Types of Breast Reconstruction

We know that choosing breast reconstruction is a personal choice, with a lot to consider. As breast care experts, we believe it’s important to provide you with the information you need to make informed decisions. However, nothing can replace talking to a doctor about your unique situation.

Choosing the Type of Procedure

Breast reconstruction surgeons at El Camino Health are well-versed in all reconstruction techniques. When choosing the surgical approach that's right for you, there are a few things to consider:

• Personal preference. Do you want to use tissue or synthetic implants? Immediate or delayed reconstruction? How many stages of surgery are you willing to undergo? These are only a few of the decisions you’ll need to discuss with your plastic surgeon.
• Type of mastectomy. Your breast surgeon and plastic surgeon will work together to tailor your mastectomy to the type of reconstruction you prefer. If you’ve already had a mastectomy and are considering reconstructive surgery, the surgical plan will be based on the type of mastectomy you had.
• Cosmetic concerns. Breast-conserving lumpectomies are more common these days, thanks to recent advances in highly targeted surgical and radiosurgical techniques. However, once tissue heals and swelling subsides, you can be left with asymmetry or indentations in your breast or changes in firmness or pigmentation. 
• Treatment plan. If you’re having radiation after mastectomy, El Camino Health offers new processes that can integrate and combine reconstruction and radiation. 
• Body type. If you’re having both breasts removed (bilateral prophylactic mastectomies), you have more leeway when it comes to determining the size and shape of your reconstructed breasts because your surgeon doesn’t have to match an existing breast. If you choose to have autologous (tissue) implants, your body type will play a role. 

Implants: Synthetic or Body Tissue?

Breast reconstruction falls into two general categories: autologous and alloplastic. Autologous uses tissue from your own body, while alloplastic uses a synthetic implant.

Autologous

Some women prefer the idea of using their own tissue instead of a synthetic implant. Tissue is commonly taken from your abdomen, back, inner thigh or buttocks — depending on where you have enough extra skin and fat available. The harvested tissue is called a flap, meaning the tissue has its own blood supply. Unfortunately, not every patient is a candidate for autologous reconstruction. In certain situations, autologous reconstruction is the preferred method for matching an existing breast.

Alloplastic

Implants are an excellent choice for women who aren’t candidates for an autologous reconstruction or who don’t want a larger surgery with multiple surgical sites. Alloplastic surgery offers more options in bilateral (both breasts) reconstruction. In addition, alloplastic reconstruction can be combined with autologous fat grafting to provide a more natural appearance.

Implants can be made of silicone or saline:

• Silicone implants. Silicone implants come pre-filled with a cohesive silicone gel. The newest implants are shaped to achieve a more natural appearance of the breast, which can significantly improve the outcome of alloplastic reconstruction.
• Saline implants. Unlike silicone implants, saline implants are placed as empty silicone shells. Your surgeon uses a valve to fill them with saline (a saltwater solution) once the implants are in place. The amount of saline injected will affect your breast's shape, firmness and feel.

Alloplastic reconstruction works best in patients undergoing immediate reconstruction without a history of prior chest wall radiation.

Alloplastic Breast Reconstruction

At El Camino Health, breast reconstruction using alloplastic implants can be performed as a one- or two-stage operation. In the more common two-stage reconstruction, a temporary saline implant expander is placed underneath a muscle in your chest to keep your skin stretched. Additional support is created using a biomaterial graft to help stabilize the reconstruction. This creates a “lattice” of tissue around which your own cells can grow. In certain cases, a tissue expander isn’t necessary and the final silicone implant is placed during the first operation.

Following the first stage of this procedure, you can expect to spend a day in the hospital for pain control. During your follow-up office visits, your plastic surgeon will begin expanding your implant until the final size is reached. The second stage, which is usually performed three months later, is an outpatient procedure in which your surgeon removes the tissue expander and places the final silicone implant. Fat grafting (removing fat from one location and injecting in the tissue around the implant) can be performed at the same time to improve the look and feel of the reconstruction. The final stages include small procedures to reconstruct the nipple and areola.

Autologous Reconstruction Using TRAM Flap

Breast reconstruction with autologous implants is most commonly performed using abdominal-based tissue, known as TRAM flap. The skin and fat quality of the abdomen makes a very good breast substitute. All abdominal-based flaps result in a scar in the lower abdomen, often around the bikini line.

El Camino Health performs TRAM-flap procedures, including:

• Pedicle-TRAM. This technique differs from other TRAM flap procedures in that the flap remains attached to your body at all times. One end of the flap remains connected to the blood supply, and the other end is tunneled into your breast cavity to recreate your breast. With this procedure, the entire rectus abdominus muscle is sacrificed, which may cause abdominal weakness. 
• Free-TRAM. During this procedure, the flap is completely disconnected from your body and reattached using refined microsurgical techniques. The flap's blood vessels are then connected to blood vessels in your chest or armpit. The majority of the rectus abdominus muscle is preserved, which improves recovery and allows you to maintain abdominal strength.
• Deep inferior epigastric perforator (DIEP). The DIEP flap represents a new class of "perforator flaps" that spares the rectus abdominus muscle. The blood vessels are separated completely from the muscle. Since the rectus abdominus muscle is almost completely preserved, there’s minimal change in abdominal strength.
• Autologous fat grafting (AFT). In this process, fat is taken from several locations around your body. It’s gently processed and reintroduced into the skin, fat and muscle around your original breast. The fat grows a new blood supply that allows it to become viable living tissue. This technique can be performed as an outpatient procedure. However, you may need more than one operation to achieve your desired breast size.

You may not be a good candidate for a TRAM flap procedure if you:

• Have an underlying medical problem.
• Had a previous TRAM flap procedure.
• Had a tummy tuck or abdominal surgery.
• Don’t have enough abdominal tissue from which to reconstruct a breast.

If TRAM flap surgery isn’t an option for you, El Camino Health also performs other types of breast reconstructions, including those that use the soft tissue and muscle from your back.