Breast reconstruction surgery is a vital component of a breast cancer treatment plan.
Breast reconstruction surgery can be done immediately after mastectomy or in a delayed
operation depending on whether post-mastectomy radiation therapy will be necessary.
Immediate reconstruction offers better aesthetic results if radiation is not needed.
When radiation is required, delayed reconstruction is preferred to avoid possible complications.
There are two main categories of reconstruction procedures: breast implant and natural tissue
breast reconstruction.
Breast implant involves insertion of a prosthesis made of synthetic material.
A typical breast implant has a silicone shell and is filled with saline or silicone gel.
Breast implant is the simplest of all procedures and requires the shortest initial hospital
stay.
However, as a result of the body's response to foreign material, the implant may be squeezed
within scar tissues leading to distorted shape, leak, rupture and infection.
In fact, as many as half of all women will require surgery to remove the implant later
in life.
Natural Tissue Breast Reconstruction Surgeries use the body's own tissue for the new breast.
In this type of procedure, a flap - a section of skin, fat, and possibly muscle - is harvested
from a donor site elsewhere in the body and transferred to the chest to make the new breast.
Possible tissue donor sites include: lower abdomen, back, buttock and inner thigh.
The lower abdomen is by far the preferred donor site as it comes with a bonus of a flatter
tummy after operation.
The use of autologous tissue allows the reconstruction of a breast which looks and feels most like
a normal breast.
More importantly, this also solves the problem of the new breast being rejected by the body's
immune system.
However, compared to breast implant, natural tissue reconstruction requires longer initial
hospital stay.
It also results in additional scar and possible weakening of the donor site due to loss of
muscle.
The technique of natural tissue breast reconstruction has evolved significantly over time.
The first of all natural tissue reconstruction procedures is the Transverse Rectus Abdominus
Myocutaneous flap – or TRAM flap.
In the original technique, called the pedicled TRAM flap, a section of skin and fat attached
to a piece of the rectus abdominis muscle – the six-pack muscle - is cut from the
lower abdomen.
The flap remains attached to the body by the piece of muscle.
The flap is then rotated together with the muscle and passed under the skin to the new
location in the chest.
Here, it is shaped to form the new breast.
The new breast is supplied by the blood vessels that run inside the rectus abdominis muscle.
A piece of synthetic mesh is placed in the abdomen to provide support for the abdominal
wall.
The disadvantages of this technique include weakening of the abdominal wall due to significant
loss of muscle.
Tethering of the flap to the body also makes it harder to be configured into the desired
shape.
Free TRAM Flap is an improvement from the original technique.
In this procedure, a section of skin, fat and part of the rectus abdominis muscle with
blood vessels within it, is separated COMPLETELY from the body and transferred to the breast
location.
The blood vessels of the flap – the deep inferior epigastric artery and vein - are
connected to recipient blood vessels in the breast using microsurgery techniques.
Free flaps are easier to sculpt into the desired shape.
Blood supply to the new breast is also more robust this way.
However, this technique requires microsurgery expertise and therefore is not offered by
many surgeons.
The amount of muscle loss from the abdomen remains significant.
Deep Inferior Epigastric Perforator flap, or DIEP flap, is a significant advancement
from TRAM flaps.
In this procedure, the blood vessels – the deep inferior epigastric artery and vein - are
meticulously dissected from the abdominal muscle.
While an incision is made in the rectus abdominis for this purpose, NO muscle is removed.
The blood vessels of the flap are then connected to the recipient vessels in the breast using
microsurgery.
Because no muscle is lost from the abdomen, the abdominal wall is NOT weakened after a
DIEP flap procedure.
Another procedure – the SIEA flap - is based on a different set of blood vessels - the
Superficial Inferior Epigastric Artery and Vein.
These vessels supply the skin and fat tissue of the abdomen and run within the fat layer.
With this flap, the abdominal muscle is left untouched.
This is therefore the preferred technique whenever it is possible.
The reason why this is not more widely used is because these vessels are not large enough
in 90% of patients.
Commonly, these superficial blood vessels are approached first during surgery.
If they are big enough, a SIEA flap will be used, if not, a DIEP flap will be performed
instead.