The aim of breast reconstruction is to have a breast shape that looks natural and matches the other breast in its size and shape. Breast reconstruction can generally fall into two categories: implant-based reconstruction and flap reconstruction (using own body tissue) or both can be performed in combination.
Breast reconstruction using implants
Implant-based reconstruction may only be possible if after a mastectomy there is enough tissue left on the chest to support an implant. Breast implants have an outer cover made of silicone elastomer and are filled inside with saline water or silicone gel.
In this technique, a silicone or gel implant is inserted into the breast and the skin is stretched over it to form the breasts. It works well for patients with small or medium size breasts and the scarring is minimal. The breasts are firmer but don't feel natural and don’t behave like usual breasts. Silicone or gel breasts carry a shelf life and need to be replaced after approximately 15 years.
-While immediate breast reconstruction
The breast reconstruction, in this case, is performed during the breast cancer surgery. The implants can be placed under or above the chest muscle. The breast implants are wrapped in an acellular dermal matrix (ADM) or a mesh and are placed under the chest wall after the breast surgeon has completed the mastectomy. This helps the implant to stay in the correct position. ADM’s are made from animal skin and are like leather, whereas meshes are synthetic supports made by man. This procedure results in immediate round shaped breasts. This is the simplest reconstruction surgery and has a quicker recovery time than others.
-While delayed breast reconstruction
The breast surgeon first performs the mastectomy, then a tissue expander is placed under the chest wall before closure. After a few weeks, the surgeon or nurse slowly fills the implant with saline solution through a small port, that can be along the rib cage (connected by a tube) or in the expander itself. The solution is filled in multiple visits and the amount injected depends on the capacity and tolerance of the patient. Once the expander tissue reaches its final expansion or stretching, the muscle is left to relax and stretch. Once this is completed, a second surgery needs to be done to remove the tissue expander and place the permanent implants. Expanders with saline have been used for years but recently there is expander that is filled with air, which gives more control to the patients. This expander decreases the visits to the doctor and the total expansion time. Tissue expansion before implants in delayed reconstruction is useful when there is not enough skin on the chest to cover and support the implants. In patients who have undergone chemotherapy, this process is a little difficult because the skin in the area reduces quality and elasticity.
Breast reconstruction using tissue flaps
Sometimes after mastectomy or chemotherapy there isn’t enough tissue or skin on the chest to support implants so reconstruction is done using flap technique. It is also called autologous reconstruction. In this procedure, reconstruction is done using flaps from the patient's own body. Skin, fat and sometimes a muscle is taken from areas such as the back, lower abdomen, inner thigh or the buttocks. These are used with or without an implant to make new breasts. A reconstructed breast with tissue flap is better in the long term and matches the other breast better. It also ages and reacts more like the normal breasts than the implants. This technique cannot be performed on women who are diabetic, overweight or heavy smokers.
There are two ways in which reconstruction is done using tissue flaps:
- Pedicled flap – the flap used in the technique is attached to its original supply at one end and just the muscle is moved to the chest to form the breasts.
- Free flap – the flap, in this case, is completely separated from the body with its blood vessels which are reattached by microsurgery in the reconstructed breasts. In rare cases, if the blood supply is poor, the tissue will die and reconstruction will fail.
There are different areas of the body from where the flaps can be taken for reconstruction. Your surgeon will guide you with the best option for your case.