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Reconstructive plastic surgery for breast cancer is performed to replace
skin, breast tissue and the nipple-areolar complex removed during mastectomy. In
general, the nipple-areolar complex is removed during any mastectomy operation
because it is breast tissue and is at risk for cancer recurrence.
The amount of missing tissue varies with each mastectomy. Factors
contributing to the amount of tissue removed include the width, size and
location of the original tumor and its proximity to the axilla, where the lymph
glands are removed.
What are the types of breast reconstruction?
- Expander/prosthesis method:
A delayed breast reconstruction because it does not provide the patient
with an immediate breast mound. The expander/prosthesis method requires
multiple stages and multiple office visits.
The first step for implant reconstruction involves placement of a balloon
expander beneath the skin and chest muscle. Several weeks after the initial
surgery, saline is periodically injected through a valve in the expander.
The expander is slowly filled over the next several weeks to months. Then
the expander is removed and replaced with a permanent implant. Nipple
reconstruction may also be performed at this time.
- Immediate breast reconstructions:
Back Flap reconstruction and TRAM flap reconstruction
These methods result in a reconstructed breast mound at the end of
mastectomy surgery. The back flap or latissimus dorsi myocutaneous (lats)
flap breast reconstruction is a procedure in which skin and muscle from the
back is used along with an implant to provide breast volume. The back flap
breast reconstruction is known as a composite method of breast
reconstruction because it combines both the patient's own tissue as well as
a breast implant.
The back flap was originally described by Tansini, an Italian professor of
surgery, in 1906. He used the procedure for coverage of a chest wall defect
following radical mastectomy. The same flap method also has been used over
the years for head and neck reconstruction, using what is called a free
flap, transferring skin and tissue to other parts of the body for coverage
of large defects.
In the mid 1970s this flap procedure was rediscovered and eventually used
and refined for use in immediate breast reconstruction.
The other type of immediate breast reconstruction is the TRAM flap or tummy
tuck reconstruction method, which uses skin from the lower abdomen to
reconstruct the breast. In most cases, the TRAM flap method does not require
an implant.
Who is a candidate for the back flap breast reconstruction?
Women
who want an immediate breast reconstruction (a completed reconstruction by the
end of surgery) are candidates for the back flap breast reconstruction surgery.
Those who are not likely to need radiation therapy after mastectomy also are
candidates for this type of reconstruction.
Women who do not have enough abdominal tissue for a TRAM flap breast
reconstruction may also consider the back flap breast reconstruction. Also,
those women who would like a shorter recovery period than that required for a
TRAM breast reconstruction (6-8 weeks) are candidates for the back flap
reconstruction.
How is the back flap procedure done?
Before
the procedure, plastic surgeons work with the general surgeon, to determine how
much skin needs to be removed during the mastectomy. The measurements are marked
on the patient's back.
After completion of the mastectomy, the patient is positioned on her side
with the mastectomy site up so the latissimus muscle can be released from her
back. Both skin and muscle are transferred.
The latissimus muscle has excellent blood supply that goes up into the axilla. The muscle remains attached to this blood supply and moved to the front
to reconstruct the breast. The back area from which the tissue was taken is then
repaired.
Next, the patient is repositioned on her back. The flap that had been
transferred is fashioned to create a breast mound by attaching it to the large
muscle of the anterior chest (the pectoralis major muscle). An implant is placed
under the two muscles (the pectoralis major and the latissimus dorsi). The
reconstructed breast is then shaped to match the woman's natural breast as
closely as possible.
How long does the reconstruction surgery last?
Delivering
anesthesia, surgery preparation and the cancer surgeon's portion of the
operation may take approximately 2 hours. Once the plastic surgery team takes
over, the reconstructive portion of the procedure is completed within an
additional 3 hours. Following surgery, the patient spends approximately 2 to 3
hours in the recovery room before being transferred to a hospital room. Although
the entire operation is a 7-hour procedure, the actual surgical time may be
about 3 to 4 hours.
What is recovery like?
All soft tissue
surgery (the mastectomy and breast reconstruction) will leave areas of numbness
where the surgery was performed. Instead of feeling pain along the back where
the tissue was taken, a patient may feel numbness and tightness. The same is
true of the reconstruction site.
The day after surgery, the patient will normally be able to sit in a chair
beside the bed. On the second day after surgery, most patients are walking
without assistance.
The usual hospital stay is approximately 3 to 4 days, including the night of
surgery. Most women return to work within 3 to 4 weeks after surgery.
The back flap is a very reliable method of breast reconstruction with a less
than 1 percent rate of tissue loss.
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