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How breast reconstruction surgery is done

Breast reconstruction surgery is done under a general anaesthetic. There are various techniques for this surgery, which we explain below. You will need to talk with your surgeon about which one is most suitable for you.

Using an implant

Breast implant scarsThis is the simplest type of reconstruction. An implant is placed under your chest muscle. This technique tends to produce a proud, or prominent, breast, and cannot create a large or droopy breast.

Your scar may be in different places, depending on whether you have an immediate or delayed reconstruction. You should talk to your surgeon about where your particular scar will be.

An inflatable implant called an expander can be used. This has an opening, or port, under the skin so saline can be added using a needle and syringe. This means the skin and muscles stretch gradually, so the breast mound droop appears more natural.

At first your breasts will not look the same size or shape. Your implant will gradually be inflated to its final size over a few months of weekly or fortnightly visits to the Outpatients Department.

Using a combination of a tissue flap and an implant

Latissimus dorsi reconstruction

The latissimus dorsi is the muscle in your back, below your shoulder blade. This operation uses a flap of this muscle, with its skin and own blood supply. The surgeon moves this muscle flap under the skin below your armpit. They reposition it on your chest to create a breast mound. Usually, you will need a silicone gel implant or tissue expander behind it to help match the size of your other breast.

This leaves a scar on your back from where the muscle flap is taken, and also one on the reconstructed breast. As well, you will also be bulkier under your arm, where the muscle has been tunnelled from your back to your chest. This will only partially settle.

Taking the muscle from your back does not affect physical activity greatly. However, you are likely to notice it is weaker if, for example, you play tennis or swim a lot.

You can see how this works in the diagram of Latissimus dorsi reconstruction on the Cancer Council Victoria website.

Using a tissue flap with no implant

This type of surgery is complex, takes many hours, and has a longer recovery. However, it can give the most natural looking breast.

TRAM flap reconstruction

TRAM flap illustrationThis uses a flap made up of tissue and muscle from the abdomen (or tummy area). It uses the vertical muscle we know as the six pack, called the rectus abdominis. The surgeon moves this muscle, with its blood supply and skin, up under the abdominal skin to form a breast mound on the chest wall. The surgeon may need to remove some of your rib cartilage to do this.

TRAM is short for transverse rectus abdominis myocutaneous. If the flap stays attached to its original blood supply we call it a pedicled flap. If the tissue is completely detached and moved to the breast it is called a free TRAM flap.

If you have this operation, the scars will be on your lower abdomen, and also on your reconstructed breast. The scars on the breast can vary and you should talk to your surgeon about what to expect. The abdomen scar runs from one hip bone to the other (it's about 50 to 70 cm), and the surgeon will aim to place it so bikini bottoms will cover it. If you have this operation, the skin on your lower abdomen will feel tight until it stretches. Most women do not gain sensation in their breast skin.

As the muscle is moved up to the breast you may notice a bulge near the base of your rib cage after this operation. This will only partially settle. As the operation uses one of a pair of abdominal muscles, you will have some permanent weakness in your abdomen. The other muscles compensate a bit, but you will not be able to sit up from lying without using your hands.

Talk to your surgeon if you are worried about how this will affect any specific activities.

After the surgery your abdomen will be flatter but weaker. Because the front of your abdomen is flatter, it can make the sides seem bulgy. A second operation can fix this.

DIEP flap reconstruction

This uses the same abdominal (or tummy) area as the TRAM flap, but it uses skin, fat and other tissue rather than muscle. The surgeon completely detaches and moves the tissue. DIEP is short for deep inferior epigastric perforator, which is the name of the blood vessels that will be moved. The blood vessels are joined to a fresh blood supply in your chest. The surgeon may need to remove a small part of one rib to do this. The surgeon may need to remove some of your rib cartilage to do this.

A DIEP flap lessens abdominal weakness by not removing the muscle, but it still causes some weakness. This is because the surgeon needs to split the muscles to get to the blood vessels that have to be moved. After the surgery your abdomen is flatter but weaker. Because the front of your abdomen is flatter after a DIEP flap, it can make the sides seem bulgy. A second operation can fix this.

The abdominal scar runs from hip to hip (around 50 to 70cm long) and your abdominal skin above the scar will be numb. The scars on the breast can vary, and are different if the reconstruction is done at the time of your mastectomy or if it's done later. Most women won't get sensation in their breast skin back. The diagram in the section on TRAM flap reconstruction shows likely scar sites.

Nipple reconstruction

Some women choose to get a nipple reconstruction, but some prefer to use stick-on nipples (known as prostheses). You should talk to your surgeon about your options. In some cases part of your own nipple can be used, in other cases the surgeon will make a new nipple from a flap or graft. Sometimes nipple tattoos are used. A reconstructed nipple will not regain sensation.

On the next page: Risks and complications of breast reconstruction surgery

Written by HealthInfo clinical advisers. Approved by Canterbury DHB Plastic Surgery Department. June 2014.

Sources

Page reference: 85842

Review key: HIBRC-85838