Types of breast reconstruction
There are three main types of breast reconstruction:
Reconstruction using an implant
This kind of reconstruction is a relatively simple procedure and involves placing a silicone or saline filled implant beneath the muscle of the chest immediately after the mastectomy has been performed. The scar from this type of operation is usually side-to-side or at an angle following the line of the original mastectomy scar.
Implants may not give a very good appearance compared to the other remaining breast, as the new breast will not have its normal droop and can look higher. Therefore surgery to the remaining breast may be required. However, this sort of reconstruction gives a better result if both breasts are being removed (bilateral mastectomy and reconstruction).
It is important that you are aware that implants are man-made and therefore will need replacing at some point.
Using tissue expansion
Breast reconstruction involving tissue expansion may be required if the skin is too tight post mastectomy and can give very good results and avoids the need for the extensive surgery involved in using tissue flaps.
An expandable implant (like an empty balloon) with a valve for filling it is put under the chest muscle. This is expanded over a few months by injecting sterile salt water (saline) into the implant through a valve just under the skin. This is done weekly or fortnightly at the outpatients clinic. The process continues until the size is slightly larger than your other breast.
After several months the expander is taken out during a second operation and replaced with a permanent implant. The implant, usually made of silicone, matches the size of the other breast and the previous over-expansion allows the breast to droop with a more natural appearance.
Another type of reconstruction using tissue expansion uses a permanent expander implant which again is overinflated and then the excess fluid and valve is removed leaving the expander in the breast. This is then a mixture of silicone and saline.
Patients with skin damaged by radiotherapy or who have very thin skin are not suited to tissue expansion as the skin will not stretch.
What are implants made of?
Breast implants have an outer silicone shell and may contain silicone gel or saline.
Saline
Saline (salt water) has the advantage of not causing any problems if it leaks out into the body. However, saline-filled implants do not have the natural feel of silicone-filled implants and give a less realistic reconstructed breast. Saline implants are more likely to leak or wrinkle than silicone implants.
Silicone
Silicone implants are very commonly used in the UK. These implants are essentially bags of silicone gel enclosed in a thin silicone rubber case. They are designed to feel soft and flexible like a natural breast and there are many different types. They can be breast-shaped or rounded and filled with solid or liquid gel.
Flap reconstruction
This type of breast reconstruction uses areas of muscle, skin and fat (known as flaps), which are usually taken from the back or abdomen (tummy). These areas of the body contain very large muscles,which give enough skin, fat and muscle with a good blood supply to create the shape of a breast on the chest wall.
This type of surgery is appropriate for women who have large breasts and who have had a total mastectomy, are unable to undergo tissue expansion due to skin damage from radiotherapy. Whichever type of procedure is used, women with very large breasts usually need to have surgery to reduce the size of the remaining breast.
Back (Latissimus Dorsi) Flap:
This type of operation involves moving a flap of fat and overlying skin from the back of your body. The flap of skin and underlying fat stays connected to the muscle in the back (latissimus dorsi).
Often, there is not enough tissue to form a whole breast, so an implant may be put behind it to match the size of the other breast. This type of operation leaves scars both from where the skin and muscle flap is taken and on the reconstructed breast.
Pedicled TRAM (transverse rectus abdominis muscle) Flap:
A flap of fat and some muscle, with its overlying skin, is taken from the abdomen. It is then rotated (with its blood supply from the abdominal muscle), tunnelled upwards from the abdomen and put on the chest wall to create the shape of a breast. This method usually gives enough tissue to match the remaining breast, so an implant is not usually needed.The scar on the abdomen is usually horizontal and just below the bikini line. During the operation the belly button (umbilicus) is repositioned.
Perforator flap reconstruction:
In Perforator reconstruction, areas of fat and skin from one part of the body are moved to another. The blood supply is cut and then a new blood supply for the flap is created at the area of the breast. These techniques involve microsurgery (rejoining arteries and veins that are only 2-3mm in diameter, using an operating microscope). Blood vessels from the armpit, or near the breastbone, are used to create a new blood supply for the tissue that has been moved to the breast.
Free perforator flaps are flaps of skin and fat with an artery and vein for blood supply. No muscle is taken. These operations are usually done by plastic surgeons, either at the time of the initial breast surgery or some months later. Most plastic surgeons advise delaying a perforator flap reconstruction if radiotherapy is planned, as the radiotherapy can change the appearance of the reconstruction. These operations take 6-8 hours if only one plastic surgeon is involved and need a hospital stay of about a week. The success rate for these types of procedures can be very high.
There are now several types of perforator flaps. They are named after the blood vessel that is used.
DIEP flap (Deep Inferior Epigastric Perforator flap) or the free SIEA (Superficial Inferior Epigastric Artery flap)
Skin and fat is taken from the lower abdomen, but no muscle is taken. Instead the tiny blood vessels are very carefully cut out from the muscle, which is left in the abdomen. The appearance of the new breast is usually very good and it feels natural. As no muscle is taken from the abdomen, the risk of hernias is almost completely removed and no mesh is required to reinforce the abdomen. The patient also benefits from a "tummy tuck" restoring the contour of the abdomen.
Free SGAP flap (Superior Gluteal Artery Perforator flap) or the IGAP flap (Inferior Gluteal Artery Perforator flap)
This uses fat and skin taken from the upper or lower buttock to create a new breast. It is generally used when abdominal tissue cannot be used due to scarring from previous surgical procedures or because the woman is too slim. The IGAP flap gives a softer feeling to the breast than the SGAP flap. The IGAP flap allows a larger breast size to be created and the scar is hidden in the crease of the buttock.
Flaps taken from other areas of the body
In very rare situations it may be possible to take flaps from other areas of the body where there is enough fat and a suitable blood supply.
Reconstruction using an implant
This kind of reconstruction is a relatively simple procedure and involves placing a silicone or saline filled implant beneath the muscle of the chest immediately after the mastectomy has been performed. The scar from this type of operation is usually side-to-side or at an angle following the line of the original mastectomy scar.
Implants may not give a very good appearance compared to the other remaining breast, as the new breast will not have its normal droop and can look higher. Therefore surgery to the remaining breast may be required. However, this sort of reconstruction gives a better result if both breasts are being removed (bilateral mastectomy and reconstruction).
It is important that you are aware that implants are man-made and therefore will need replacing at some point.
Using tissue expansion
Breast reconstruction involving tissue expansion may be required if the skin is too tight post mastectomy and can give very good results and avoids the need for the extensive surgery involved in using tissue flaps.
An expandable implant (like an empty balloon) with a valve for filling it is put under the chest muscle. This is expanded over a few months by injecting sterile salt water (saline) into the implant through a valve just under the skin. This is done weekly or fortnightly at the outpatients clinic. The process continues until the size is slightly larger than your other breast.
After several months the expander is taken out during a second operation and replaced with a permanent implant. The implant, usually made of silicone, matches the size of the other breast and the previous over-expansion allows the breast to droop with a more natural appearance.
Another type of reconstruction using tissue expansion uses a permanent expander implant which again is overinflated and then the excess fluid and valve is removed leaving the expander in the breast. This is then a mixture of silicone and saline.
Patients with skin damaged by radiotherapy or who have very thin skin are not suited to tissue expansion as the skin will not stretch.
What are implants made of?
Breast implants have an outer silicone shell and may contain silicone gel or saline.
Saline
Saline (salt water) has the advantage of not causing any problems if it leaks out into the body. However, saline-filled implants do not have the natural feel of silicone-filled implants and give a less realistic reconstructed breast. Saline implants are more likely to leak or wrinkle than silicone implants.
Silicone
Silicone implants are very commonly used in the UK. These implants are essentially bags of silicone gel enclosed in a thin silicone rubber case. They are designed to feel soft and flexible like a natural breast and there are many different types. They can be breast-shaped or rounded and filled with solid or liquid gel.
Flap reconstruction
This type of breast reconstruction uses areas of muscle, skin and fat (known as flaps), which are usually taken from the back or abdomen (tummy). These areas of the body contain very large muscles,which give enough skin, fat and muscle with a good blood supply to create the shape of a breast on the chest wall.
This type of surgery is appropriate for women who have large breasts and who have had a total mastectomy, are unable to undergo tissue expansion due to skin damage from radiotherapy. Whichever type of procedure is used, women with very large breasts usually need to have surgery to reduce the size of the remaining breast.
Back (Latissimus Dorsi) Flap:
This type of operation involves moving a flap of fat and overlying skin from the back of your body. The flap of skin and underlying fat stays connected to the muscle in the back (latissimus dorsi).
Often, there is not enough tissue to form a whole breast, so an implant may be put behind it to match the size of the other breast. This type of operation leaves scars both from where the skin and muscle flap is taken and on the reconstructed breast.
Pedicled TRAM (transverse rectus abdominis muscle) Flap:
A flap of fat and some muscle, with its overlying skin, is taken from the abdomen. It is then rotated (with its blood supply from the abdominal muscle), tunnelled upwards from the abdomen and put on the chest wall to create the shape of a breast. This method usually gives enough tissue to match the remaining breast, so an implant is not usually needed.The scar on the abdomen is usually horizontal and just below the bikini line. During the operation the belly button (umbilicus) is repositioned.
Perforator flap reconstruction:
In Perforator reconstruction, areas of fat and skin from one part of the body are moved to another. The blood supply is cut and then a new blood supply for the flap is created at the area of the breast. These techniques involve microsurgery (rejoining arteries and veins that are only 2-3mm in diameter, using an operating microscope). Blood vessels from the armpit, or near the breastbone, are used to create a new blood supply for the tissue that has been moved to the breast.
Free perforator flaps are flaps of skin and fat with an artery and vein for blood supply. No muscle is taken. These operations are usually done by plastic surgeons, either at the time of the initial breast surgery or some months later. Most plastic surgeons advise delaying a perforator flap reconstruction if radiotherapy is planned, as the radiotherapy can change the appearance of the reconstruction. These operations take 6-8 hours if only one plastic surgeon is involved and need a hospital stay of about a week. The success rate for these types of procedures can be very high.
There are now several types of perforator flaps. They are named after the blood vessel that is used.
DIEP flap (Deep Inferior Epigastric Perforator flap) or the free SIEA (Superficial Inferior Epigastric Artery flap)
Skin and fat is taken from the lower abdomen, but no muscle is taken. Instead the tiny blood vessels are very carefully cut out from the muscle, which is left in the abdomen. The appearance of the new breast is usually very good and it feels natural. As no muscle is taken from the abdomen, the risk of hernias is almost completely removed and no mesh is required to reinforce the abdomen. The patient also benefits from a "tummy tuck" restoring the contour of the abdomen.
Free SGAP flap (Superior Gluteal Artery Perforator flap) or the IGAP flap (Inferior Gluteal Artery Perforator flap)
This uses fat and skin taken from the upper or lower buttock to create a new breast. It is generally used when abdominal tissue cannot be used due to scarring from previous surgical procedures or because the woman is too slim. The IGAP flap gives a softer feeling to the breast than the SGAP flap. The IGAP flap allows a larger breast size to be created and the scar is hidden in the crease of the buttock.
Flaps taken from other areas of the body
In very rare situations it may be possible to take flaps from other areas of the body where there is enough fat and a suitable blood supply.
