Breast reconstruction can be a life-changing and life affirming surgery. It is not for everyone, and there is no ‘right’ time or ‘right’ operation that suits all women, but if the time is right and the operation is carefully considered and selected it will add a huge amount to your quality of life!
There are many different types of breast reconstruction available. Only a Plastic Surgeon can offer you all the types possible and discuss these fully with you. If you would like to be fully informed about all your options please contact me for a discussion.
The choice to have breast reconstruction is yours to make. I hope this information will help you make your decision. Try to learn as much as you can before you decide what to do. No one source of information can give you every fact or give you all the answers. You and those close to you should talk to your health care team about any questions and concerns you have about this type of surgery.
TRAM flap breast reconstruction
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What is breast reconstruction?
Breast reconstruction is a range of operations for women who have had a breast removed (mastectomy). The surgery rebuilds the breast mound so that it is about the same size and shape as it was before. The nipple and the darker area around the nipple (areola) can also be added. Many women who have had a mastectomy can have reconstruction. Women who have had only the part of the breast around the cancer removed (lumpectomy) may not need reconstruction. Breast reconstruction is done by a Plastic Surgeon.
Why have breast reconstruction?
Women choose breast reconstruction for many reasons:
•To make their chest look balanced when they are wearing a bra or swimsuit
•To permanently regain their breast shape
• So they don’t have to use a form that fits inside the bra (an external prosthesis)
You will be able to see the difference between the reconstructed breast and the remaining breast when you are nude. But when you are wearing a bra, the breasts should be alike enough in size and shape that you will feel comfortable about how you look in most types of clothing.
Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery. Also, some women are not happy with how the reconstructed breast looks and feels after surgery. You and those close to you must know the facts about what to expect from reconstruction.
There are often many options to think about as you and your doctors talk about what is best for you. The reconstruction process often means one or more operations. Talk about the benefits and risks of reconstruction with your doctors before the mastectomy surgery is planned. Give yourself plenty of time to make the best decision for you. You should decide about breast reconstruction only after you are fully informed.
Immediate or Delayed breast reconstruction?
Immediate breast reconstruction is done, or at least started, at the same time as the mastectomy. An advantage to this is that the chest tissues are not damaged by radiation therapy or scarring. This often means that the final result looks better. Also, immediate reconstruction may mean less surgery.
After the first surgery, there still may be a number of steps that are needed to complete the immediate reconstruction process. If you are planning to have immediate reconstruction, be sure to ask what will need to be done afterward and how long it will take.
Delayed breast reconstruction means that the rebuilding is started later, after your mastectomy has healed, and after any other treatment you may need such as radiotherapy and chemotherapy. This may be a better choice for some women who need radiation to the chest area after the mastectomy. Radiation therapy given after breast reconstruction surgery can cause problems, which may be reduced if he reconstruction is done after the radiotherapy is finished.
You will still need several operations to finish the reconstruction, so be sure to ask about each step.
What are some of the options?
Breast reconstruction may be implant based, consist of your own tissue which has been moved around, or a combination of the two.
Implant Based Reconstruction
One-stage immediate breast reconstruction may be done at the same time as mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant. The implant may be put in the space created when the breast tissue was removed or behind the chest muscles to form the breast contour. This option has very specific criteria that not everyone meets, depending on their initial diagnosis.
Two-stage reconstruction or two-stage delayed reconstruction is the type most often done if implants are used. It may be done at the time of the mastectomy, or as a delayed procedure any time after your reconstruciotn. An implanted tissue expander, which is like a balloon, is put under the skin and chest muscle. Through a tiny valve under the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over time (about 4 to 6 months). After the skin over the breast area has stretched enough, a second surgery is done to remove the expander and put in the permanent implant.
This is generally not a good option if radiotherapy is required.
I suggest you read the information sheets in the Breast Augmentation section for information regarding the implants used.
Tissue Based Reconstruction
These procedures use tissue from your tummy, thighs, or buttocks to rebuild the breast. The 2 most common types of tissue flap procedures are the TRAM flap (or transverse rectus abdominis muscle flap), which uses tissue from the lower tummy area, and the latissimus dorsi flap, which uses tissue from the upper back. Other tissue flap surgeries described are more specialized, and may not be suitable.
These operations leave 2 surgical sites and scars – one where the tissue was taken and one on the reconstructed breast. The scars fade over time, but they will never go away completely. There can be donor site problems such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the breasts, which can often be addressed at a second surgery. Because healthy blood vessels are needed for the tissue’s blood supply, flap procedures are not usually offered to women with diabetes, connective tissue or vascular disease, or to smokers.
In general, flap procedures behave more like the rest of your body tissue. For instance, they may enlarge or shrink as you gain or lose weight. There is also no worry about replacement or rupture.
The TRAM flap procedure uses tissue and muscle from the tummy (the lower abdominal wall). The tissue from this area alone is often enough to shape the breast, so that an implant may not be needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly (abdomen) to the chest. The TRAM flap can decrease the strength in your belly, and may not be possible in women who have had abdominal tissue removed in previous surgeries. The procedure also results in a tightening of the lower belly, or a “tummy tuck.”
There are 2 types of TRAM flaps:
- A pedicle flap leaves the flap attached to its original blood supply and tunnels it under the skin to the breast area. This can leave an area of fullness where the tissue is tunnelled through.
- In a free flap, the surgeon cuts the flap of skin, fat, blood vessels, and muscle for the implant free from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer than a pedicle flap. The free flap is not done as often as the pedicle flap, but some doctors think that it can result in a more natural shape.
A newer type of flap procedure, the DIEP flap, uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This results in less skin and fat in the lower belly (abdomen), or a “tummy tuck.” This method uses a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels. The procedure takes longer than the TRAM pedicle flap discussed above, but leaves less muscle weakness and causes fewer hernias.
The use of the back muscle often requires an implant for volume, whilst using the bodies own tissues for softness and a more natural feel.
The latissimus dorsi flap moves muscle and skin from your upper back when extra tissue is needed. The flap is made up of skin, fat, muscle, and blood vessels. It is tunnelled under the skin to the front of the chest. This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast. Though it is not common, some women may have weakness in their back, shoulder, or arm after this surgery.
Can you make me a nipple?
You can decide if you want to have your nipple and the dark area around the nipple (areola) reconstructed. Nipple and areola reconstructions are optional and usually the final phase of breast reconstruction. This is a separate surgery that is done to make the reconstructed breast look more like the original breast. It can be done as an outpatient after drugs are used to make the area numb (under local anaesthetic). It is usually done after the new breast has had time to heal (about 3 to 4 months after surgery).
The ideal nipple and areola reconstruction requires that the position, size, shape, texture, colour, and projection of the new nipple match the natural one. Tissue used to rebuild the nipple and areola also is taken from your body, such as from the newly created breast, or the opposite nipple. A tattoo may be used to match the colour of the nipple of the other breast and to create the areola.
A nipple reconstruction can be considered ‘the cherry on top’ and turns a mound on your chest into a breast. I recommend a nipple reconstruction!
Can I keep my own nipple?
In a procedure called nipple-sparing mastectomy, the nipple and areola are left in place while the breast tissue under them is removed. Women who have a small early stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple, may be able to have nipple-sparing surgery. (Cancers that are larger or nearby are more likely to have cancer cells hidden in the nipple, which means a higher risk the cancer will come back.) Some doctors give the nipple tissue a dose of radiation during or after the surgery to try and reduce the risk of the cancer coming back.
There are still some problems with nipple-sparing operations. Afterward, the nipple does not always have a good blood supply, so sometimes it can wither away or become deformed. Because the nerves are also cut, there is little or no feeling left in the nipple. In some cases, the nipple may look out of place later, mostly in women with larger breasts. Doctors are working to try and improve the safety and outcomes of nipple-sparing surgeries.
It can give a lovely result however if you are a suitable candidate and is worth discussing with your Plastic and General Surgeons.
Saving the nipple from the breast that has been removed to use it later (called nipple saving or nipple banking) is no longer favoured by most surgeons. The tissue can be injured by the way it is stored or preserved, and there have been other problems with this surgery.