A mastectomy, or removal of the breast, is performed to treat cancer, chronic pain, or prophylacticly in women who are genetically predisposed to breast cancer.
Several breast reconstructive options are available to replace the breast. The advantages and limitations of each option should be considered, as the optimal choice of reconstruction will not be the same for everyone. Breast reconstruction can be performed at the time of the mastectomy or anytime thereafter. Insurance plans are required to cover this benefit by law.
Below are the main options available for breast reconstruction. A consultation with a plastic surgeon prior to having a mastectomy allows for optimal education regarding these reconstructive options.
Tissue Expander (implant)
A tissue expander (T.E.) is an implant with a port that can be accessed in the office to adjust the size of the prosthetic. It is a temporary device that requires a second surgery to exchange it for a permanent implant once the size desired is achieved. Placement of a T.E. at the time of a skin sparing or nipple areolar sparing mastectomy allows for the maintenance of breast skin not involved with cancer resulting in a more optimal breast shape.
Latissimus Dorsi Myocutaneous Flap +/- T.E. or Implant
The latissimus dorsi (L.D.) flap involves using the muscle and overlying fat and skin from its location on the back to create a breast mound on the anterior chest. The blood supply to this flap originates in the axillary (armpit) region. The flap can be transposed from the back to the breast area by tunneling it under the armpit without disconnecting the blood supply. Depending on the size of the breast to be reconstructed and the body habitus of the patient, a T.E. or implant can be utilized to achieve the desired breast size.
Transverse Rectus Abdominus Myoocutaneous Flap
The transverse rectus abdominus myocutaneous (TRAM) flap involves using the lower abdominal tissue attached to the rectus abdominus (six pack) muscle to create a breast mound.
The muscle remains connected to the ribs but is transected in the lower abdomen. The lower abdominal flap consisting of muscle and overlying fat and skin is then tunneled under the upper abdominal tissue into the space left by the mastectomy.
The blood supply to the TRAM runs through the muscle and is not disconnected, requiring sacrifice of the muscle to maintain perfusion to the flap. The muscle does not add bulk because it atrophies or shrinks over time. Mesh or an equivalent is oftentimes necessary to reconstruct the abdominal wall.
Deep Inferior Epigastric Artery Perforator (DIEP) Free Flap
The latest innovation in breast reconstruction is the concept of perforator free flaps, of which the deep inferior epigastric artery (DIEP) free flap is one. This surgery is an evolution of the TRAM flap procedure by using skin and fat from the abdomen without sacrificing the rectus muscle.
This can avoid complications such as a hernia, bulging or abdominal wall weakness in addition to possible mesh complications. This technique essentially provides the patient with a tummy tuck in addition to the breast reconstruction, but maintains the rectus abdominus (six-pack) muscles in their original location.
The blood vessels going to the fat and skin in a tummy tuck run through the rectus muscles. The blood vessels are isolated from the surrounding muscle fibers then disconnected so the flap can be brought to the breast area (free flap).
The blood vessels are then connected under a microscope to blood vessels in the chest area to re-establish circulation. Recovery time is usually more expeditious because the rectus muscle is spared.
Superior Gluteal Artery Perforator (S-GAP) Free Flap
The superficial gluteal artery perforator (S-GAP) free flap is another perforator free flap that allows utilization of the buttock tissue to create a breast mound.
The skin and fat over the buttock region is raised off the muscle and a blood vessel branch is followed and isolated as it courses through the muscle.
The gluteal muscle is left in place and the skin, fat, and vascular pedicle (free flap) is brought to the chest where the blood vessels from the free flap are connected to blood vessels at the chest using a microscope to reestablish circulation.
By leaving the muscle behind, patients are ambulatory and recover rather quickly with minimal pain. The removal of the skin and fat from the gluteal area results in a slight butt lift.
Transverse Upper Gluteal (TUG) Free Flap
The transverse upper gluteal artery (TUG) free flap uses the excess skin and fat located in the medial thigh region.
One of the underlying muscles, the gracilis, remains attached to the overlying skin and fat of the free flap to provide the circulation to that tissue. Despite sacrifice of the muscle, no residual deficit in strength or function of the leg is noted.
The residual scar is parallel to the groin crease. The free flap is then brought to the chest and sewn to recipient vessels to reestablish circulation. This is an option for fewer individuals as it provides a smaller amount of tissue for creation of the breast mound.
Schedule a Consultation to Learn More
To learn more about breast reconstruction in Salt Lake City, please contact us by calling 801-943-0401 or by sending an email through the online contact form. The staff at Dr. Chen's office is prepared to handle your questions and comments.