Breast Reconstruction Baltimore

WHAT IS BREAST RECONSTRUCTION?

Breast reconstruction aims to create a breast that resembles a natural breast in appearance and form. This is done by using the woman’s own tissues or an implant. It may be done after removal of a whole breast (mastectomy/bilateral [double] mastectomy) or part of the breast (segmental mastectomy, quadrantectomy or wide local excision). The new breast shape can be created using an implant and/or your own tissue from another part of the body, usually the back or lower abdomen. Reconstructed breasts don’t usually have a nipple but one can be created with surgery.

WHO CAN HAVE RECONSTRUCTION?

Most women who have had a whole or partial mastectomy can have breast reconstruction, either at the same time as their initial surgery for cancer (immediate reconstruction) or months, even years, later (delayed reconstruction).

DECIDING TO HAVE A RECONSTRUCTION

Dr. Del Corral will want you to go into the operation with a full understanding of what is going to happen and realistic expectations of how your reconstructed breast will look. Don’t go ahead until you feel you’ve got all the facts and have received answers to all your questions. You may find it helpful to write down any questions you want to ask and to take notes during consultations. Taking someone with you can help you to remember what has been discussed and give you extra support.

HOW DOES DR. DEL CORRAL USE IMPLANTS TO RECONSTRUCT A WOMAN’S BREAST?

Implants can be inserted underneath the skin and chest muscle that remain after a mastectomy, usually as part of a two-stage procedure.

In the first stage, the surgeon places a device called an expander under the chest muscle. The expander is slowly filled with saline during visits to the doctor after surgery. In the second stage, after the chest tissue has relaxed and healed enough, the expander is removed and replaced with an implant. The chest tissue is usually ready for the implant six weeks to six months after mastectomy.

Expanders can be placed as part of either immediate or delayed reconstructions. An optional third stage of breast reconstruction involves recreating a nipple on the reconstructed breast.

HOW DOES DR. DEL CORRAL USE YOUR OWN TISSUE TO RECONSTRUCT A WOMAN’S BREAST?

Another commonly used reconstruction technique uses flaps of your own tissue (with or without an implant), including the skin, usually taken from your back or lower abdomen, or from the thigh or buttock. This is then reshaped to form the new breast. Because the skin used is taken from another area of the body, it may be a slightly different shade or texture to the rest of the breast. This method is particularly suitable for creating moderate to large-sized breasts that have a natural droop.

It is commonly used in delayed reconstruction when women can’t have tissue expansion because they’ve had radiotherapy. Flaps without implants may also be used for immediate reconstructions for women who are going to have radiotherapy treatment.

This type of surgery involves a longer operation and more recovery time than an implant-only reconstruction. But you will be less likely to need further surgery in the future than with reconstruction using implants alone. A reconstructed breast using tissue instead of an implant may also provide a better match with your other breast in the long term. This is because tissue reacts to gravity, aging and weight change more naturally.

TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM FLAP)

TRAM stands for the transverse rectus abdominal muscle, which is located in the lower abdomen, between the waist and the pubic bone.
An oval section of skin, fat, and muscle is taken from the lower half of the abdomen and slid up through a tunnel under the skin to the breast area. Blood vessels remain attached whenever it’s possible. The tissue is shaped into a natural-looking breast and sewn into place.

When reconstruction is performed after a double mastectomy your surgeon must first determine if there is enough excess tissue to do both breasts. If so, a single piece of tissue (skin, muscle, and fat) is removed from the abdomen. The flap is divided in half, and each half is placed in position, in paired openings on the chest. This surgery takes twice as long as a single reconstruction (about six hours) and the recovery time can be difficult.

Things to keep in mind about a TRAM Flap are that you will have a long scar. This abdominal incision runs along your body from hip bone to hip bone midway between the top of your pubic hair and your belly button. The benefit of this scar that most women report is that they have a flatter lower tummy (resembling the effects of a ‘tummy tuck’). Because of the positioning of your abdominal incision, Dr. Del Corral may need to build you a new belly button, or your original one may be distorted. Because the nerves are cut during your surgery there is a high chance that you will have limited (if any) feeling or sensitivity in your breasts and around your abdominal incision. This can differ significantly from one person to another.

DEEP INFERIOR EPIGASTRIC ARTERY FLAP (DIEP FLAP)

DIEP stands for deep inferior epigastric perforator. This is the name of the main blood vessel that runs through the tissue that will be used to reconstruct the breast. In DIEP flap reconstruction, only skin, fat, and blood vessels are removed from the lower belly (the abdomen between the waist and hips). No muscle is removed. This is one of the main differences between the DIEP flap and the TRAM flap–the TRAM flap procedure removes muscle (along with fat, skin and blood vessels) and the DIEP procedure does not.

Because no abdominal muscle is removed, most women recover more quickly from DIEP compared to TRAM and have a lower risk of losing abdominal muscle strength. There also tends to be less abdominal wall discomfort because your muscle isn’t involved.

The other main difference between the DIEP and TRAM procedures is how blood is supplied to the belly tissue once it becomes your new breast. The DIEP is a called a “free” flap because the tissue is completely detached from the belly and then reattached to the chest area. Hooking up the blood vessels from the belly tissue to chest blood vessels is delicate work. Your doctor has to use a microscope during surgery, which is why DIEP is known as microsurgery. The TRAM procedure doesn’t detach the belly tissue from the blood vessels in the belly. The belly tissue, still attached to its belly blood supply, is moved up to the chest area. No blood vessel surgery is necessary. Because of the extra time required for the blood vessel microsurgery, DIEP flap surgery takes longer than TRAM flap surgery (about 5 hours to reconstruct one breast and up to 8 hours if you’re having both breasts reconstructed).

Like the TRAM flap, you end up with a tummy tuck as a benefit of DIEP surgery because fat from your abdomen is removed to reconstruct your breast and loose skin is tightened up (there has to be some benefit!).

WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF DIEP/SIEA FLAP RECONSTRUCTION?

Advantages:

  • Since the reconstruction involves using the patient’s own tissues, the risks of implant reconstruction are avoided.
  • Most patients have less postoperative pain than after a TRAM flap and are therefore able to leave the hospital sooner, and return to normal activities quicker than after a TRAM flap.
  • Because the abdominal muscle is not removed, patients have less risk of developing hernias at the site where the flap is removed than patients who have had a TRAM flap.
  • It is typically easier to match the contralateral natural breast with the patient’s own tissue when compared with implant reconstruction.
  • Patients essentially end up with a “tummy tuck” at the same time as the breast reconstruction.

Disadvantages:

  • DIEP/SIEA flap reconstruction generally requires a longer and more difficult surgery at the first stage when compared with implants or TRAM flaps.
  • Patients will have a scar across the lower abdomen where the flap is obtained.

Breast reconstruction using your own tissue is popular because it’s a long-lasting solution (implants usually have to be replaced after about 10 to 15 years) and the consistency of the belly tissue is very similar to natural breast tissue. But the new breast will have little, if any, sensation.

DIEP has been used since the early 1990s. Because the surgery is more complicated, it’s not offered everywhere. It’s usually done by plastic surgeons who specialize in free flap breast microsurgery. If you’re interested in DIEP, ask your breast cancer surgeon for recommendations.

The DIEP flap procedure isn’t for everyone. It’s a good choice for women who have enough tissue to reconstruct one or both breasts. In general, you can still have DIEP if you’ve had abdominal surgery (hysterectomy, c-section, appendectomy, bowel resection, liposuction, tummy tuck).

DIEP may NOT be a good choice for:

  • thin women who have very little abdominal fat to spare
  • women who smoke and have blood vessels that are narrow and less flexible

SUPERFICIAL INFERIOR EPIGASTRIC ARTERY FLAP (SIEA FLAP)

This is similar to the DIEP flap as it uses only skin and fat from the lower abdomen and no muscle, but the vessels taken are superficial (nearer the surface) rather than the deep vessels used in the DIEP flap.

LATISSIMUS DORSI FLAP

An oval section of skin, fat, and latissimus dorsi muscle is detached and slid around through a tunnel under the skin to the breast area. Blood vessels remain attached whenever possible. The tissue is shaped into a natural-looking breast and sewn into place. If blood vessels have been cut, they are reattached by microscopic surgery to blood vessels in the chest area. The procedure takes about two to three hours.

In general, latissimus dorsi is only a good option for a woman with small- to medium-sized breasts, because there is so little body fat in this part of the back. An implant (inserted during the same operation) is almost always necessary to create a breast of moderate size.

Things to keep in mind about the latissimus dorsi reconstruction is that the skin on your back has a different texture and color than your breast and it can also result in some asymmetry of your back. Usually though, back function and strength are not affected.

SUPERIOR GLUTEAL ARTERY PERFORATOR FLAP (S GAP FLAP) AND INFERIOR GLUTEAL ARTERY PERFORATOR FLAP (IGAP FLAP)

The free SGAP and IGAP use only fat and skin taken from the upper or lower buttock to create a new breast. Microvascular surgery is needed to join the blood vessels.

With the GAP flap technique, the resulting breast shape is usually soft and feels very natural as long as the patient’s buttocks tissue is soft. In most women, a very small amount of buttocks tissue needs to be removed and it will not interfere with sitting. However, if the surgery leaves a noticeable depression in the flesh, liposuction can be done to remedy the problem.

TRANSVERSE MYOCUTANEOUS GRACILIS FLAP (TMG) OR TRANSVERSE UPPER GRACILIS (TUG)

Thigh tissue results in soft and naturally shaped breasts, and the scar can usually be well hidden in the groin area. This is another good alternative if scars on the abdomen from previous surgery prevent its tissue from being used in DIEP or SIEA flap breast reconstruction surgery, and for patients who don’t have enough abdominal tissue, or those who don’t want abdominal scars.

I AM INTERESTED! WHAT DO I DO NEXT?

If you are considering breast reconstruction we encourage you to contact us to schedule a consultation and/or treatment at Dr. Del Corral’s office. During this visit we will listen to your concerns and discuss your options. After careful analysis of your breasts, we will tell you whether you are a suitable candidate for this procedure and inform you of the alternatives and potential risks of the procedure.