More than 79,000 women a year have some form of breast reconstruction after mastectomy. Most of the time, that is either silicone or saline breast implants to recreate the breast. Newer forms of breast reconstruction, however, now make it possible to reconstruct the breast out of the patient’s own tissue, without the use of implants.
“For about five years now, we have been doing a procedure called a free tram, which takes a cuff (flap) of muscle, fat and skin to the new position, disconnecting it completely from the donor site and hooking it up to blood vessels in the chest,” says Dr. Samer Cabbabe of Cabbabe Plastic Surgery. A sizable amount of muscle is moved to take the place of or augment the chest muscle that may have been removed or irradiated during cancer treatment. Since then, procedures have continued to evolve, and some flap options take very little muscle or none at all.
Two flap procedures, SIEA (superficial inferior epigastric artery) and DIEP (deep inferior epigastric perforator) take about the same amount of skin and fat from the abdomen as a tummy tuck. “When I sit down with patients, I want to know the size of the breast we are replacing and whether they are having radiation,” says Cabbabe. “If radiation is part of the treatment plan, an implant is not the best option because of the post-radiation condition of the skin and muscle. Our best option is one of these flaps.”
He says if the reconstruction can’t be done at the same time as the mastectomy, the patient can have a skin-sparing mastectomy, which leaves an envelope of skin for future reconstruction. “Too many women don’t understand all their options,” says Cabbabe. “We can make much better breasts these days.”
Dr. Terry Myckatyn, a plastic reconstructive surgeon with Washington University School of Medicine, does 300 breast reconstruction procedures a year. He says the surgeons in his practice do about 200 flap procedures a year. “I estimate we do 98 percent of the free flaps in the Midwest; we have patients from Denver to Chicago,” Myckatyn says. He explains that each patient’s needs are highly individualized. Their height, weight and body mass index (BMI) are all considered. “Some prior abdominal surgeries can interfere with using an abdominal flap,” he says. “And we don’t want to do a flap and then have the patient have radiation. It can lose volume, discolor or become too firm. Without radiation or prophylactic mastectomy, we can do the flap immediately at the time of the mastectomy.”
Plastic surgeon Judith Gurley says implants continue to be a very good option for women seeking reconstruction. “Silicone gel implants are now FDA-approved and are most women’s first choice because they are made of a cohesive gel that behaves like a solid and can’t spill out even if the implant is ruptured,” she says. “Silicone also provides many more options in terms of shapes than saline implants.” She says that when women are trying to decide on a reconstruction option, the key to success is having healthy tissue. “Patients who undergo mastectomy after radiation or followed by radiation have more limited options. They may not be candidates for implants and will need to consider using their own tissue to bring healthy non-radiated tissue to the breast.”
Immediate breast reconstruction with implants has become more popular because women wake up from their mastectomy with a small breast, rather than nothing at all, Gurley says. The advantages of implant reconstruction include the shorter time required for the procedure and the fewer scars that result. It takes only an additional 45 minutes for the plastic surgeon to reconstruct a breast with a tissue expander at the time of mastectomy. The expander is replaced with a permanent implant three months later. Gurley urges women to choose surgeons who are up to date on the latest advances in reconstruction and who do a lot of it. “Ask to see many examples of their results.”