BREAST RECONSTRUCTION CHOICES
You should choose a reconstructive surgeon based on what your individual breast reconstruction goals are. Although we make every effort to include many surgical options available, as new techniques are developed all the time, this cannot be an completely exhaustive list. We briefly discuss the most commonly performed and widely available reconstructive surgeries on this page. Not all of these options may be appropriate for you, and there may be some that are not listed here. Additionally, not all surgeons can perform all surgeries. The general information below is courtesy of The Buncke Clinic in San Francisco, an Institute of Plastic and Reconstructive Surgery and Microsurgery.
Advanced microsurgery (SIEA, DIEP, TUG- all of which use your own tissue) is commonly referred to as the gold-standard of breast reconstruction. Also known as perforator flap surgery or microsurgery, these procedures were developed in the 20th century by combining techniques of vascular surgery with an operating microscope, fine instruments, micro-sutures and new operative strategies. To create a reconstructed breast, tissue is transferred from your abdomen (SIEA, DIEP) or your inner thigh (TUG). In essence, the patient will have a tummy tuck or an inner thigh lift and the excess fat and skin is used to create a new breast. A reconstructed breast made from a patient’s own tissue generally looks and feels very similar to a natural breast.
Microsurgery tends to be a more permanent option than implant reconstruction. Microsurgery also lessens the extent of surgery needed at the donor area (abdomen, thigh, etc.) as compared to traditional flap surgery (TRAM, free TRAM). Because there is less surgery required at the donor site, there is less rick of complications like abdominal bulging, hernia and loss of function. Advanced microsurgery (SIEA, DIEP) also tend to have shorter recovery times for the same reasons.
FINDING OUT IF MICROSURGERY IS A GOOD OPTION FOR YOU
The unique history, circumstances and goals of each specific patient help define the choice of a reconstruction method. No single technique is applicable to everyone. Some patients may be better candidates for implants, an expander or latissimus reconstruction. Although technically more complex, the potential benefits of microsurgical reconstruction can be significant relative to implant or TRAM reconstruction.
It is very important to have a qualified microsurgeon/plastic surgeon perform any microsurgical reconstruction such as SIEA, DIEP, GAP and TUG. Since microsurgery is relatively complex, having more than one specialty trained microsurgeon working together in a practice is ideal. This is known as the TWO-TEAM APPROACH MICROSURGERY. Using a team approach, two microsurgeons with extensive microsurgical experience, will cut down on surgery and anesthesia time considerably.
ADVANTAGES MICROSURGERY: warm, soft, natural feeling reconstructed breast(s), lower risk of complications and loss of function from donor site, longevity of reconstruction
DISADVANTAGES MICROSURGERY: lower number of qualified surgeons, increased operating time (if only one surgeon)
The DIEP flap provides the abdominal skin and subcutaneous tissue for a reconstructed breast while sparing the abdominal muscles. Patients typically have decreased post-operative pain, less post-surgical abdominal wall weakness and a decreased chance of abdominal wall hernia formation as compared to the traditional abdominal flap surgery (TRAM).
Like the DIEP, the SIEA flap provides the same abdominal skin and fat, but it relies on a different blood supply and requires less surgical dissection than the DIEP flap. SIEA vessels can be quite small and present different anatomic challenges for inserting at the recipient (breast) area. Patients that have had previous abdominal surgery (such as a c-section) may not have usable SIEA vessels as a result of the previous surgery. Hernia formation is exceedingly rare.
The TUG flap flap relies on tissue from the inner upper thigh as well as a portion of the gracilis muscle. This tissue is similar to the skin and fat removed in the cosmetic medial thigh lift procedure. Loss of the gracilis muscle, unlike the rectus muscle in the abdomen, does not lead to hernia formation or loss of strength. Although the TUG flap usually has good sized blood vessels, they can occasionly be quite small. The amount of tissue supplied by the inner thigh tends to be less than what is available for most patients on their abdomen. The shape of the TUG flap provides superior projection when compared to abdominal tissue. The inner thigh skin mimics a nipple areola complex unusually well when shaped correctly.
- ADVANTAGES MICROSURGERY: warm, soft, natural feeling reconstructed breast(s), lower risk of complications and loss of function from donor site, longevity of reconstruction
- DISADVANTAGES MICROSURGERY: lower number of qualified surgeons, increased operating time (if only one surgeon)
TRADITIONAL MUSCLE FLAP SURGERY
During flap procedures, the surgeon disconnects a section of tissue – including skin, fat and sometimes muscle – from its blood supply and attaches the tissue to blood vessels in your chest area.
- ADVANTAGES TRADITIONAL FLAP SURGERY: soft, natural reconstructed breast(s), longevity of reconstruction, more surgeons are qualified to perform, shorter operating time as compared to microsurgery
- DISADVANTAGES TRADITIONAL FLAP SURGERY: increased risk of donor site complications (hernia, loss of function from donor site), some activities (including certain exercises) may be compromised because of having to utilize the muscle from abdomen or back
The most common technique for autologous (donor and recipient are the same person) reconstruction is the TRAM flap. The TRAM provides the advantages of abdominal tissue, but requires removal of part or all of the rectus muscles from the abdomen and some of the fascia of the abdominal wall. One of the main reasons women have been seeking out microsurgical breast reconstruction is because they worry about the loss of abdominal muscles with the TRAM flap. A very popular form of reconstruction, TRAM flaps have become widely available and have produced excellent aesthetic results in many women. The TRAM was a major advance in breast reconstruction when it became available decades ago. The abdominal skin and fat is soft, feels like a breast and has all the advantages of using your own tissue. The results are similar to microsurgery: the reconstruction is permanent and there is no need to worry about changes in appearance of the reconstructed breast over time due to capsule formation or contracture of the implant from scarring.
However, the TRAM flap has some significant drawbacks. It requires removal of part or most of a rectus muscle and part of the rectus fascia from your abdominal wall. The rectus muscle provides abdominal strength and support. This muscle is used when sitting up. In bilateral TRAM flaps (used to reconstruct both breasts or a large single breast), function in both rectus muscles is lost, and more fascia is sacrificed. In some TRAMS the abdominal wall may need synthetic reinforcement of the rectus fascia. The ability to perform a sit-up may be lost lost with TRAM flaps, resulting in patients needing to roll on their side before getting out of bed or lying down. The loss of abdominal support can also lead to hernia formation and bulging.
LATISSIMUS DORSI FLAP
The latissimus dorsi flap (LAT FLAP) is a tissue flap method first utilized in the 1970’s that uses muscle and skin from your upper back to create a new breast mound after mastectomy. This procedure is generally combined with a tissue expander or implant, giving the surgeon additional options for the reconstructed breast.
Breast implants the are the reconstruction choice for the least amount of surgery. Currently, about half of breast reconstructions are done using implants. Most plastic surgeons will work with saline or silicone breast implants. You may also need a tissue expander which stretches the muscles and/or skin to the appropriate size, then another surgery is scheduled for the exchange of the actual implant. You should ask to see and hold your surgeon’s sample implants. Whichever you choose, an implant won’t last for your lifetime, and may have to be replaced at some point.
- ADVANTAGES IMPLANT SURGERY: less surgical time, less recovery time
- DISADVANTAGES IMPLANT SURGERY: implants can be uncomfortably firm, activities may be limited, implants may need exchanging, scarring can lead to implant loss, some implants have been known to leak, should not be run through a mammography machine after mastectomy
Will my insurance cover my reconstruction??
This is a very important question for many women facing mastectomy. The Women’s Health and Cancer Rights Act (WHCRA) of 1998 is a federal mandate with protections for women who will have mastectomy because of a cancer diagnosis or other medical reasons. The WHCRA declares that if a group health plan covers a mastectomy, the plan must also provide reconstructive surgery and other post-mastectomy benefits for the patient, including procedures for the opposite (non-cancerous) breast to restore symmetry.
“Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage also must provide coverage for certain services relating to the mastectomy in a manner determined in consultation with your attending physician and you. This required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema. “ (taken from U.S. Dept of Labor website)
A health plan should consider the patient's reconstruction of choice to be a covered benefit when the insurance covers mastectomy. Deductibles, co-payments and co-insurance requirements for reconstructive surgery must be consistent with other benefits offered in the patient’s health plan. Each patient should be sure to find out what their out-of-pocket costs will be after insurance coverage for reconstruction surgery is verified.
Each patient must find out if their particular health plan is subject to this federal law. The WHCRA is a complicated federal law and insurance plan requirements vary by state. Find out more information by calling your health plan directly, your State Insurance Commissioner’s office or the US Department of Labor at their toll free number: 1- 866-487-2365.
Your reconstructive surgeon's office should be very experienced in billing health insurance for all stages of reconstructive surgery. Not only do you want a surgeon who routinely performs the reconstruction surgery of your choice, but also one who has exceptional office personnel and experience in billing insurance for these procedures.
Why should I consider breast reconstruction?
The goal of breast reconstruction is to restore the appearance of a natural breast when a breast is lost for medical reasons. Not every patient will elect to have reconstructive breast surgery, but every patient should at least consider her breast reconstruction options. Breast reconstruction can be an important part of rebuilding a women's self-esteem after losing a breast to cancer.
There are many options for reconstructing a breast. Make sure you are informed about all of them. A plastic surgeon performs breast reconstruction surgery. A patient should arrange for a consultation to discuss their options.
A cancer diagnosis means physical changes as well as emotional challenges. Although a cancer diagnosis can certainly send someone into a tailspin, it is important for a woman to take the time to fully understand her reconstructive options before deciding on her surgical care. This may not be easy since there are many factors to consider: the stage of breast cancer, overall health of patient, the size of natural breast, availability of tissue if considering a tissue-based reconstruction, ability to match other breast, recovery time needed, coordinating with chemotherapy and radiation therapy if necessary. Making the commitment to investigate reconstructive options as thoroughly as possible can have a lasting benefit for a patient’s quality of life.
What is natural breast reconstruction?
Natural breast reconstruction generally describes procedures that use the patient's own tissue (from abdomen, inner thigh or back) to reconstruct a breast after mastectomy. These procedures are commonly referred to as "flap" procedures. The "flap" refers to the skin and fat tissue that is transferred and reshaped into a breast. Either a section of muscle is also removed to provide the blood supply for the new breast (e.g. TRAM, free TRAM, lat flap) or the muscle is spared with a perforator flap procedure. “Perforator” refers to the blood vessels that are carefully dissected from the donor site and microsurgically re-established for the new blood supply of the reconstructed breast. These muscle-sparing perforator surgeries (SIEA, DIEP, TUG) are named for what blood vessel is being used for the transfer. Perforator flap surgeries are the gold-standard of breast reconstruction and require a qualified microsurgeon who also has training in vascular surgery.
As opposed to breast implants, naturally reconstructed breasts are made of natural tissues and they generally feel like natural breast tissue (i.e. warm, soft). Unlike when implants are placed behind breast tissue in a breast enlargement surgery, implant placement for breast reconstruction is typically behind a thin layer of skin (and possibly muscle). The results of implant breast reconstruction can therefore be very firm.
Although the reconstructed breasts from flap procedures may retain tiny micro-clips remaining on the newly established blood vessels, there is no foreign component that may leak or contract and require replacement.
TRAVEL & SUPPORT
Sources of help with air transportation costs
The American Cancer Society Air Miles Program is a joint effort between Mercy Medical Airlift (MMA)/National Patient Travel Helpline (NPATH) and the American Cancer Society. The program is designed to help patients with the costs of air travel for cancer-related reasons. Call us at 1-800-227-2345 to find out if you are eligible for help with air travel. MMA/NPATH helps set up the travel on behalf of ACS, through the ACS call center staff.
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