,000 U.S. women undergo some form of mastectomy each year to either treat or prevent breast cancer.

Many of those women have breast reconstruction surgery following a mastectomy; according to Yale Medicine, nearly 138,000 reconstructions took place in the U.S. in 2020.There are many breast reconstruction techniques, including those that use silicone or saline breast implants and others that use a flap of tissue from another part of the body.

Breast reconstruction can happen right after breast cancer surgery (immediate reconstruction) or months or years later (delayed reconstruction). The surgery might involve reconstruction of both breasts, or the surgeon may replace one breast and reshape it to match the other. Providers may recommend multiple surgeries over several stages depending on the patient's circumstances.

The decision to have breast reconstruction is deeply personal, and it's important to understand the many options and what is involved in each.

What are the types of breast reconstruction surgery?

There are two main types of breast reconstruction surgery after mastectomies:

Flap reconstruction

In flap reconstruction, the surgeon takes tissue from the patient's body (autologous tissue) and uses it to form a breast. Usually, they take the tissue from the lower abdomen, but it also can come from the thigh, back or buttocks. Healthcare providers call this tissue a "flap."

The surgeon may remove fat, skin, blood vessels and muscle from these parts of the body to form a new breast. Sometimes, surgeons move a flap through the body (pedicled flap) to retain its blood supply or they detach the flap from its blood supply (free flap) and attach it to blood vessels in the chest.

Types of flap reconstruction include:

• DIEP flap: Skin, fat and blood vessels are taken from the lower belly. A DIEP flap does not remove the underlying abdominal (belly) muscle.
• TRAM flap: Skin, fat, blood vessels and muscle are removed from the lower belly.
• Latissimus dorsi (LD) flap: Tissue and muscle are removed from the back. The LD flap (still connected to its blood supply) is transplanted through the back to the breast area.
• IGAP flap: For this procedure, the tissue comes from the buttocks. Muscle is not used in this procedure.
• SGAP flap: This technique also removes tissue (not muscle) from the buttocks. It uses a different group of blood vessels than the IGAP flap procedure.
• PAP flap: The surgeon removes tissue from the inner and back portions of the thigh and uses it to form a breast. This procedure does not transplant muscle from the thigh.
• TUG flap: Similar to a PAP flap, this technique uses tissue from the thigh. A TUG flap transplants muscle as well as tissue.
• SIEA flap (or SIEP flap): This procedure is like a DIEP flap, but it uses different blood vessels. Providers do not use this technique as often. Few people have the blood vessels necessary for the surgery to be successful.

Implant reconstruction

In implant reconstruction, surgeons use saline or silicone implants to recreate breast tissue. Sometimes surgeons use a combination of implants and tissue from the body. Implant reconstruction can happen along with a mastectomy or after.

Types of implant reconstruction include:

• Under the chest muscle: The surgeon lifts the chest muscle and places the implant underneath it.
• Above the chest muscle: The implant is placed on top of the chest muscle. Patients may not need as much recovery time because the chest muscle remains in place.
• Implant with tissue expander: The surgeon places an expander under the skin. About once per week, the patient or healthcare provider fills the expander with saline and the skin gradually expands. The surgeon will place the implant once the skin has expanded enough to cover it.

Oncoplastic reconstruction after lumpectomy

Candidates for lumpectomy may benefit from oncoplastic reconstruction (an oncologic breast surgeon will help determine a patient's candidacy for breast conservation). Radiation is required when a lumpectomy is performed.

In oncoplastic reconstruction, surgeons use the techniques of breast reduction or breast lift at the same time as the lumpectomy. The breast reduction or breast lift helps to fill in the defect created by the lumpectomy and improves the breast shape. A breast reduction or lift on the other breast is required for symmetry.

How to know what type of breast reconstruction surgery to get?

A provider will recommend the most appropriate technique based on:

• Age, overall health and lifestyle
• The kind of mastectomy or lumpectomy the patient has had and how much tissue remains
• Whether additional treatments are needed for breast cancer (such as chemotherapy or radiation)
• Past surgeries that may make it difficult or impossible to take a flap from the patient's belly. One example is abdominal surgery
• The patient's goals and desired appearance

What are the risks and benefits of breast reconstruction surgery?

Breast reconstruction surgery can improve self-confidence after a mastectomy or lumpectomy and help patients feel more empowered.

As with any surgical procedure, risks of breast reconstruction include infection and bleeding. Results vary depending on the type of procedure and how much tissue remains after breast cancer surgery and radiation.

After surgery, there is often little or no sensation in the newly reconstructed breasts. Over time, some patients regain sensation in the skin, though not to the same degree as before.

Complications of breast reconstruction surgery may include:

• Blood clots: These may be more likely to happen after some types of flap reconstruction surgeries.
• Breasts that are a different size or shape: One may feel firmer than the other. The nipples and areolas may not be symmetrical.
• Bruising or scarring around the reconstructed breasts: All breast reconstruction surgeries leave scars. They may fade over time.
• Fat necrosis: Death of the transplanted tissue after flap surgery.
• Problems with the implants (for implant reconstruction): These problems can include wrinkling, rippling and ruptures (tears) in the implant.
• Weakness, pain or sensitivity at the donor site after a flap reconstruction procedure: Donor sites may include the lower belly, thigh, back or buttocks.

Any woman who decides to have breast reconstruction should talk to their provider about the technique that is right for them, as well as have an open and honest conversation about their goals, lifestyle and desired appearance.