Implant reconstruction is one of the most commonly performed breast reconstructions following mastectomy. The reason for its popularity is due in part to the relative low invasiveness of the procedure, the aesthetic outcome, lack of donor site comorbidity, and the relatively low downtime.
Implant reconstruction is a staged reconstructive procedure, meaning that it involves multiple states.
- First Stage of Breast Implant Reconstruction: The first stage often involves the placement of an allograft sling to support the eventual breast implant and the placement of a temporary place holder which is called a tissue expander. Depending on the type of cancer you have and what we call the skin envelope, some patients are candidates for direct implant reconstruction. Depending on various factors, the first stage may be carried out immediate after a mastectomy (termed Immediate Breast Reconstruction) or may be delayed (termed Delayed Breast Reconstruction)
- Second Stage of Breast Implant Reconstruction: The second stage involves removal of the tissue expander and replacement with a permanent breast implant. This is often carried out between 3 to 9 months after the first stage, and the timing of which may depend on other factors such as, but not limited to, radiation, chemotherapy, comorbidities, and overall healing. It is often during this stage that a procedure on the other unaffected breast is carried out (termed a contralateral procedure).
- Third Stage of Breast Implant Reconstruction: Depending on the desires of the patient, a third stage may be carried out which involves procedures such as ‘touch up’ procedures. During these procedures, various modalities such as, but not limited to, fat grafting, contouring of the breast, nipple reconstruction may be performed to enhance the final result of the breast(s).
Like-tissue (autologous) breast reconstruction is a reconstruction in which the Plastic Surgeon reconstructs the breasts with similar tissue to what was removed. During this surgery, fat, and sometimes skin, is transferred to the ‘pocket’ which was left-over from the breast mastectomy. Albeit a more lengthy and more technical procedure than implant reconstruction, autologous reconstruction leaves the breast in a natural state wherein gravity will affect the tissue much the same way as it would have naturally. We call this effect breast(s) ptosis. Autologous reconstruction are often utilized to replace skin and soft tissue when breast radiation leaves a scarred skin envelope. Due to the technical nature of these procedures, they may require longer surgical times and hospital stays. In addition, there are greater risks of complications with these types of procedures
- Transverse Rectus Abdominis Myocutaneous (TRAM) Flap: TRAM flap is a surgery wherein the Plastic Surgeon harvests fat, muscle, and sometimes skin from the abdomen in order to transfer it to the breast for reconstruction. The surgeon harvests one side of the rectus muscles (termed unilateral) or both sides of the rectus muscles (termed bilateral) along with the overlying abdominal fat and skin (termed a myocutaneous flap). The myocutaneous flap is tunneled under the skin and inset into one or both of the breasts. The donor site of the abdomen is closed in much the same way as an abdominoplasty with a long incision which spans from one hip bone to another.
- Latissimus Dorsi Muscle or Myocutaneous (Lat Dorsi) Flap: In a latissimus dorsi flap, the Plastic Surgeon harvests fat, muscle, and sometimes skin from the back in order to transfer it to the breast for reconstruction. The surgeon harvests one or both sides of the large spanning latissimus dorsi flap of the back along with the overlying fat and skin (termed myocutaneous flap). The flap is tunneled under the skin of the axilla and inset upon the front side of the body to reconstruct the breast(s). The donor site of the back is typically able to be closed with sutures and/or staples, but if large, may need additional procedures to close it such as skin grafting. Depending on the size of the donor skin and fat, a tissue expander and/or implant may need to be placed to replace the lost volume of the breast(s).
- Deep Inferior Epigastric Perforator (DIEP) Flap: DIEP Flap is a surgery wherein the Plastic Surgeon harvests fat and skin (notice no muscle is harvested) from the abdomen in orde to transfer it to the breast for reconstruction. This procedure is similar to the TRAM flap in terms of the incisions and donor sites used; however, the difference is that no muscle is harvested with the DIEP flap. During the DIEP flap, the fat and skin is harvested with its blood vessels which are disconnected from the deep larger blood vessels. Once disconnected, the flap is inset into the chest by reconnecting it to blood vessels in the chest. Due to the technical nature of this flap, special equipment such as a microscope is used to reconnect the blood vessels. This is called a free flap procedure because the tissue is ‘freed’ from its native blood supply. Besides the DIEP flap, there are other types of free flap procedures for breast reconstruction, and the surgical time varies depending on multiple factors.