Operations to make a new breast

The techniques for rebuilding the breast fall into two main groups

•  Techniques that depend on a breast implant to recreate the volume of the missing breast
•  Techniques that use a 'flap' of your own tissues from elsewhere.

The favoured technique amongst many plastic surgeons is to use your own tissue from elsewhere on your body to reconstruct the breast. In recent years, own tissue or 'autologous' reconstructions have become more and more popular with patients because the breast can appear more natural looking. Tissue is usually taken from the tummy or back, but sometimes the buttocks or thighs.

For some patients, however, using a breast implant is more appropriate.

Reconstruction using only an implant

If your breast is reconstructed using an implant on its own, a silicone prosthesis is inserted under the skin and muscle of the chest to replace the volume of breast tissue that has been removed at the time of mastectomy. This is quite a simple operation that does not involve scars elsewhere on your body. The implant will be very like one that is used in cosmetic surgery. Sometimes an implant called an “expander-prosthesis” might be used, which can have its volume adjusted by injections of salt water which can be done in the outpatient clinic in the weeks after the operation. This will help give the best match for your other breast.
Figure 2
Implants will be offered to you if you are not suitable for reconstruction using your own tissue. This might be because of a variety of reasons, such as:

•  You have no spare tissue to use
•  You are not well enough for a larger operation
•  You simply do not want a big operation involving cuts and scars elsewhere on your body

It can be difficult to get a natural breast shape with an implant alone and so these kinds of reconstructions are best for women with relatively small breasts that do not droop at all, or if both breasts are being removed.

The main disadvantage of implant-based breast reconstruction is that it is impossible to create a breast with an entirely natural shape and feel.

Many women choosing an implant-only reconstruction will need to have the other breast adjusted to improve the shape and size match. Whilst the breasts can look a good match whilst dressed they will usually be different shapes when undressed. If you choose an implant-based reconstruction you should expect to need to have further operations in the future to adjust or exchange the implant.

Potential problems
Implants are prone to hardening, deflation, visible folds and creases, and do not give good results if you have to have radiotherapy either before or after the reconstruction is carried out.

A flap of tissue from your back- with or without an implant

One type of flap transfer for breast reconstruction uses the latissimus dorsi muscle from the back along with an overlying patch of skin. This muscle has a good blood supply from the vessels emerging from the armpit which makes it extremely useful for breast reconstruction. 

In this procedure, the muscle is transferred to the breast area by swinging it around the ribcage so that it lies at the front of the body. This procedure means that the skin removed at the time of mastectomy is replaced along with some volume. 

Figure 3

Many women will also need an implant to further supplement the volume of the breast, but sometimes it is possible to remove enough fat from the back along with the flap of skin and muscle to replace the missing breast volume without the need for an implant. This is called an autologous latissimus dorsi reconstruction. This procedure is a larger operation than using an implant alone, but it will usually give a more natural result, particularly if an implant is not needed. It should also be noted:

•  It does result in quite a large scar on your back, but this can usually be positioned to be concealed by most clothing and underwear
•  Losing the muscle from the back does not seem to cause any restriction of shoulder movement or strength in most patients
•  Latissimus dorsi flap reconstruction is most suitable if you do not need too much skin replacement and your tummy is not suitable for flap transfer
•  It can be ideal for relatively heavily built women who have small to medium sized breasts

Figure 4
In the above image, the first picture shows the expected result of a delayed latissimus dorsi breast reconstruction. The flap has replaced the skin that was removed at the time of the mastectomy. The volume is replaced either with just the muscle and fat of the back, but if this is insufficient an implant is also used. The second picture shows the final result after nipple areola reconstruction.

Flaps taken from the tummy

The skin and fat of the lower tummy is often the ideal tissue for breast reconstruction because a large amount of skin and volume can be replaced to achieve a very natural look and feel. Removal of excess skin and
fat can often be a welcome bonus, resulting in a “tummy tuck”.

When first conducted, the operation involved moving the lower abdominal flap with the underlying rectus abdominis muscle beneath the skin of the upper tummy to the chest – a so called “pedicled” flap. Whilst this technique is still sometimes used, most surgeons find that transferring this tissue completely as a “free” flap is more reliable. 

Free flaps are entirely disconnected from their original blood supply during the operation and are reconnected using microsurgery and very fine stitches to join the arteries and veins to vessels near the breast area.

In free flap breast reconstruction, skin, fat and sometimes muscle from one part of the body is transferred to make a new breast. Blood vessels from the armpit, or near the breastbone, are used to create a new blood supply for the transferred tissue. There are several types of lower abdominal free flap depending on which blood vessels are used and whether any muscle is transferred:

Free TRAM flap- In this operation a small piece of muscle is taken along with the blood vessels, skin and fat
Free DIEP flap- This variant uses the same blood vessels as the TRAM flap, but they are carefully dissected out from the muscle when the flap is raised and DIEP flap contains no muscle
Free SIEA flap- In this operation some of the more superficial blood vessels on the tummy are used and no muscle is dissected or transferred

Each of these flaps can achieve the same thing in terms of the eventual reconstruction, but the DIEP and SIEA involve less or no interference with the function of the tummy muscles. Some surgeons have a particular preference and experience with one or other type.

It should be noted that sometimes the exact flap used has to be decided during the operation, so it is not possible for you to pick one technique that will definitely be used. In these circumstances you would have to rely on the surgeon to use the most reliable technique

Whilst abdominal flap reconstruction can give the best results, this is a major operation:
•  You spend about a week in hospital and will undergo a recovery period lasting several weeks
•  There will be scars on the breast and a large scar across the lower tummy as well as around the tummy button (umbilicus)
•  You may have some difficulty sitting up from lying down initially, if your tummy muscles are used. However, in the long term, most women notice no real problems in day-to-day activities.

Once the breast reconstruction process is complete then the shape and appearance are usually stable and permanent

3.Abdominal flap(A5)
The above image  illustrates a breast reconstruction using a free lower abdominal flap. A large flap of skin and fat from the lower abdomen is raised along with the blood vessels that keep it alive. In this case a small portion of muscle has also been taken (TRAM flap). In some cases it is possible to take blood vessels without taking any muscle (DIEP flap). The flap is transferred to the chest to replace the missing skin and volume. The blood vessels of the flap are joined microsurgically to blood vessels in the chest to restore the blood supply to the flap

Other flaps

If your tummy is not suitable as a source of tissue, a flap can sometimes be taken from the buttocks or upper inner thighs. These flaps are much less commonly used and not all breast reconstruction centres will offer these techniques, so you might have to travel to see a suitable expert if this is the best option for you. Buttock flaps are based on one or other of the blood vessels emerging from the buttock muscles and the flaps are named after them: the SGAP flap or IGAP flap. Flaps from the upper inner thighs are known as TUG flaps.

In general these other flaps are used if you want reconstruction using only your own tissues and are very slim or have had previous tummy surgery

Flaps containing muscle are named after the muscle:
•  TRAM- Transverse rectus abdominis muscle from the abdomen
•  Latissimus dorsi- Latisimus dorsi muscle from the back
•  TUG- Transverse upper gracilis muscle from the upper inner thigh

Perforator flaps are free flaps that only contain skin and fat and are named after the delicate performing artery that supplies blood to the area:
•  DIEP- Deep inferior epigastric perforator from the abdomen
•  ​SIEA​- Superficial inferior epigastric artery from the abdomen
•  ​IGAP- ​Inferior gluteal artery perforator from the buttock crease
•  ​SGAP- ​Superior gluteal artery perforator from the upper buttock.

Read more

Introduction to breast reconstruction
When to have breast reconstruction
Further operations and nipple reconstruction
Reconstruction in other situations
Where can you have breast reconstruction?
Other questions and where to get more information 
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