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Understanding BRCA & HBOC > Breast Reconstruction > Types of Reconstruction

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Types of Reconstruction

This section outlines the many options available and information about reconstructing breasts following mastectomy.

Implant reconstruction

Implant reconstruction uses saline or silicone breast implants to create breast shape and volume.

Both types are available in different volumes and shapes, so your surgeon can choose one that best fits your anatomy and desired size. Saline implants have a silicone shell filled with salt water. Breasts reconstructed with saline implants tend to feel firmer than silicone, which is softer and has a texture more like natural breast tissue. Silicone implants are filled with liquid or cohesive gel silicone. Their use is still controversial; while some fear implants may leak and spread silicone into the breast tissue or beyond, others consider the natural feel and weight of silicone implants is worth the risk. No matter which type implant is used, it is always placed under the pectoralis chest muscle (unlike breast augmentation, which usually places the implant between the breast tissue and muscle).

Generally, implant reconstruction involves two phases: first, temporary implants called expanders are placed in pockets formed under the chest muscles. Over several weeks the expanders are gradually inflated with saline to stretch the skin and muscles. During a second shorter surgery, the expanders are replaced with implants that best fit your anatomy and desired size.

Two single-step procedures may be options for small-breasted women. An adjustable hybrid  expander-implant can be placed and gradually inflated. When fully expanded, it is sealed and remains in place, eliminating the need for exchange surgery. Another newer technique completely eliminates the need for expansion. Non-expansive breast reconstruction uses Alloderm, a synthesized skin product, to cover portions of the implant.

Implants aren’t permanent. Sooner or later they wear out and must be removed and/or replaced. Sometimes this occurs sooner if the implant leaks or is distorted by hard scar tissue that forms around it. Some women need their implants replaced within a year of reconstruction; others may have their implants for 15 years or longer. It is obvious when a saline implant deflates, because the breast collapses (think of a balloon losing air). Deflation of silicone implants is often undetected, because the implant retains its shape. For this reason, some experts recommend women have a yearly MRI to determine if their silicone implants are intact. 

Implants are a good option for women who:

  • don’t mind potentially having less projection
  • haven’t previously had chest or breast irradiation
  • don’t mind having to replace the implants at sometime in the future
  • don’t want to endure a longer recovery from tissue flap surgery or scar another area of the body

Flap reconstruction

The most natural breast reconstruction uses a woman’s own skin, fat, and sometimes muscle.

Breasts made with the body's own tissue feel and move more naturally than those reconstructed with implants. However, tissue flap procedures are more complex and recovery is sometimes more intense—this involves surgery at the chest and the donor site—but the overall reconstruction timeline is shorter. Unlike implants, flaps form full-size breasts during the initial operation. Additional surgery later refines the breast shape and creates the nipples.

Two distinct types of tissue flaps are performed. The older “attached flap” surgeries use skin, fat and muscle from the back (latissimus dorsi flap) or the abdomen (pedicle TRAM flap). A portion of tissue and muscle is tunneled under the skin from the donor site to the chest, where it is shaped into a breast. It remains connected to its original blood supply (so it is “attached”).

“Free flaps” are complete transplants. They take skin, fat, and a small portion of muscle surrounding the blood vessels. This is technically more demanding than implant surgery; the surgeon need special skill and operates with a surgical microscope. Free flaps can be taken from the abdomen (free TRAM) and the buttock (gluteal flap). 

“Perforator flaps,” are a type of free flap that allows the surgeon to spare the entire muscle. Fewer surgeons are qualified to do this exacting procedure. They must completely remove the tiny blood vessels feeding the flap from the surrounding muscle, and reconnect them in the chest. Perforator flaps can be taken from the abdomen (DIEP and SIEA flaps), hip or thigh, (TUG) or the buttock (GAP flap).

Flaps are a good option for women who:

  • want the most natural reconstruction possible
  • have previously had chest or breast irradiation
  • don’t want to risk the problems inherent with implants or don’t want to endure the expansion process
  • don’t want to surgically modify their opposite healthy breast for symmetry

One disadvantage of flaps is the risk for some or all of the flap tissue to die, this is known as necrosis. When necrosis occurs, the skin and/or fat at the mastectomy or donor site dies because of insufficient blood supply. It may appear as a hard lump or an area that feels thickened. A small area of necrosis may be left as is or surgically removed. Rarely, an entire flap dies. This is known as "flap failure" and when it does occur it is usually within the first few days after reconstruction. When flap failure occurs, the reconstruction must be entirely removed.

Direct-to-implant

"Direct-to-implant," (sometimes called "one-step") reconstruction is a type of implant reconstruction where the surgeon places the permanent implant in the breast during the initial reconstruction surgery. Unlike "expander-implant" reconstruction, which requires 2 surgeries, the direct-to-implant option often allows women to avoid a second surgery. Direct-to-implant surgeries typically are used with nipple-sparing mastectomy so there is no need to reconstruct the nipple or areolar complex during a second surgery. 

Two common methods are used for direct-to-implant reconstruction. 

Direct-to-implant using permanent expanders

This reconstruction involves a special type of implant known as a "permanent expander." Like traditional expanders, permanent expanders can be gradually filled with saline over time. Unlike traditional expanders - which are replaced with a new implant during a second surgery - once permanent expanders are filled to the desired volume the surgeon can remove the port and the expanders remain in place as the final implant. Because permanent expanders are a type of saline implants, they are not as soft or comfortable as silicone implants and some women end up exchanging their permanent expanders for silicone implants later. 

Non-expansion using tissue

With this direct-to-implant reconstruction the surgeon places the permanent implant during the first surgery. The surgeon uses specially prepared synthetic tissue placed over the implant allowing women to avoid tissue expanders and fills.