The art of breast reconstruction

Venus de Milo. Musée du Louvre.

In the United States, more than 250,000 new diagnoses of invasive breast cancer are made every year, with more than 3.1 million breast cancer survivors living today. Although the quality of life and psychosocial benefits of breast reconstruction after mastectomy and partial mastectomy (for example lumpectomy) has been well-established, less than half of women who require mastectomy are currently offered breast reconstruction. Even though more than 100,000 breast reconstruction procedures are performed every year, fewer than 20 percent of women undergoing mastectomy elect to undergo immediate reconstruction at the same time as their mastectomy. For women who did not undergo immediate breast reconstruction or who are unhappy with their breast reconstruction, many may not realize that they may be candidates for delayed breast reconstruction long after their mastectomy or revisions of prior breast reconstruction. Both primary and secondary breast reconstruction is covered by health insurance. 

After mastectomy, there are two main categories of breast reconstruction. The first category is implant-based breast reconstruction. More than 80 percent of women in the United States who undergo breast reconstruction will have some type of implant-based reconstruction. Usually, this involves a tissue expander that is placed underneath the pectoralis muscle on the chest wall and filled with saline to expand the pectoralis muscle and the breast skin. The tissue expander is then changed to a permanent breast implant, which can be filled with saline or silicone. A newer technique involves placing the tissue expander over the pectoralis muscle, where the breast tissue used to be. When the tissue expander is exchanged, a permanent breast implant, a shaped cohesive gel (or “gummy bear”) silicone implant, is usually chosen for the best results. Placing the implant over the muscle, or “prepectoral” breast implants, significantly reduces the pain and discomfort of breast implants. Many women also feel that prepectoral breast implants look and feel more natural.

The second category of breast reconstruction is natural tissue breast reconstruction. In natural tissue breast reconstruction, the surgeon will transfer the patient’s own tissue to her chest wall to reconstruct the breast. Most commonly, excess tissue from the lower abdomen is used to reconstruct the breast, leaving a scar similar to that of a tummy tuck. An older technique used the patient’s skin, fat and muscle to reconstruct the breast, as in the TRAM (transverse rectus abdominis muscle) flap or latissimus dorsi flap, which uses tissue from the lower abdomen or back. The problem with the TRAM and latissimus dorsi flaps is that it sacrifices the muscle in the donor site to reconstruct the breast, which not only weakens the abdomen or back but can also cause excessive pain.

The gold standard for natural tissue breast reconstruction is “perforator flap” breast reconstruction, in which the patient’s skin and fat is transferred to reconstruct the breast, but her muscles are completely preserved. The most common type of perforator flap breast reconstruction is the DIEP (deep inferior epigastric perforator) flap breast reconstruction, in which the skin and fat of the lower abdomen are used to reconstruct the breast. The result is similar to a tummy tuck, except the tissue removed from the abdomen is used to reconstruct the breasts. The result is soft, warm and natural breasts and a flat abdomen.

For very thin women or for women who have already had tummy tucks, another type of perforator flap breast reconstruction is the PAP (profunda artery perforator) flap breast reconstruction. The PAP flap breast reconstruction uses excess skin and fat from the upper inner thigh to reconstruct the breasts. Not only does the PAP flap create soft, warm and perky breasts, but the patient has the equivalent of a thigh lift as well. Furthermore, the scar from the PAP flap is hidden in the buttock crease so that women can wear bikinis after surgery without visible scars.

By far, the best results in breast reconstruction come when patients have nipple-sparing mastectomies and natural tissue breast reconstruction. Furthermore, in natural tissue breast reconstruction, it is possible to reconnect the nerves, so that the women will have sensation in her breasts after mastectomy. In the best surgeries, it can be almost impossible to tell that a patient has had a mastectomy at all. 

Many of the more innovative types of mastectomy and breast reconstruction, however, such as nipple-sparing mastectomies, prepectoral breast implants, DIEP flaps, PAP flaps and sensory restoration of the breast, are not standard. It may take extra research and effort to find a team of surgeons that is capable of offering the most advanced procedures. At the end of the day, however, asking questions and refusing to settle can make a lifetime of difference. Sometimes, it can even turn a potentially traumatic experience such as breast cancer surgery into a life-transforming experience where a woman feels like she is actually living her best and most beautiful life.

– Constance M. Chen, MD

Leave a Reply

Your email address will not be published. Required fields are marked *