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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. Talk to your surgeon about which 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 can't 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 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 makes the skin and muscles stretch gradually so the breast mound droop appears more natural.

At first, your breasts won't be 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

This is called latissimus dorsi reconstruction.

The latissimus dorsi is the muscle in your back below your shoulder blade. The operation uses a flap of this muscle, with its skin and own blood supply. The surgeon moves the muscle flap under the skin below your armpit. They reposition it on your chest to create a breast mound. Usually, you'll 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 where the muscle flap is taken from and one on your reconstructed breast. You'll also be bulkier under your arm where the muscle has been tunnelled from your back to your chest. This won't completely go away.

Taking the muscle from your back won't greatly affect your physical activity. But you're likely to notice that it's weaker if you play tennis or swim a lot, for example.

You can see how this works in the latissimus dorsi reconstruction diagram 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 time. But it can give the most natural looking breast.

TRAM flap reconstruction

TRAM flap illustrationThis uses a flap made up of tissue and muscle from your abdomen (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 your abdominal skin to form a breast mound on your 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, it's called a pedicled flap. If the tissue is completely detached and moved to the breast, it's called a free TRAM flap.

If you have this operation, the scars will be on your lower abdomen and reconstructed breast. The scars on your 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 long), 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 won't get sensation in their breast skin back.

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 won't completely go away. As the operation uses one of a pair of abdominal muscles, you'll have some permanent weakness in your abdomen. The other muscles compensate a bit, but you won't be able to sit up from lying down without using your hands.

Talk to your surgeon if you're 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's 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. They may also need to remove some of your rib cartilage.

A DIEP flap minimises 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 are moved. 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.

The abdominal scar runs from hip to hip (around 50 to 70 cm long) and your abdominal skin above the scar will be numb. The scars on the breast can vary and depend on if the reconstruction is done at the time of your mastectomy or later. Most women won't get sensation in their breast skin back.

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 won't regain sensation.

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

Written by HealthInfo clinical advisers. Endorsed by Canterbury DHB Plastic Surgery Department. Last reviewed April 2018.

Sources

Page reference: 85842

Review key: HIBRC-85838