RECONSTRUCTION WITH YOUR OWN TISSUES
Breast reconstruction can be done using skin, muscle, and fat taken from another part of your body. This is also called an autologous reconstruction, myocutaneous flap, or simply, a flap.
There are different types of flaps. Some, (like TRAM flaps and latissimus dorsi flaps), move tissues from an area of the body to the breast area, while preserving the original blood supply. Others, (like the DIEP, SIEP, or IGAP) are free flaps—the original blood supply to the transplanted tissue is cut then reconstructed.Ω
TRAM (Transverse Rectus Abdominis) Flap
The TRAM flap has been one of the most common flaps for years. It uses one of the rectus abdominis muscles—the “abs,” as weight lifters call them. The muscle, fat, and skin are separated from their natural attachments, and pulled up, under the skin, to the breast area. The flap is then shaped into the form of a breast. Some of the original blood supply is preserved.
The TRAM flap is the most versatile of the tissue flaps, and can create a good match to the other breast for all but the largest-breasted women.
The procedure takes three to five hours, and usually requires a four to seven day hospital stay. It also entails an abdominal incision, and does result in significant discomfort for some time after the surgery.
Rarely, a hernia may develop in the area from where the muscle was taken. But an additional cosmetic benefit of a TRAM flap is that it also gives the woman a “tummy tuck” as part of the procedure.
Latissimus Dorsi Flap
The latissimus dorsi flap is sometimes referred to as Lat flap. For this procedure, an incision is made under the shoulder blade, and a temporary tunnel is created under the skin, just like for the TRAM flap. A portion of the latissimus dorsi muscle from the upper back, and the fat and skin covering it, are pulled through this tunnel and relocated to the breast area. The procedure takes five to six hours and is done under general anesthesia.
For most women, the latissimus muscle does not provide enough bulk to match the opposite breast, so a synthetic implant is added to make the reconstructed breast larger.
To create a free flap, tissue is removed from the abdomen or buttocks, and transplanted to the breast site. The original blood supply to the flap is cut, and then reconnected to a new artery and vein in the breast area. These procedures require a plastic surgeon who is skilled in micro-surgery, because they involve sewing blood vessels so thin, that the work must be done under a microscope.
Several more advanced forms of free flaps are gaining popularity. They use the so-called perforator vessels—blood vessels that branch off a deep artery and pass through the muscle, on the way to the fat and skin. The plastic surgeon isolates these vessels from the bigger artery, and dissects them out through the muscle, rather than taking them with the muscle. This technique offers the benefit of a longer blood vessel that is easier to re-attach in the breast area. By preserving the muscle, the patient’s recovery is shorter, there is much less discomfort after surgery.
One example of a perforator flap is the DIEP (deep inferior epigastric perforator) flap. This flap uses fat and skin from the same area as the TRAM flap, but does not disturb the muscle. Recovery time is shorter, post-operative discomfort is less. In addition, the muscle in the donor area is not damaged, and retains its shape and function, unlike for the traditional TRAM flap, in which most, if not all the muscle is removed. A welcome by-product of the DIEP flap procedure is a tummy tuck.
Another option in free flaps is the IGAP flap that uses the inferior gluteal artery and a portion of the buttock tissue. The location of the donor site can be effectively concealed, and the outline of the buttock preserved.
Nipple and Areola Reconstruction
Women who want their reconstructed breast to look as natural as possible may choose to have a nipple and areola reconstruction. This procedure is usually done a few months after the breast reconstruction, so that the breast has had time to settle into its natural sag.
Small flaps of skin on the reconstructed breast are raised and brought together into the shape of a nipple. The areola is created either from a skin graft, or by tattooing. The procedures can be done under local anesthesia.
If you prefer, you can buy plastic removable nipples that come in semi-erect form. They are surprisingly lifelike in texture and color.