Definition

After a mastectomy, some women choose to have surgery to remake their breast. This type of surgery is called breast reconstruction. It can be performed at the same time as a mastectomy (immediate reconstruction) or later (delayed reconstruction).

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

Alternative Names

Transverse rectus abdominus muscle flap; TRAM; Latissimus muscle flap with a breast implant; DIEP flap; DIEAP flap; Gluteal free flap; Transverse upper gracilis flap; TUG; Mastectomy - breast reconstruction with natural tissue; Breast cancer - breast reconstruction with natural tissue

Description

If you are having breast reconstruction at the same time as mastectomy, the surgeon may do either of the following:

• Skin-sparing mastectomy. This means that the nipple and areola and a small area of skin around it is removed.
• Nipple-sparing mastectomy. This means all of the skin, nipple, and areola (the pigmented skin around the nipple) are kept.

In either case, skin is left to make reconstruction easier.

If you will have breast reconstruction later, the surgeon can still do skin- or nipple-sparing mastectomy. If you are not sure about having reconstruction, the surgeon will remove the nipple and enough skin to make the chest wall as smooth and flat as possible.

Types of breast reconstruction include the following:

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

For any of these procedures, you will have general anesthesia. This is medicine that keeps you asleep and pain-free.

For TRAM surgery:

• The surgeon makes a cut (incision) across your lower belly, from one hip to the other. Your scar will be hidden later by most clothing and bathing suits.
• The surgeon loosens skin, fat, and muscle in this area. This tissue is then tunneled under the skin of your abdomen up to the breast area 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. 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 matches 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. Or, the nipple and areola can be created with a tattoo.

For latissimus muscle flap with a breast implant:

• The surgeon makes a cut in your upper back, on the side of your breast that was removed.
• The surgeon loosens skin, fat, and muscle from this area. This tissue is then tunneled under your skin to the breast area to create your new breast. Blood vessels remain connected to the area from where the tissue was taken.
• This tissue is then shaped into a new breast. The surgeon matches 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.
• The incisions are closed with stitches.
• If you would like a new nipple and areola created, you will need a second, much smaller surgery later. Or, the nipple and areola can be created with a tattoo.

For a DIEP or DIEAP flap:

• The surgeon makes a cut across your lower belly. Skin and fat from this area is 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 matches the size and shape of your remaining natural breast as closely as possible.
• The incisions are closed with stitches.
• If you would like a new nipple and areola created, you will need a second, much smaller surgery later. Or, the nipple and areola can be created with a tattoo.

For a gluteal flap:

• The surgeon makes a cut in your buttocks. Skin, fat, and possibly muscle from this area are 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 matches the size and shape of your remaining natural breast as closely as possible.
• The incisions are closed with stitches.
• If you would like a new nipple and areola created, you will need a second, much smaller surgery later. Or, the nipple and areola can be created with a tattoo.

For a TUG flap:

• The surgeon makes a cut in your thigh. Skin, fat, and muscle from this area are 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 matches the size and shape of your remaining natural breast as closely as possible.
• The incisions are closed with stitches.
• If you would like a new nipple and areola created, you will need a second, much smaller surgery later. Or, the nipple and areola can be created with a tattoo.

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.

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.

Some 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 anesthesia and surgery are:

• Reactions to medicines
• Breathing problems
• Bleeding, blood clots, or infection

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 your surgeon if you are taking any medicines, including supplements, or herbs you bought without a prescription.

During the week before your surgery:

• You may be asked to stop taking blood thinning medicines. These include aspirin, ibuprofen (Advil, Motrin), vitamin E, clopidogrel (Plavix), warfarin (Coumadin, Jantoven), and others.
• Ask your surgeon which medicines you should still take on the day of your surgery.
• If you smoke, try to stop. Smoking may slow healing and increase the risk for problems. Ask your health care provider for help quitting.

On the day of your surgery:

• Follow instructions about not eating or drinking and about showering before you go to the hospital.
• Take your medicines your surgeon told you to take with a small sip of water.
• Arrive at the hospital on time.

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 cuts after surgery. Follow instructions about taking pain medicine.

Fluid may collect under the incision. This is called a seroma. It is fairly common. A seroma may go away on its own. If it doesn't go away, it may need to be drained by the surgeon during an office visit.

Outlook (Prognosis)

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

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

References

Boukovalas S, Kalaria SS, Park JE. Breast reconstruction. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 21st ed. St Louis, MO: Elsevier; 2022:chap 36.

Cameron J. Breast. In: Cameron J, ed. Current Surgical Therapy. 14th ed. Philadelphia, PA: Elsevier; 2023:717-808.