Understanding Your Options

One of the more confusing aspects of breast cancer surgery is choosing from all the reconstruction options. First comes the shock of a cancer diagnosis, and then you must adapt to the idea of a mastectomy, and finally familiarize yourself with reconstructive options. It’s understandable to be stressed, but it’s important to know about each procedure in order to make the right decision.

Learn about the TRAM flap procedure »

Learn about the DIEP flap procedure »

Implant with Expanders

This is the most common reconstruction surgery done today. It’s usually a two-step process: Step one is to place the expander. Step two is to later replace it with either a silicone or saline implant. The expander is often placed at the time of mastectomy, although it can even be done years after surgery.

First, your breast surgeon will perform a mastectomy to remove cancer and all necessary breast tissue. Then a plastic surgeon will divide the muscles in your chest wall and place a medical device called an expander inside.

After about a month of healing, you’ll go in to see the plastic surgeon for what are called “fills.” Your doctor will insert a thin needle into your chest and then pump saline into the expander. Your skin will be numb, so this is a painless procedure. The fills will be done at regular intervals over the course of several months to allow the skin to expand and eventually accommodate an implant.

In a second surgery, the expanders will be removed and the implant inserted. If you choose, a nipple can be created out of skin from the inner thigh or elsewhere. Or, you can get a 3-D nipple can be tattooed on your breast.

The implant procedure is a relatively easy surgery with a short recovery. But the expanders don’t look natural as they’re being pumped up, and they feel hard until they’re replaced with the implant. You will have to dress creatively to accommodate this process.

Scar tissue hardening around the implant (capsular contracture) is sometimes a problem. Implants don’t last a lifetime, and often must be replaced after about 10 years. This requires regular MRIs.

There is also a one-step option, in which the implant is placed at the time of the mastectomy. This isn’t a viable procedure for many, but it’s always good to ask your plastic surgeon if you’re interested.

Flap Procedures

Flap procedures are much more complicated, with a lengthy time under anesthesia. They’re considered major surgery, and require a patient to be hospitalized for several days. This procedure should only be performed by a qualified plastic surgeon skilled in vascular surgery.

The body’s own tissue is used to create a breast mound in this type of surgery. There are several types of flap procedures, and there are two ways to do these surgeries:

  • Skin and muscle can be taken from another part of the body and placed to create a breast.
  • The tissue is removed entirely and reattached in the new spot.

Below is a description of the various flap procedures.

Transverse Rectus Abdominal Muscle (TRAM) Flaps

Your plastic surgeon will take muscle and tissue from your abdomen and use them to create a breast. Because one of the abdominal muscles is sometimes removed, your core may be weak and you must do physical therapy to regain your strength.

Back (Latissimus Dorsi) Flap

Similar to the others, this procedure takes skin, fat, and muscle from the upper back, tunneling it under skin to the chest. This is typically used for smaller sized breasts, or for creating a pocket for an implant. Some women have reported weak backs and arms after this surgery.

Gluteal and Thigh Flap

This is another option for women who may have more tissue in their bottom and legs than in their abdomen.

Deep Inferior Epigastric Perforator (DIEP) Flap

This is similar to the TRAM flap, but only skin and fat are removed. Attaching the blood vessels in this case requires an expert in microsurgery. A DIEP will leave you with more strength in your abdomen than a TRAM, but not every woman qualifies.

The advantages of a flap procedure are that the shape, texture, and appearance of the reconstructed breasts are more natural. They have a blood flow and are part of your body. The skin will age and sag, and will grow or shrink with weight gain and loss unlike an implant, which will remain high and tight. It may also feel more natural to your partner. Many women are pleased that they will also get a tummy tuck with this surgery.

The downside is that it’s a very long surgery, with a real risk of infection and tissue necrosis. There is scarring in more areas of the body, and there can be problems besides the loss of muscle, such as hernias. Thinner women often don’t have enough tissue to qualify for this surgery.

Thinking It Over

It’s important to know that federal law says your insurance company must pay for breast reconstruction after mastectomy. Keep in mind that reconstructive surgery is not the same thing as enhancement surgery. The doctor is trying to create something that no longer exists. Keeping your expectations realistic will lead to a more satisfying outcome.

Your doctor can help you weigh the pros and cons of various surgeries. While it may seem urgent, you have a few weeks to research your options and get a second opinion if necessary.