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Breast reconstruction surgery is a vital component of breast cancer treatment plan. Breast reconstruction surgery can be done immediately after mastectomy or in a delayed operation depending on whether post-mastectomy radiation therapy will be needed. Immediate reconstruction offers better aesthetic results if radiation is not needed. When radiation is required, delayed reconstruction is preferred to avoid possible complications.

Breast Implant

Breast implant involves insertion of a breast prosthesis made of synthetic material. A typical breast implant has a silicone shell and is filled with saline or silicone gel.

Advantages: requires short initial hospital stay, simplest of all procedures, no additional scars, no other sites on body to heal except for the breast.

Disadvantages: As a result of the body’s response to foreign material, the implant may be squeezed within scar tissues leading to distorted shape (capsular contracture), leak, rupture and infection. In fact as many as half of all women will require surgery to remove the implant later in life.

Natural Tissue Breast Reconstruction Surgery

These techniques use body’s own tissue for the new breast. A section (flap) of skin, fat, and possibly muscle is harvested from a donor site elsewhere in the body and transferred to the chest to make the new breast. Possible tissue donor sites include: lower abdomen, back, buttock and area above it, inner thigh. Lower abdomen is by far the preferred donor site as it comes with a bonus of a flatter tummy after operation.

Advantages compared to breast implants: The use of autologous tissue allows the reconstruction of a breast which looks and feels most like a normal breast. More importantly, this also solves the problem of the new breast being rejected by body’s immune system.

Disadvantages compared to breast implants: Longer initial hospital stay; additional scar on the donor site; donor site may be weaken due to loss of muscle.

Below we discuss different techniques available for breast reconstruction surgery with lower abdomen as the donor site, in order from the oldest to the newest, with advantages and disadvantages of each as compared to each other.

TRAM flaps

Transverse Rectus Abdominus Myocutaneous flap – the first of all natural tissue reconstruction technique.

Fig. 1 : Pedicle TRAM flap breast reconstruction surgery. Click on image to see it on Alila Medical Media website where the image is also available for licensing.

The original (pedicled) TRAM flap (Fig. 1) : A section of skin and fat is cut from the lower abdomen. One of the rectus abdominis muscles (six-pack muscles) is divided in the lower abdomen. The lower end of the muscle remains attached to the skin/fat tissue. This is the flap that is now attached to the body by the upper end of the muscle at its original position. The flap is rotated together with the muscle and passed under the skin to the new location in the chest. Here it is shaped to form the new breast. The flap is supplied by the blood vessels that run inside the rectus abdominis muscle. A piece of synthetic mesh is placed in the abdomen to provide support for the abdominal wall that is now weakened due to removal of the muscle.

Advantages: Relatively simpler procedure compared to newer techniques as microsurgery expertise is not required, more surgeons are able to offer this procedure.

Disadvantages: Significant loss of muscle from the abdomen makes the abdominal wall weakened and subject to risk of hernia; attachment of the flap to the body makes it harder to be configured into desired shape.

Free TRAM Flaps

An improvement from the original TRAM flaps technique. In this procedure, a section of skin, fat and part of rectus abdominis muscle with blood vessels within it, is separated completely from the body (hence “free”) and transferred to the breast location. The blood vessels of the flap (deep inferior epigastric artery and vein) are connected to recipient vessels in the breast using microsurgery technique.

Fig. 2 : Free TRAM flap breast reconstruction surgery. Click on image to see it on Alila Medical Media website where the image is also available for licensing.

Advantages: Free flaps are easier to sculpt into desired shape; blood supply is more robust.

Disadvantages: Microsurgery expertise is required; weakened abdominal wall due to muscle loss.

A modification of the procedure called muscle-sparing (MS) free TRAM flap is designed to remove only a minimum amount of muscle.

DIEP Flaps

Deep Inferior Epigastric Perforator flaps. A significant improvement from TRAM flaps. In this procedure the blood vessels (deep inferior epigastric artery and vein) are carefully dissected from the muscle. An incision is made in the rectus abdominis muscle for dissection of blood vessels but no muscle is taken out. The flap contains skin, fat, blood vessels but no muscle. The blood vessels of the flap are then connected to recipient vessels in the breast using microsurgery technique (Fig. 3 and Fig. 5).

Fig. 3 : DIEP flap breast reconstruction surgery. Click on image to see it on Alila Medical Media website where the image is also available for licensing.

Advantages: all advantages of a free flap; no muscle taken from donor site.

Disadvantages: Microsurgery required; longer operation time; not offered by many surgeons.

SIEA Flaps

This procedure is based on a different set of blood vessels – Superficial Inferior Epigastric Artery and Vein. These vessels supply the skin and fat tissue of the abdomen and run within the fat layer. With this flap, the abdominal muscle is left untouched, and therefore this is the preferred technique whenever it’s possible. The reason why this is not widely used is because these vessels are not large enough in 90% of patients. Commonly, these superficial blood vessels are approached first during surgery. If the surgeon sees that they are big enough, a SIEA flap will be used, if not, a DIEP flap will be performed instead.

Fig. 4 : SIEA flap breast reconstruction surgery. Click on image to see it on Alila Medical Media website where the image is also available for licensing.

Advantages: all advantages of a free flap; no muscle taken from donor site; no damage to the muscle.

Disadvantages: only possible in about 10% of women; microsurgery required; not offered by many surgeons.

Fig. 5 : Comparing the flaps from different breast reconstruction surgery techniques. Click on image to see it on Alila Medical Media website where the image is also available for licensing.