Yale Breast Reconstruction Program
In most cases, reconstruction can be performed immediately following a mastectomy during the same operation. In other cases, reconstruction should be performed in a delayed fashion, after the breast cancer is fully treated. Regardless of timing, federal law mandates that all insurance companies pay for breast reconstruction when a mastectomy is indicated.
- For women who choose implant reconstruction, this usually involves multiples stages. Reconstruction begins at the time of mastectomy with tissue expanders placed on the chest wall beneath the skin and muscle. The expander is filled with saline (salt water) every two to three weeks in the office under local anesthesia, until the breast reaches the desired size. The patient then returns to the operating room for an outpatient procedure to remove the tissue expander and place a permanent implant. In some cases, specifically in women with a smaller breast size, a one-stage implant reconstruction may be possible with placement of a permanent implant at the time of mastectomy.
The benefit of implant-based breast reconstruction is that it involves a shorter operation, shorter recovery, and it limits the operative field to the chest. It does have its limitations. Since the implant is a foreign body, it can potentially be felt and seen beneath the skin of the breast. It can also become infected, which would potentially require removal of the implant. Excessive scar tissue (capsular contraction) can also form around the implants causing them to become firm, change shape/position, and be tender. Severe capsular contraction (Baker Grade 3 and 4) may require revisional surgery. Finally, implants have the potential to rupture, and may need to be replaced over a patient’s lifetime.
Autologous Breast Tissue Reconstruction
The main alternative to implant-based reconstruction is using a patient's own tissue to reconstruct the breast. The most common donor site for this tissue is the abdomen, but there are several other choices.
The use of abdominal tissue for breast reconstruction was first described in 1982, and has been named the Transverse Rectus Abdominis Myocutaneous (TRAM) flap. An alternative to a pedicled TRAM is a free TRAM (fTRAM). To decrease the risk of bulge, hernia, or abdominal weakness following breast reconstruction, the Deep Inferior Epigastric artery Perforator (DIEP) flap was developed. This flap also uses the tissue of the lower abdomen, but it does not use any of the abdominal wall muscles. A flap that completely spares dissection of the abdominal muscles and fascia is the Superficial Inferior Epigastric Artery (SIEA) flap.
For women who do not have enough tissue on their abdomen to use for a TRAM, DIEP, or SIEA flap, there are a number of other areas on the body where tissue can be obtained. The buttock can supply either a Superior Gluteal Artery Perforator (SGAP) or an Inferior Gluteal Artery Perforator (IGAP) flap. The thigh can supply a Transverse Upper Gracilis (TUG) flap. Or a combination of the patient's own tissue from the back (latissimus flap) can be used in conjunction with implant-based reconstruction.
Is it important to remember that reconstruction is a process and is rarely completed in one operation. Typically, four months after the initial operation, revisions are performed to improve the contour of the reconstructed breast. If only one breast was treated, the other breast may need a lift, reduction, or augmentation to improve the balance and appearance between both breasts. In addition, nipple areolar reconstruction may be performed if the nipple was removed at the time of mastectomy.
Nipple and Areola Reconstruction
- At Yale Plastic and Reconstructive Surgery, we understand that for many women the nipple is an integral part of feeling that their breast reconstruction is complete. Most often, the nipple and areola are removed with the breast tissue at the time of mastectomy. This is done because the nipple contains ducts that carry the risk of developing breast cancer. Regardless of the form of breast reconstruction, the initial post-operative result is left without a nipple. Several months after the initial surgery, a nipple and areola can be reconstructed with local flaps, grafts, or a combination of the two. Additionally, tattooing can be used to restore color to the nipple and areola.