One of the most important decisions a newly diagnosed patient with breast cancer must make is to choose between breast preservation (i.e. lumpectomy and radiation) and mastectomy. Although breast preservation is generally considered the procedure of choice for women with early stage breast cancers, for various reasons many women are either not candidates for breast preservation, or choose mastectomy for personal peace of mind.

If a woman is considering mastectomy, it is important that she be given the option of immediate breast reconstruction. One problem facing such women is that it is sometimes difficult to coordinate the reconstructive surgery with the mastectomy in a timely manner. Some of the more common options include:

Tissue expanders : Our most common reconstruction option is the placement of a tissue expander under the pectoral (chest) muscle at the time of the mastectomy. After the wounds have healed, the expander is slowly filled with saline over a period of several weeks. Once the skin is adequately stretched, the expander is exchanged for permanent implant. Nipple reconstruction can be performed within a few months following the placement of the permanent implant.

Tissue transfer techniques : Not all women are candidates for tissue expanders, and some women prefer the advantages of reconstructing the breast with natural tissue. For these women, the option of tissue transfer is a logical alternative. The two standard options for tissue transfer are:

a. Transverse Rectus Abdominus Muscle Flap (TRAM) : Transverse Rectus Abdominus Musculo-cutaneous Flap (TRAM): In this procedure, tissue from the lower abdomen is transferred to the chest, and a breast mound is reconstructed to match the opposite breast. This procedure is often done at the time of the initial mastectomy. The patient leaves the hospital with remarkable breast symmetry, natural-feeling and appearing tissue in the reconstructed breast, and also a modified tummy tuck.

b. Latissimus Dorsi Flap : Latissimus Dorsi Flap: This flap comes from the back and can be used in situations where extra skin is needed to close the mastectomy incision. It is often used when the breast has been previously irradiated, or for patients who are not candidates for the TRAM flap (i.e. very thin patients with inadequate abdominal tissue to create a breast flap).

Overview of Photographic section.
The following section provides a brief description of the various reconstruction options, as well as pictures of our own results. Please Note: Some viewers may find these pictures to be disturbing, and viewer discretion is advised. Before viewing pictures, please link to Informed Consent.

Section 1: Reconstruction with tissue expander following mastectomy :

Placement of a tissue expander under the muscle at the time of mastectomy is the least traumatic and most popular of our reconstruction options. The tissue expander is nothing more than an empty silicone sac that is placed under the pectoral (chest) muscle after the breast has been removed. Most patients go home on the first or second day after surgery, and generally the post-operative pain is easily controlled with oral medication.

The surgical wounds are usually given a few weeks to heal before the process of expansion is started. Over a period of several months, saline is injected gradually into the implant (this is a simple in office procedure) until it enlarges to a size that is slightly larger than the original breast. Following the completion of the expansion process, the expander is exchanged for a permanent implant which is filled with either saline or silicone. This is usually an outpatient procedure performed under general anesthesia.

After another few months of healing, a woman may choose to have nipple reconstruction. This again is done as an outpatient procedure, and is well-tolerated. After the reconstructed nipple heals, it is tattooed so that the color matches the opposite nipple.

In some cases, there is the need to modify the opposite breast to produce a more cosmetic result. In cases where the opposite breast is smaller, an implant can be added to it. If the opposite breast is larger, it can be reduced. Examples of the results of reconstruction can be seen in the following pictures:

Example 1 : Late results following right mastectomy and immediate reconstruction with a tissue expander. This patient is several months post-operative, and has had nipple reconstruction.

Example 2 : Late results following immediate reconstruction after a right mastectomy with a tissue expander, and reduction mammoplasty of the left breast. This result is in a patient who had nipple reconstruction on the right breast.

Example 3 : Bilateral reconstruction with tissues expanders; late post-operative result.

Example 4 : Nipple tattooing

Section 2: Tissue transfer techniques :

A. Tram flap (tranverse rectus abdominal muscle flap) :
The Tram flap has several advantages. In this procedure, skin and fatty tissue from the lower abdomen are transferred under the skin to the mastectomy incision. A new breast is fashioned using the transferred tissue. The tissue transferred to the chest has its own blood supply, and feels much like normal breast tissue. Thus, immediately after the breast has been removed, a new breast can be reconstructed. Nipple reconstruction typically takes place a few months later, at which time the shape of the newly reconstructed breast is often revised. Not only does this reconstructed breast look and feel like a normal breast, but the woman also gets a partial tummy tuck as a result. Click here for post-reconstruction pictures:

Example 1 : Bilateral tram flap with nipple reconstruction:

Example 2 : Left breast TRAM flap with completed nipple reconstruction:

Example 3 : Right breast TRAM flap reconstruction with reduction mammoplasty of the left breast:

Example 4 : Left TRAM flap with right mastopexy (breast lift):

Example 5 : Right breast TRAM flap following nipple reconstruction:

B. Latissimus Dorsi Flap :

The latissimus dorsi flap is remarkably well-tolerated by the patient, and is associated with very few complications. It is our flap of choice for older patients and for patients with medical problems. In this procedure, a portion of the skin, fatty tissue, and muscle is taken from the back and transferred under the skin to the mastectomy cavity following the removal of the breast (it can also be done as a delayed procedure following mastectomy). In many cases, an implant is placed under the latissimus flap in order to create a breast that is symmetric with the other breast. The following are examples of latissimus flap reconstruction:

Example 1 : Latissimus flap reconstruction of the left breast, plus implant and nipple reconstruction; also, implant of the right breast:

Section 3: Special problems :

A. Reconstruction following lumpectomy and radiation :

Most patients who have lumpectomy and radiation for the treatment of their breast cancer have a good to excellent cosmetic result. However, in some cases the breast is distorted following completion of radiation therapy, and reconstruction is an option for selected patients. Our standard approach to reconstructing the irradiated breast is to place an implant under the breast. Other approaches to reconstruction include the transfer of a latissimus flap to fill in the surgical defect, or mastectomy with TRAM flap reconstruction.

See Example1 : Left breast reconstruction following lumpectomy and radiation using a tissue expander, followed by placement of a silicone implant; also, right breast reduction.