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Breast reconstruction - natural tissue

After a mastectomy , some women choose to have cosmetic surgery to remake their breast. This type of surgery is called breast reconstruction.

During breast reconstruction that uses natural tissue, the breast is reshaped using muscle, skin, or fat from another part of your body.

This surgery can be performed at the same time as mastectomy or later.

If you are having breast reconstruction at the same time as mastectomy, the surgeon may do a skin- or nipple-sparing mastectomy. With skin-sparing mastectomy, only the area around your nipple and areola is removed. With nipple-sparing mastectomy, all of the skin, nipple, and areola are kept. In either case, skin is left to make reconstruction easier.

If you will have breast reconstruction later, the surgeon will remove just enough skin over your breast to be able to close the skin flaps.

Types of breast reconstruction include the following:

  • Transverserectus abdominous myocutaneous flap (TRAM)
  • Latissimus muscle flap
  • Deep inferior epigastric artery perforator flap (DIEP or DIEAP)
  • Gluteal flap
  • Transverse upper gracilis flap (TUG)

For any of these procedures, you will have general anesthesia (asleep and pain-free).

For TRAM surgery:

  • The surgeon will make a cut across your lower belly, from one hip to the other. Your scar will be hidden later by most clothing and bathing suits.
  • The surgeon will loosen skin, fat, and muscle in this area. The surgeon will then tunnel this tissue under the skin of your abdomen up to the breast area. This tissue is used to create your new breast. Blood vessels remain connected to the area from where the tissue is taken.
  • In another method called the free flap procedure, skin, fat, and muscle tissue are removed from your lower belly. This tissue is placed in your breast area to create your new breast. During this method, the arteries and veins are cut and reattached to blood vessels under your arm or behind your breastbone.
  • This tissue is then shaped into a new breast. The surgeon will match the size and shape of your remaining natural breast as closely as possible.
  • The incisions on your belly are closed with stitches.
  • If you would like a new nipple and areola created, you will need a second, much smaller surgery later.

For latissimus muscle flap with a breast implant:

  • The surgeon will make a surgical cut in your upper back, on the side of your breast that was removed.
  • The surgeon will loosen skin, fat, and muscle from this area and then tunnel this tissue under your skin to the breast area. This tissue will be used to create your new breast. Blood vessels will remain connected to the area from where the tissue was taken.
  • This tissue is then shaped into a new breast. The surgeon will match the size and shape of your remaining natural breast as closely as possible.
  • An implant may be placed underneath the chest wall muscles to help match the size of your other breast.
  • If you would like a new nipple and areola created, you will need a second, much smaller surgery later.

For a DIEP or DIEAP flap:

  • The surgeon will make a cutinacross your lower belly. Skin and fat from this area will be loosened. This tissue is then placed in your breast area to create your new breast. The arteries and veins are cut and then reattached to the blood vessels under your arm or behind your breastbone.
  • The tissue is then shaped into a new breast. The surgeon will try to match the size and shape of your remaining natural breast as closely as possible.
  • The incisions will be closed with stitches.
  • If you would like a new nipple and areola created, you will need a second, much smaller surgery later.

For a gluteal flap:

  • The surgeon will make a cut in your buttocks. Skin, fat, and possibly muscle from this area will be loosened. This tissue is placed in your breast area to create your new breast. The arteries and veins are cut and then reattached to the blood vessels under your arm or behind your breastbone.
  • The tissue is then shaped into a new breast. The surgeon will try to match the size and shape of your remaining natural breast as closely as possible.
  • The incisions will be closed with stitches.
  • If you would like a new nipple and areola created, you will need a second, much smaller surgery later.

For a TUG flap:

  • The surgeon will make a cut in your thigh. Skin, fat, and muscle from this area will be loosened. This tissue will be placed in your breast area to create your new breast. The arteries and veins are cut and then reattached to the blood vessels under your arm or behind your breastbone.
  • The tissue is then shaped into a new breast. The surgeon will try to match the size and shape of your remaining natural breast as closely as possible.
  • The incisions will be closed with stitches.
  • If you would like a new nipple and areola created, you will need a second, much smaller surgery later.

When breast reconstruction is done at the same time as a mastectomy, the entire surgery may last 8 to 10 hours. When it is done as a second surgery, it may take up to 12 hours.

Alternative Names

Transverse rectus abdominous muscle flap; TRAM; Latissimus muscle flap with a breast implant; DIEP flap; DIEAP flap; Gluteal free flap; Transverse upper gracilis flap; TUG

Why the Procedure Is Performed

You and your surgeon will decide together about whether to have breast reconstruction and when. The decision depends on many different factors.

Having breast reconstruction does not make it harder to find a tumor if your breast cancer comes back.

The advantage of breast reconstruction with natural tissue is that the remade breast is softer and more natural than breast implants . The size, fullness, and shape of the new breast can be closely matched to your other breast.

But muscle flap procedures are more complicated than placing breast implants. You may need blood transfusions during the procedure. You will usually spend 2 or 3 more days in the hospital after this surgery compared to other reconstruction procedures. Also, your recovery time at home will be much longer.

Many women choose not to have breast reconstruction or implants. They may use a prosthesis (an artificial breast) in their bra that gives a natural shape. Or they may choose to use nothing at all.

Risks

Risks of any surgery are:

Risks of breast reconstruction with natural tissue are:

  • Loss of sensation around the nipple and areola
  • Noticeable scar
  • One breast is larger than the other (asymmetry of the breasts)
  • Loss of the flap because of problems with blood supply, requiring more surgery to save the flap or to remove it
  • Bleeding into the area where the breast used to be, sometimes requiring a second surgery to control the bleeding

Before the Procedure

Tell the health care provider if you are taking any drugs, supplements, or herbs you bought without a prescription.

During the week before your surgery:

  • Several days before surgery, you may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), vitamin E, clopidogrel (Plavix), warfarin (Coumadin), and any other drugs that make it hard for your blood to clot.
  • Ask your doctor which drugs you should still take on the day of your surgery.

On the day of your surgery:

  • Follow your surgeon's instructions about not eating or drinking anything before surgery.
  • Take your drugs your doctor told you to take with a small sip of water.
  • Shower the night before or the morning of surgery.
  • Arrive on time at the hospital.

After the Procedure

You will stay in the hospital for 2 to 5 days.

You may still have drains in your chest when you go home. Your surgeon will remove them later during an office visit. You may have pain around your cut after surgery.

Fluid may collect under the incision. This is called a seroma. It is fairly common. Seromas may go away on their own, but sometimes they need to be drained by the surgeon during an office visit.

Outlook (Prognosis)

Results of reconstruction surgery using natural tissue are usually very good. But reconstruction will not restore normal sensation of your new breast or nipple.

Recovery is usually faster when reconstruction is done after the mastectomy wound has healed.

Having breast reconstruction surgery after breast cancer can improve your sense of well-being and quality of life.

References

McGrath, MH, Pomerantz J. Plastic surgery. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 69.

Roehl KR, Wilhelmi BJ, Phillips LG. Breast reconstruction. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 375.

Updated: 1/24/2013

Debra G. Wechter, MD, FACS, General Surgery practice specializing in breast cancer, Virginia Mason Medical Center, Seattle, Washington. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, Bethanne Black, Stephanie Slon, and Nissi Wang.


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