Breast Reconstruction

Breast reconstruction can be performed in patients at the time of total or partial mastectomy, previous mastectomy, or for congenital defects or differences in size or shape. The general approaches for breast reconstruction include techniques that involve breast implant devices or those that utilize the patient's own tissue for reconstruction. Most approaches are applicable whether a patient is considering reconstruction at the time of mastectomy or at a later date. Most patients, however, tend to prefer immediate reconstruction if possible.

The most common approach that we use for immediate breast reconstruction is to use a tissue expander, or temporary breast implant, placed beneath the muscle layer of the chest at the time of mastectomy. A tissue expander is a special type of breast implant in that it has an incorporated fill mechanism that allows for sterile saline to be injected on an interval basis, resulting in the ability to stretch overlying muscle and skin over a period of time. This creates a space over time that allows for a permanent breast implant to be placed later. If the patient’s tissue will permit, in many patients we can speed the course of expansion by the addition of a tissue material called Alloderm®, that aids in the creation of a loose tissue sling that allows for the device to be partly filled at the time of placement with excellent control of shape of the reconstructed breast. The process of expansion is started, or continued, about one month following device placement at the time of mastectomy, or at a time that the patient has no remaining tenderness or healing issues following mastectomy. The injections are performed during routine clinic visits, usually two weeks apart, anywhere from 2-6 times, depending upon how much volume was placed in the tissue expander device at the time of placement. After completion of expansion, two months of observation follow prior to permanent implant placement to allow for stabilization of the tissue pocket surrounding the tissue expander. The permanent implant placement procedure is performed as an outpatient, with the patient able to return home for recovery on the day of surgery. For single side reconstruction, any modifications of the other breast needed for symmetry are performed at that time. Nipple reconstruction is then performed about two months following permanent implant placement, to allow for the implant position to stabilize and ensure correct nipple position on the reconstructed breast mound.

Muscle flaps have an important place in breast reconstruction following mastectomy. While the latissimus dorsi muscle flap from the back and the TRAM flap from the abdominal wall have been used for immediate breast reconstruction at the time of mastectomy for many years, the more frequent use of radiation treatment following mastectomy has changed the use and sequence of these techniques. They are preferred by many patients who seek to avoid the use of breast implants in reconstruction, but these tissue flaps tend to not tolerate radiation well. They are typically not preferred for immediate reconstruction in patients for whom radiation is planned, but may be helpful in the ultimate reconstruction of patients following completion of adjuvant radiation treatment. The latissimus dorsi muscle of the back can be used to convert a radiated mastectomy site into a largely non-radiated environment for a permanent breast implant in patients following tissue expansion with radiation treatment. A TRAM flap can be used in a similar fashion following radiation, providing a large potential donor area for soft tissue and skin. There is still an important place for use of these techniques in immediate reconstruction following mastectomy in selected patients.